Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients with Heart Failure: A Pilot Randomized Controlled Trial.

BACKGROUND: Heart failure (HF) is a burdensome condition and a leading cause of 30-day hospital readmissions in the US. Clinical and social factors are key drivers of hospitalization. Two strategies, digital platforms and home-based social needs care, have shown preliminary effectiveness in improving adherence to clinical care plans and reducing acute care utilization in HF. Few studies, if any, have tested a combination of these two strategies in a single intervention. OBJECTIVE: To perform a pilot RCT assessing the acceptability, feasibility, and preliminary effectiveness of a 30-day digitally-enabled CHW intervention in HF. METHODS: Adults hospitalized with a diagnosis of HF at an academic hospital were randomly assigned to receive digitally-enabled CHW care (intervention; digital platform + CHW) or CHW-enhanced usual care (control; CHW only) for 30 days after hospital discharge. Primary outcomes were feasibility (use of the platform) and acceptability (willingness to use the platform in the future). Secondary outcomes assessed preliminary effectiveness (30-day readmissions, emergency department (ED) visits, and missed clinic appointments). RESULTS: A total of 56 participants were randomized (N=31 control; N=25 intervention) and 47 participants (N=28 control; N=19 intervention) completed all trial activities. Intervention participants who completed trial activities wore the digital sensor on 78.0% of study days with mean use of 11.4 hours/day (SD 4.6), completed symptom questionnaires on 75% of study days, used the blood pressure monitor 1.1 times/day (SD=0.19), and used the digital weight scale 1 time/day (SD= 0.13). Of intervention participants, 89.5% responded very or somewhat true to the statement "If I have access to the [platform] moving forward, I will use it." Nine (47.4%) intervention participants indicated they required support to use the digital platform. Nineteen (100%) intervention participants and 25 (89.3%) control participants had ≥5 CHW interactions during the 30 day study period. All intervention (N=19 [100%]) and control (N=26 [92.9%]) participants who completed trial activities indicated their CHW interactions were "very satisfying." In the full sample (N=56), fewer participants in the intervention group were readmitted 30 days after hospital discharge compared to the control group (3 [12%] vs 8 [25.8%]; P= 0.12). Both arms had similar rates of missed clinic appointments and ED visits. CONCLUSIONS: This pilot trial of a digitally-enabled CHW intervention for HF demonstrated feasibility, acceptability, and a clinically-relevant reduction in 30-day readmissions among participants who received the intervention. Additional investigation is needed in a larger trial to determine the effect of this intervention on HF home management and clinical outcomes. CLINICALTRIAL: Clinicaltrials.gov NCT05130008. INTERNATIONAL REGISTERED REPORT: RR2-10.2196/55687.

Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Protocol for a Randomized Controlled Trial.

BACKGROUND: Interventions focused on remote monitoring and social needs care have shown promise in improving clinical outcomes for patients with heart failure (HF). However, patient willingness to use technology as well as concerns about access in underresourced settings have limited digital platform implementation and adoption. There is little research in HF populations examining the effect of a combined digital and social needs care intervention that could enhance patient engagement in digital platform use while closing gaps in care related to social determinants of health. Here, we describe the protocol for a clinical trial of a digitally enabled community health worker intervention designed for patients with HF. OBJECTIVE: This study aims to describe the protocol for a randomized controlled trial assessing the acceptability, feasibility, and preliminary effectiveness of an intervention that combines remote monitoring with a digital platform and community health worker (CHW) social needs care for patients with HF who are transitioning from hospital to home. Given the elevated morbidity and mortality, identifying comprehensive and patient-centered interventions at the time of hospital care transitions that can improve clinical outcomes, impact cost, and augment the quality of care for this cohort is a priority. METHODS: This trial randomized adult inpatient participants (n=50) with a diagnosis of HF receiving care at a single academic health care institution to the 30-day intervention (digital platform+CHW pairing+usual care) or the 30-day control (CHW pairing+usual care) arms. All study participants completed baseline questionnaires and 30-day exit interviews and questionnaires. The primary outcomes will be acceptability, feasibility, and preliminary effectiveness. RESULTS: This clinical trial opened for enrollment in September 2022 and was completed in June 2023. Initial results are expected to be published in the spring of 2024, and analysis is currently underway. Feasibility outcome measures will include the use rates of the biometric sensor (average hours per day), the digital blood pressure monitor (average times per day), the weight scale (average times per day), and the completion of the symptoms questionnaire (average times per day). The acceptability outcome will be measured by the patients' response to the truthfulness of the statement that they would be willing to use the digital platform in the future (response options: very true, somewhat true, or not true). Preliminary effectiveness will be measured by tracking 30-day clinical outcomes (hospital readmissions, emergency room visits, and missed primary care and cardiology appointments). CONCLUSIONS: The results of this investigation are expected to contribute to our understanding of the use of digital interventions and the implementation of supportive home-based social needs care to enhance engagement and the potential effectiveness of clinically focused digital platforms. These results may inform the construction of a future multi-institutional trial designed to test the true effectiveness of this intervention in HF. TRIAL REGISTRATION: ClinicalTrials.gov NCT05130008; https://clinicaltrials.gov/study/NCT05130008. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55687.

