The Impact of Social Determinants of Health on Patient-Defined Post-Discharge Goals: Implications for Health Social Work

Background and Purpose: Increased attention has been given to the role of social determinants of health (such as race, ethnicity, education, poverty, mobility, and social isolation) on patient outcomes, notably preventable readmissions to hospitals, which have been a target of the Affordable Care Act. Through the use of health social workers, transitional care interventions have emerged as an important strategy in improving health outcomes and preventing readmissions. In order to better understand the role of these social factors on transitions of care, the goal of the present paper is to explore the experiences of transitioning from hospital to community setting for patients in their own words; specifically the barriers and supports to achieving patient-defined social goals after discharge.

Methods:In-depth, semi-structured interviews were conducted with patients discharged from a large midwestern academic tertiary-care hospital. Patients were interviewed in their home environment. Field observations of the patient’s physical and social environment were also collected at the time of the in-home interview. The interviews were audio recorded and transcribed verbatim. Interview transcripts and observational field notes were systematically coded using NVivo 9.0 software. The principles of grounded theory guided the development of themes related to patient defined post-discharge goals and perceived social barriers and supports to achieving these goals.

Findings: Thirty patients participated in the in-depth interviews (15 men, 15 women). Two-thirds were African American; 33% White American. Forty-five percent reported a household annual income under $20,000, 20% between $20,000 and $39,000, and 35% over $40,000. Just under half of the sample reported achieving a high school diploma or less (44%); while the majority of the sample reported some college (23%) or a college degree (33%). Analysis revealed that patients of both low and high educational and income levels reported multiple social determinants that affected their ability to achieve their self-defined post-discharge goals, including limited mobility, increased social and physical isolation and difficulty adjusting to a new quality of life. Patients reported challenges interacting with their grandchildren, working in their gardens, or attending family graduations contributed to a state of depression following their discharge from the hospital. Patients reported a variety of supports used during the post-discharge period to overcome these psychosocial barriers, often through the use of relationships with family, friends, and/or case management personnel. Patients who reported the presence of one or more supportive persons to help “champion” their post-discharge transition expressed satisfaction with their ability to achieve their stated goals.

Conclusions and Implications These findings suggest that the input of patients in partnership with healthcare providers, such as health social workers, who have training in assessing social determinants and designing interventions related to these factors is important when developing and implementing policies related to the effect of social factors on patient outcomes. Additionally, these results support additional attention to the standardization of data collection of these social factors by healthcare providers prior to discharge in order to identify barriers and supports to the patient’s ability to achieve their post-discharge goals.