• Jungyoon Kim, Hongmei Wang, Jihyun Ma, Daniel Jeffrey, Stephen Mohring, April Recher, and Jane F Potter.
• Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA. Jungyoon.kim@unmc.edu.
• J Gen Intern Med. 2024 Sep 17.

BackgroundHealth care systems are increasingly partnering with community-based organizations to address social determinants of health (SDH). We established a program that educates and connects patients with SDH needs at a primary care clinic to community services and facilitated referrals.ObjectiveTo evaluate the effect of addressing SDH soon after discharge on hospital readmission in a clinic population.DesignPre/post, quasi-experimental design with longitudinal data analysis for quality improvement.ParticipantsClinic patients (n = 754) having at least one hospital discharge between June 1, 2020, and October 31, 2021, were included. Of these, 145 patients received the intervention and 609 served as comparison.InterventionsA primary care liaison was employed to assess and educate recently discharged clinic patients for SDH needs and refer them for needed community services from June 1, 2020, to October 31, 2021.Main MeasuresHospital readmissions within 30, 60, and 90 days of discharge were tracked at 6-month intervals. Covariates included patient age, sex, race/ethnicity, insurance status, income, Hierarchical Condition Category risk scores, and Clinical Classification Software diagnosis groups. Data for all hospital discharges during the intervention period were used for the main analysis and data for the year before the intervention were extracted for comparison.Key ResultsOverall, patients in the intervention group were older, sicker, and more likely to have public insurance. The reductions in 30-, 60-, and 90-day readmissions during the intervention period were 14.39%, 13.28%, and 12.04% respectively in the intervention group, while no significant change was observed in the comparison group. The group difference in reduction over time was statistically significant for 30-day (Diff = 12.54%; p = 0.032), 60-day (Diff = 14.40%; p = 0.012), and 90-day readmissions (Diff = 14.71%; p = 0.036).ConclusionOur findings suggest that screening clinic patients for SDH, and educating and connecting them to community services during post-hospital care may be associated with reductions in hospital readmissions.© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.

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