Sports Participation, Frequency, and Competence Differentially Impact Youth Depressive, Anxious, and Somatic Symptoms: Gender, Neighborhood, and Sports Type Effects.

Mental health problems are prevalent in adolescence, but sports participation may offer mental health benefits through this developmental period and beyond. Characteristics of sports participation including perceived frequency and competence may differentially predict adolescent depressive, anxious, and somatic symptoms over time and results may further vary according to gender, neighborhood context, and type of sport engagement. Data were collected at two time-points six months apart from an ethnically diverse sample of adolescents (N = 183, female = 51%). Youth sports participation and symptoms were measured using the Youth Self-Report (YSR; Achenbach & Rescorla, 2001). Path analyses were used to test for main and moderating effects of sports on symptoms. Results showed that categorical sports participation did not prospectively predict any type of internalizing symptoms, but perceived frequency and competence did. Competence predicted lower levels of symptoms while frequency predicted higher levels of symptoms. These results were further moderated by gender, neighborhood, and sport type such that frequency and competence predicted symptoms for girls and for youth in more resourced neighborhoods and who participated in team sports. These findings highlight the impact that sports participation can have on adolescent mental health in an ethnically diverse sample of urban youth.

Feasibility and Acceptability of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Single-Arm Pilot Study.

BACKGROUND: Heart failure (HF) is one of the leading causes of hospital admissions. Clinical (eg, complex comorbidities and low ejection fraction) and social needs factors (eg, access to transportation, food security, and housing security) have both contributed to hospitalizations, emphasizing the importance of increased clinical and social needs support at home. Digital platforms designed for remote monitoring of HF can improve clinical outcomes, but their effectiveness has been limited by patient barriers such as lack of familiarity with technology and unmet social care needs. To address these barriers, this study explored combining a digital platform with community health worker (CHW) social needs care for patients with HF. OBJECTIVE: We aim to determine the feasibility and acceptability of an intervention combining digital platform use and CHW social needs care for patients with HF. METHODS: Adults (aged ≥18 years) with HF receiving care at a single health care institution and with a history of hospital admission in the previous 12 months were enrolled in a single-arm pilot study from July to November 2021 (N=14). The 30-day intervention used a digital platform within a mobile app that included symptom questionnaire and educational videos connected to a biometric sensor (tracking heart rate, oxygenation, and steps taken), a digital weight scale, and a digital blood pressure monitor. All patients were paired with a CHW who had access to the digital platform data. A CHW provided routine phone calls to patients throughout the study period to discuss their biometric data and to address barriers to any social needs. Feasibility outcomes were patient use of the platform and engagement with the CHW. The acceptability outcome was patient willingness to use the intervention again. RESULTS: Participants (N=14) were 67.7 (SD 11.7) years old; 8 (57.1%) were women, and 7 (50%) were insured by Medicare. Participants wore the sensor for 82.2% (n=24.66) of study days with an average of 13.5 (SD 2.1) hours per day. Participants used the digital blood pressure monitor and digital weight scale for an average of 1.2 (SD 0.17) times per day and 1.1 (SD 0.12) times per day, respectively. All participants completed the symptom questionnaire on at least 71% (n=21.3) of study days; 11 (78.6%) participants had ≥3 CHW interactions, and 11 (78.6%) indicated that if given the opportunity, they would use the platform again in the future. Exit interviews found that despite some platform "glitches," participants generally found the remote monitoring platform to be "helpful" and "motivating." CONCLUSIONS: A novel intervention combining a digital platform with CHW social needs care for patients with HF was feasible and acceptable. The majority of participants were engaged throughout the study and indicated their willingness to use the intervention again. A future clinical trial is needed to determine the effectiveness of this intervention.

