Dr Susan Mani: How LifeBridge Health Came to Recognize the Importance of SDOH

Looking at readmissions for congestive heart failure, we realized that the majority of our patients were being readmitted because of care coordination and social determinants of health, explained Susan Mani, MD, vice president of Clinical Transformation and Ambulatory Quality at LifeBridge Health.

Transcript

How did LifeBridge Health initially get involved with social determinants of health?

One of the things that we had to address for readmission was to really try to understand why patients were getting readmitted in the first place. When we took a look at our data, congestive heart failure patients had a particularly high rate of readmission, which really mimics what’s happening in the national sphere, as well. As we delved deep into each of our patients for their readmissions, both by interviewing them as well as looking for reason of readmission from a clinical review, what we were finding is most patients were not being readmitted because of a clinical issue that didn’t happen when they were first hospitalized. What we were finding is the vast majority of our patients were being readmitted because they really didn’t have access to care coordination, they really had issues with social determinants of health. So, that was a big aha moment for us as a health system to say, "If we don’t address this particular arena, we really aren’t going to be successful at preventing readmissions."

So, with that, and speaking with our patients and speaking with our clinicians, we really had to start thinking about transportation needs, how are our patients going to get the medications they’re prescribed, how are they going to get the kinds of foods they need to prevent them from coming back into the hospital, how are they going to be able to coordinate with the 4 or 5 different physicians that they might have to see after being in the hospital? And, even, how are they doing to manage really from a psychosocial standpoint, because they are extremely fragile after a hospital discharge from a clinical standpoint, so we really need to think about them holistically.