Characteristics of hospital and health system initiatives to address social determinants of health in the United States: a scoping review of the peer-reviewed literature.

Background: Despite the incentives and provisions created for hospitals by the US Affordable Care Act related to value-based payment and community health needs assessments, concerns remain regarding the adequacy and distribution of hospital efforts to address SDOH. This scoping review of the peer-reviewed literature identifies the key characteristics of hospital/health system initiatives to address SDOH in the US, to gain insight into the progress and gaps. Methods: PRISMA-ScR criteria were used to inform a scoping review of the literature. The article search was guided by an integrated framework of Healthy People SDOH domains and industry recommended SDOH types for hospitals. Three academic databases were searched for eligible articles from 1 January 2018 to 30 June 2023. Database searches yielded 3,027 articles, of which 70 peer-reviewed articles met the eligibility criteria for the review. Results: Most articles (73%) were published during or after 2020 and 37% were based in Northeast US. More initiatives were undertaken by academic health centers (34%) compared to safety-net facilities (16%). Most (79%) were research initiatives, including clinical trials (40%). Only 34% of all initiatives used the EHR to collect SDOH data. Most initiatives (73%) addressed two or more types of SDOH, e.g., food and housing. A majority (74%) were downstream initiatives to address individual health-related social needs (HRSNs). Only 9% were upstream efforts to address community-level structural SDOH, e.g., housing investments. Most initiatives (74%) involved hot spotting to target HRSNs of high-risk patients, while 26% relied on screening and referral. Most initiatives (60%) relied on internal capacity vs. community partnerships (4%). Health disparities received limited attention (11%). Challenges included implementation issues and limited evidence on the systemic impact and cost savings from interventions. Conclusion: Hospital/health system initiatives have predominantly taken the form of downstream initiatives to address HRSNs through hot-spotting or screening-and-referral. The emphasis on clinical trials coupled with lower use of EHR to collect SDOH data, limits transferability to safety-net facilities. Policymakers must create incentives for hospitals to invest in integrating SDOH data into EHR systems and harnessing community partnerships to address SDOH. Future research is needed on the systemic impact of hospital initiatives to address SDOH.

An Education In Meeting Patients Where They Live.

In Richmond, Virginia, an interprofessional group of health care students and faculty members is helping seniors solve problems early.

Characteristics of Hospital and Emergency Care Super-utilizers with Multiple Chronic Conditions.

BACKGROUND: Targeted care transitions programs may improve the value of hospital-based health care. Super-utilizing patients with multiple chronic conditions (MCC) are thought to be particularly amenable to care transitions interventions. OBJECTIVES: To identify characteristics, future utilization patterns, and health outcomes for super-utilizers with MCC. METHODS: Retrospective cohort study of patients receiving care in an urban multi-hospital system in Tennessee over 3 years. Adult patients with Medicaid or Medicare insurance, or both, MCC, and multiple hospitalizations and emergency department (ED) visits in a 6-month period were included. The primary outcome measures were numbers of hospitalizations and ED visits in the 12 months after the 6-month period of high utilization. Secondary outcomes included 30-day readmissions and discharge disposition. RESULTS: Of 1537 super-utilizing patients, 59.0% (n = 907) had at least two targeted chronic conditions. This final study cohort (n = 638) experienced a mean of 3.2 hospitalizations and 2.8 ED visits without hospitalization in the 12-month follow-up period. During follow-up, 26% experienced one or more 30-day readmission(s) within the health care system. Despite their medical complexity, 46% reported not having a regular primary care provider, and 48% had presenting pain scores ≥8/10. Only 1% of the visits to the ED were triaged as nonurgent. CONCLUSIONS: Medicare and Medicaid patients with high baseline utilization and MCC experience continued high health care utilization. Patient characteristics, future utilization patterns, and health outcomes suggest the subgroup identified is an important subgroup of super-utilizers that merits attention because they may be particularly amenable to intervention.

Early efforts to target and enroll high-risk diabetic patients into urban community-based programs.

Health care disparities in minority populations can be attributed to a number of factors, including lack of access to coordinated primary care and chronic disease management programming. Interventions using a data-centric, coordinated, multidisciplinary, team-based approach to address patients with complex chronic comorbidities have demonstrated improvements in patient outcomes. The use of hospital admission and billing data coupled with care management teams to care for high-risk patients with chronic conditions may be an effective model for improving quality of care while reducing health care costs. This article describes how Camden city, the poorest city in the nation, has made headway toward developing an integrated approach to improving care while reducing costs for the city's most vulnerable.