An Adaptive Healthcare Organization Can Effectively Respond to Medical Crises.

Healthcare systems are challenged by unexpected medical crises. Established frameworks and approaches to guide healthcare institutions during these crises are limited in their effectiveness. We propose an Adaptive Healthcare Organization (AHO) system as a framework focused on the dynamic nature of healthcare delivery. Based on seven key capabilities, the AHO framework can guide single and multi-institutional healthcare organizations to adapt in real time to an unexpected medical crisis and improve their efficiency and effectiveness.

Natural mentoring among college students of color: Considerations for their ethnic-racial identity and psychological well-being.

This study examined: (a) the roles of ethnic-racial similarity between mentors and mentees and mentors' support for ethnic-racial identity (ERI) in mentees' ERI private regard, (b) the roles of ethnic-racial similarity and ERI support in mentees' psychological well-being, and (c) the indirect effects of ethnic-racial similarity and ERI support on psychological well-being via private regard. Participants were 231 college students of color who completed a survey and reported having a natural mentor. Path analyses were conducted to test the hypothesized model. More support for ERI was significantly associated with higher private regard and higher self-esteem. Higher ethnic-racial similarity was significantly related to higher psychological distress and higher self-esteem. An indirect effect was found between ERI support and ethnic-racial similarity and psychological well-being via private regard. The findings fill a gap in the literature on ethnic-racial processes in mentoring critical to the development of college students of color.

Integration of patient experience factors improves readmission prediction.

Many readmission prediction models have marginal accuracy and are based on clinical and demographic data that exclude patient response data. The objective of this study was to evaluate the accuracy of a 30-day hospital readmission prediction model that incorporates patient response data capturing the patient experience. This was a prospective cohort study of 30-day hospital readmissions. A logistic regression model to predict readmission risk was created using patient responses obtained during interviewer-administered questionnaires as well as demographic and clinical data. Participants (N = 846) were admitted to 2 inpatient adult medicine units at Massachusetts General Hospital from 2012 to 2016. The primary outcome was the accuracy (measured by receiver operating characteristic) of a 30-day readmission risk prediction model. Secondary analyses included a readmission-focused factor analysis of individual versus collective patient experience questions. Of 1754 eligible participants, 846 (48%) were enrolled and 201 (23.8%) had a 30-day readmission. Demographic factors had an accuracy of 0.56 (confidence interval [CI], 0.50-0.62), clinical disease factors had an accuracy of 0.59 (CI, 0.54-0.65), and the patient experience factors had an accuracy of 0.60 (CI, 0.56-0.64). Taken together, their combined accuracy of receiver operating characteristic = 0.78 (CI, 0.74-0.82) was significantly more accurate than these factors were individually. The individual accuracy of patient experience, demographic, and clinical data was relatively poor and consistent with other risk prediction models. The combination of the 3 types of data significantly improved the ability to predict 30-day readmissions. This study suggests that more accurate 30-day readmission risk prediction models can be generated by including information about the patient experience.

Patient Perspectives on Home-Based Care and Remote Monitoring in Heart Failure: A Qualitative Study.

