Social Needs and Resources in the Evaluation and Enhancement of Discharge Support: The NEEDS Study

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PROJECT SUMMARY Of the nearly 35 million Americans discharged to community settings after an acute hospitalization, 18% require re-hospitalization for the same or related condition within 30 days. Research continues to document how social needs (e.g. food and housing insecurity) and supportive resources (e.g. instrumental social support) play important roles in health outcomes, including hospital readmissions. Yet, while assessment at admission is required for hospital certification bodies and payers, our previous research has identified that inpatient teams are often unaware of patients’ social needs and supportive resources, and lack of agreement on the day of discharge between patients and nurses regarding readiness for hospital discharge (an assessment of personal status, knowledge, coping ability, and expected support) is associated with patient coping difficulties and hospital readmissions. These findings suggest that facilitating communication between patients, family members, and inpatient health care providers regarding patients’ social needs and resources holds high promise for developing more informed discharge plans, and for improving patient outcomes (e.g., readiness for hospital discharge, decreasing readmissions). The objective of this study is to provide inpatient health care teams with information about patients’ social needs and supportive resources, evaluating whether it facilitates clinical decision-making, impacts readiness for hospital discharge and, ultimately, reduces hospital readmission. The aims of this study are to 1) test the effect of assessing and communicating patients’ social needs and supportive resources on health team- patient- caregiver- outcomes; 2) test the effect of social needs and supportive resources assessment on discharge planning processes; and 3) examine provider and patient experiences of social needs and supportive resources assessment. Using an interrupted time series design and regression discontinuity analysis, we will test the effect of communicating results of a social needs and supportive resources assessment findings to medical and surgical inpatient teams during routine discharge planning rounds. The overall hypothesis is that inclusion of patients’ social needs and supportive resources during inpatient care will result in higher and more congruent readiness for hospital discharge ratings (between patients, caregivers, and members of their health team) compared to patients without social needs and supportive resources assessment. Because patients’ social needs and supportive resources are not uniformly or universally assessed, results of this study will provide health systems additional information about factors placing patients at risk for poor outcomes after discharge, and identify whether integrating social needs and supportive resource information informs and improves clinical care delivery.