Social determinants of health have long been recognized as crucial factors in patient outcomes, but their integration into readmission prevention strategies has been slow. Recent studies, however, are changing this landscape dramatically. A 2024 study published in the Journal of General Internal Medicine found that screening clinic patients for SDOH and connecting them to community services during post-hospital care was associated with significant reductions in hospital readmissions
The 5-Minute Connection: A Case Study
At Chicago’s Southland Coalition for Transition Care (CSCTC), a revolutionary program has demonstrated the power of addressing SDOH through brief but meaningful patient interactions. The program, which utilized social workers to manage care transitions, reduced 30-day readmission rates by an impressive 14% or more
Case Study: Mrs. Johnson’s Journey
Mrs. Johnson, a 72-year-old African American woman with congestive heart failure, was a frequent flyer at Chicago Memorial Hospital. Despite receiving excellent medical care, she found herself back in the emergency room every few weeks. That changed when she encountered the CSCTC program.During a 5-minute conversation with a social worker, Mrs. Johnson revealed that she struggled to afford her medications and often had to choose between buying food and filling her prescriptions. Additionally, her apartment building’s elevator was frequently out of order, making it difficult for her to attend follow-up appointments.Armed with this information, the CSCTC team:
- Connected Mrs. Johnson with a prescription assistance program
- Arranged for meal delivery services
- Coordinated with her landlord to prioritize elevator repairs
- Set up telehealth appointments for days when leaving home was challenging
The result? Mrs. Johnson hasn’t been readmitted in over six months, a dramatic improvement in her quality of life and a significant cost saving for the healthcare system.
Implementing SDOH Strategies in Your Facility
To replicate the success of programs like CSCTC, healthcare facilities should consider the following steps:
- Train staff in SDOH assessment: Equip your team with the skills to quickly identify social and economic factors affecting patient health.
- Develop community partnerships: Create a network of local organizations that can address various social needs, from housing to food security.
- Implement brief, targeted assessments: Design short questionnaires that can be completed in under 5 minutes to capture crucial SDOH information.
- Create a resource database: Maintain an up-to-date list of community resources that can be quickly accessed to support patients.
- Follow up post-discharge: Implement a system for checking in with patients after they leave the hospital to ensure their social needs are being met.
The Impact on Readmission Rates
By addressing SDOH and taking the time to truly understand patient circumstances, healthcare facilities can see dramatic improvements in readmission rates. The CSCTC program’s success is not an isolated incident. A study published in 2021 found that addressing SDOH factors could reduce 30-day readmissions among Medicare beneficiaries with heart failure by up to 58%
As we move forward in 2025, it’s clear that the future of healthcare lies not just in medical interventions, but in understanding and addressing the social fabric of our patients’ lives. By taking just 5 minutes to connect and leveraging SDOH strategies, we can dramatically reduce readmission rates, improve patient outcomes, and create a more compassionate, effective healthcare system for all.