INTRODUCTION: As individual interventions, home-based care and remote monitoring have been shown to help prevent hospitalizations for those with heart failure (HF) although both interventions have been limited by scalability and technical constraints, respectively. Few qualitative studies have explored patient perspectives, including acceptability, barriers, and facilitators of HF care inclusive of both interventions. The objective of this study is to explore patient perceptions on HF management at home, the use of home-based remote monitoring, and the value of home-based care. METHODS: Qualitative interviews (N = 27) were conducted via phone (12/2020-3/2021) with adults with HF. A framework analysis was used to identify main themes along with verbatim transcription for coding and analyses. There were 5 key interview domains: general HF knowledge, perceptions of the value of home-based care, unmet needs related to the social determinants of health (SDOH), experience with healthcare technology and remote monitoring, and challenges in HF home management. RESULTS: Five major themes emerged. Patients reported: (1) home-based care plan instructions are understood; (2) following medication, diet, and fluid management instructions are challenging due to difficult adherence to and implementation at home; (3) financial limitations serve as barriers to acquiring healthy food; (4) home-based support is a valuable component of managing medications, diet, and fluid; (5) despite limited use of technology, strong willingness to use remote monitoring is present amongst most. CONCLUSIONS: Participants reported understanding of care plan instructions and challenges adhering to care plans at home. Barriers included needing more home-based support for medications, diet, and fluid management and requiring additional assistance with financial barriers related to unmet social needs. A combined intervention inclusive of remote monitoring and home-based support has potential to improve home-based strategies and clinical outcomes for HF patients.

Meeting the Needs of Vulnerable Primary Care Patients Without COVID-19 Infections During the Pandemic: Observations From a Community Health Worker Lens.

BACKGROUND: During the height of the COVID-19 pandemic, healthcare systems were forced to focus their efforts on the rapidly rising numbers of patients contracting COVID-19. Although a myriad of publications focused on COVID-19 care have rapidly emerged, few have studied the impact of the pandemic on care received by patients without COVID-19. OBJECTIVES: To identify the experiences of Medicaid patients without COVID-19 related illness during the pandemic through the lens of community health worker outreach. METHODS: From July 15, 2020 through February 1, 2021 patients previously enrolled in the C-CAT initiative were contacted by telephone for patient check-ins by CHW staff. RESULTS: A total of 24 patients were contacted telephonically. Six patients had no active needs. Of the remaining patients, 70% of participants indicated that they had been unable to communicate with PCP or physician specialist care teams since the beginning of the pandemic and requested assistance from our CHW. Resulting unmet needs included the inability to obtain prescriptions drugs, necessary medical equipment, or supplies. CONCLUSION: The shift to COVID-19 focused care during the pandemic limited access to primary care for patients without COVID-19. The identified unmet patient needs included obtaining prescription medications, acute on chronic clinical condition management, healthcare services at home, and connection to social services. CHWs are uniquely positioned to assist patients as they connect to necessary clinical care, whether it be virtual or in-person, as they recover from the pandemic experience.

The Reciprocal Effects of Language Proficiency and Depression among Low-Income Latinx Youth.

Extant research associates language with essential social and emotional processes. Although the risk for depression among Latinx youth in the United States is well documented, the link between their language proficiency and depressive symptoms remains poorly understood. Further, research employing standardized language assessments with Latinx early adolescents is scarce and reciprocal associations between language proficiency and depressive symptoms have not been examined. This longitudinal study addressed these gaps by investigating the relation between language proficiency and depression in a sample of 218 dual language Latinx students of predominantly low-income backgrounds (Mage = 12.1, SD = 1.1; 49.1% female) recruited from seven public schools in a large city in the Midwest of the United States. Language proficiency in English and Spanish was assessed using the Woodcock-Muñoz Language Survey-Revised and depressive symptoms were assessed using the Children's Depression Inventory. Paired samples t-tests showed lower than expected growth in English vocabulary and higher than expected growth in the ability to reason using lexical knowledge in Spanish over a one-year period. Cross-lagged panel analyses (χ2 (99) = 211.19, p < .001, CFI = .93, TLI = .92, RMSEA = .07 (90% CI [.06, .09])) indicated that growth in English language proficiency is predictive of decreased depressive symptoms. Likewise, increases in depressive symptoms are predictive of decreased English language proficiency. Results have important implications for the design of appropriate psychological interventions and sensible educational policies for students of linguistic minority backgrounds.

Examining current physical activity interventions in Black school-age children and parents: A systematic review.

