Emergency room (ER) visits are a significant concern for assisted living facilities, often signaling preventable issues related to chronic disease management, social isolation, or gaps in care coordination. Leveraging Social Determinants of Health (SDOH) metrics offers a powerful opportunity to address these challenges, leading to improved resident outcomes and reduced strain on healthcare systems. By integrating SDOH insights into operational strategies, assisted living facilities can proactively identify risks and implement solutions that decrease unnecessary ER visits.
The Link Between SDOH and ER Visits
Social Determinants of Health encompass the non-medical factors that influence health outcomes, such as access to nutritious food, transportation, and social support systems. For older adults in assisted living facilities, these determinants often intersect with health conditions, contributing to preventable emergencies. Research has consistently shown that addressing SDOH can improve overall health outcomes and reduce healthcare utilization.
For instance, a study published in the Journal of the American Geriatrics Society found that older adults experiencing food insecurity were significantly more likely to have multiple chronic conditions, increasing their likelihood of ER visits (Berkowitz et al., 2019). Similarly, limited access to transportation and social isolation have been directly linked to delayed care, poor chronic disease management, and increased emergency healthcare usage.
Using SDOH Metrics to Identify Risks
- Tracking Social Isolation and Loneliness
Social isolation is a prevalent issue among older adults in assisted living settings, often exacerbating mental health challenges and leading to neglect of physical health. Facilities can use validated tools such as the UCLA Loneliness Scale to monitor residents’ social engagement levels.
Actionable Insight: If metrics indicate high levels of isolation, facilities can implement group activities, intergenerational programs, or technology-based solutions to encourage interaction.
- Monitoring Nutritional Health
Food insecurity and malnutrition are critical determinants that increase susceptibility to chronic diseases and infections. Metrics like body mass index (BMI) trends, meal consumption rates, and resident feedback can identify at-risk individuals.
Actionable Insight: Introducing on-site nutritionists or improving meal planning can address nutritional gaps and reduce emergency incidents related to malnutrition.
- Assessing Transportation Needs
For assisted living residents who require transportation for medical appointments or social activities, barriers in this area can lead to delayed care and preventable emergencies. Tracking transportation availability and usage can highlight gaps.
Actionable Insight: Partnering with local transit services or offering facility-owned transportation for appointments can improve access to preventive care, reducing reliance on emergency services.
Case Study: Reducing ER Visits Through SDOH Integration
A mid-sized assisted living facility in the Midwest faced rising ER visits, primarily due to unmanaged chronic conditions and late recognition of health declines. After implementing an SDOH-based approach, they achieved a 25% reduction in ER visits within one year.
Steps Taken:
- Baseline Assessment: The facility began by collecting SDOH data on social isolation, nutrition, transportation access, and caregiver support.
- Interventions:
- Launched a “Community Connection” program, pairing residents with local volunteers for weekly social visits.
- Introduced regular nutrition workshops and improved dining options with input from residents.
- Partnered with a local health system to offer telehealth services, reducing the need for emergency care.
- Monitoring: Residents’ progress was tracked monthly, focusing on hospitalizations and feedback from participants.
Outcomes:
- A significant drop in ER visits, especially among residents who previously reported high levels of social isolation.
- Improved resident satisfaction and perceived quality of life.
- Enhanced relationships with local healthcare providers and community organizations.
The Role of Technology and Collaboration
Technology plays a critical role in using SDOH metrics to reduce ER visits. Digital health platforms can aggregate SDOH data, track trends, and alert staff to emerging risks. For example, predictive analytics can identify residents likely to experience a decline in health based on a combination of medical history and SDOH factors.
Collaboration with external organizations, such as local food banks, transit authorities, and mental health services, further strengthens the ability to address these determinants. Assisted living facilities that integrate community resources into their care models can provide more comprehensive support, ensuring residents’ needs are met before they escalate into emergencies.
Call to Action for Assisted Living Facilities
Reducing ER visits in assisted living facilities requires a proactive and data-driven approach. By focusing on SDOH metrics, facilities can anticipate risks, improve resident care, and reduce avoidable healthcare utilization.
Next Steps:
- Begin collecting SDOH data as part of routine assessments.
- Train staff to recognize and address SDOH-related risks.
- Partner with local organizations to expand resources for residents.
- Use technology to track progress and refine interventions over time.
By prioritizing SDOH, assisted living facilities can create healthier environments where residents thrive, emergencies are minimized, and care is both efficient and compassionate.
Reference:
Berkowitz, S. A., Kondo, K., Edwards, S. T., et al. (2019). Food insecurity, chronic disease, and health among older adults in the United States. Journal of the American Geriatrics Society, 67(3), 421–428. https://doi.org/10.1111/jgs.15722