Obesity is prevalent in Black children and adults; increasing physical activity (PA) can aid in reducing childhood obesity in both age groups. The purpose of this systematic review is to examine current research on PA interventions in school-age Black children. Adhering to PRISMA guidelines, a systematic search was conducted in six databases for PA interventions in Black children. A total of 13 articles met inclusion criteria (n = 7 randomized controlled trial, n = 5 quasi-experimental, n = 1 cross-sectional). The majority of the articles were on a combination of diet and PA programs (n = 9). Four articles targeted PA and parental role modeling of PA as the outcome showing positive intervention effects. Nine additional studies included PA as an outcome variable along with at least one additional obesity-related predictor. PA interventions for Black school-age children typically use a parent-child dyadic approach (n = 13), are guided by theory (n = 11) and are high quality. However, continued investigation is warranted to draw definitive conclusions and determine how to best involve parents within the PA interventions. Theory-driven higher quality trials that clearly describe the structured PA component and outcomes among Black parent-child dyads are needed.

Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS: A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS: The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS: Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.

Digital Health Intervention in Acute Myocardial Infarction.

BACKGROUND: Thirty-day readmissions among patients with acute myocardial infarction (AMI) contribute to the US health care burden of preventable complications and costs. Digital health interventions (DHIs) may improve patient health care self-management and outcomes. We aimed to determine if patients with AMI using a DHI have lower 30-day unplanned all-cause readmissions than a historical control. METHODS: This nonrandomized controlled trial with a historical control, conducted at 4 US hospitals from 2015 to 2019, included 1064 patients with AMI (DHI n=200, control n=864). The DHI integrated a smartphone application, smartwatch, and blood pressure monitor to support guideline-directed care during hospitalization and through 30-days post-discharge via (1) medication reminders, (2) vital sign and activity tracking, (3) education, and (4) outpatient care coordination. The Patient Activation Measure assessed patient knowledge, skills, and confidence for health care self-management. All-cause 30-day readmissions were measured through administrative databases. Propensity score-adjusted Cox proportional hazard models estimated hazard ratios of readmission for the DHI group relative to the control group. RESULTS: Following propensity score adjustment, baseline characteristics were well-balanced between the DHI versus control patients (standardized differences <0.07), including a mean age of 59.3 versus 60.1 years, 30% versus 29% Women, 70% versus 70% White, 54% versus 54% with private insurance, 61% versus 60% patients with a non ST-elevation myocardial infarction, and 15% versus 15% with high comorbidity burden. DHI patients were predominantly in the highest levels of patient activation for health care self-management (mean score 71.7±16.6 at 30 days). The DHI group had fewer all-cause 30-day readmissions than the control group (6.5% versus 16.8%, respectively). Adjusting for hospital site and a propensity score inclusive of age, sex, race, AMI type, comorbidities, and 6 additional confounding factors, the DHI group had a 52% lower risk for all-cause 30-day readmissions (hazard ratio, 0.48 [95% CI, 0.26-0.88]). Similar results were obtained in a sensitivity analysis employing propensity matching. CONCLUSIONS: Our results suggest that in patients with AMI, the DHI may be associated with high patient activation for health care self-management and lower risk of all-cause unplanned 30-day readmissions. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03760796.

The role of race, ethnicity, and language in care transitions.

OBJECTIVES: To identify areas where transition from hospital to community could be improved, with a special focus on racial, ethnic, and language differences. STUDY DESIGN: A cross-sectional survey administered by postal mail and bilingual telephone interviewers. METHODS: Patients were randomly selected within strata by race, ethnicity, and language proficiency. A total of 224 patients (response rate: 63.5%) who had recently experienced a hospital stay completed the survey. RESULTS: Overall, 1 in 4 patients were alone at discharge. More than half of patients with limited English proficiency reported lack of access to medical interpreters and translated materials. We noted significant differences by race, ethnicity, and language in technology access and in patient-reported worries in the posthospital period. Hispanic or Latino patients and patients with limited English proficiency were less likely to report access to a computer and less likely to access the Patient Gateway portal. Black or African American patients were also less likely to use the Patient Gateway portal. Asian patients were more likely to be worried about getting home health services. CONCLUSIONS: Our findings highlight the enhanced difficulties that diverse patients may experience when transitioning from hospital to community-based settings. When considering how to best address the complex needs of diverse populations, interventions must be sensitive to the presence or absence of others, potential digital divides, and medical interpretation.

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial.

Importance: Value-based care within accountable care organizations (ACOs) has magnified the importance of reducing preventable hospital readmissions. Community health worker (CHW) interventions may address patients' unmet psychosocial and clinical care needs but have been underused in inpatient and postdischarge care. Objective: To determine if pairing hospitalized patients with ACO insurance with CHWs would reduce 30-day readmission rates. Design, Setting, and Participants: This randomized clinical trial was conducted in 6 general medicine hospital units within 1 academic medical center in Boston, Massachusetts. Participants included adults hospitalized from April 1, 2017, through March 31, 2019, who had ACO insurance and were at risk for 30-day readmission based on a hospital readmission algorithm. The main inclusion criterion was frequency of prior nonelective hospitalizations (≥2 in the past 3 months or ≥3 in the 12 months prior to enrollment). Data were analyzed from February 1, 2018, through March 3, 2021. Intervention: CHWs met with intervention participants prior to discharge and maintained contact for 30 days postdischarge to assist participants with clinical access and social resources via telephone calls, text messages, and field visits. CHWs additionally provided psychosocial support and health coaching, using motivational interviewing, goal-setting, and other behavioral strategies. The control group received usual care, which included routine care from primary care clinics and any outpatient referrals made by hospital case management or social work at the time of discharge. Main Outcomes and Measures: The primary outcome was 30-day hospital readmissions. Secondary outcomes included 30-day missed primary care physician or specialty appointments. Results: A total of 573 participants were enrolled, and 550 participants (mean [SD] age, 70.1 [15.7] years; 266 [48.4%] women) were included in analysis, with 277 participants randomized to the intervention group and 273 participants randomized to the control group. At baseline, participants had a mean (SD) of 3 (0.8) hospitalizations in the prior 12 months. There were 432 participants (78.5%) discharged home and 127 participants (23.1%) discharged to a short rehabilitation stay prior to returning home. Compared with participants in the control group, participants in the intervention group were less likely to be readmitted within 30 days (odds ratio [OR], 0.44; 95% CI, 0.28-0.90) and to miss clinic appointments within 30 days (OR, 0.56; 95% CI, 0.38-0.81). A post hoc subgroup analysis showed that compared with control participants, intervention participants discharged to rehabilitation had a reduction in readmissions (OR, 0.09; 95% CI, 0.03-0.31), but there was no significant reduction for those discharged home (OR, 0.68; 95% CI, 0.41-1.12). Conclusions and Relevance: This randomized clinical trial found that pairing ACO-insured inpatient adults with CHWs reduced readmissions and missed outpatient visits 30 days postdischarge. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home. Trial Registration: ClinicalTrials.gov Identifier: NCT03085264.

Social Factors and Patient Perceptions Associated With Preventable Hospital Readmissions.

BACKGROUND: Preventable hospital readmissions are costly and erode the quality of care delivery. Few efforts to incorporate the patient perspectives and social factors associated with readmission preventability exist. OBJECTIVE: To identify patient perceptions and social barriers to care related to readmission. METHODS: Prospective cohort study of 202 respondents readmitted within 30 days of hospital discharge from 2 inpatient adult medicine units at Massachusetts General Hospital, Boston, Massachusetts between January 2012 and January 2016. RESULTS: Few participants indicated that their readmission was due to unattainable health care after discharge. Almost half indicated that they needed more general assistance to stay well outside the hospital. Those reporting a barrier related to at least 2 measures of social determinants of health were more likely to have preventable readmissions (34% vs 17%, P = .006). Participants with a history of homelessness or substance use disorder were more likely to have preventable readmissions (44% vs 20%, P = .04 and 32% vs 18%, P = .03, respectively). CONCLUSION: Strengthening nonmedical support systems and general social policy may be required to reduce preventable readmissions.