Decreasing Hospital Readmissions: Addressing SDoH and Disparities in the Behavioral Health Population

The McNemar Test determined that there was a statistically significant difference between the readmission rates of patients not enrolled in the TOC program and those that were enrolled. The readmission rate for those not enrolled was 26% and for those enrolled was 16% with a P<0.005. Behavioral health (BH) conditions are on the rise while access to care becomes increasingly difficult. Researchers have found significant trends regarding the BH of Americans leading to an increase in hospital admissions. According to the survey conducted by The National Center for Health Statistics, 40% of Americans reported BH conditions in 2020 compared to only 11% in 2019. Unfortunately, the numbers are much higher in low-income groups. This project decreased hospital readmissions across 9 acute care facilities from 26% to 16% and addressed the SDoH needs that increase the readmission risk for uninsured and underinsured patients.

Problem: Health inequities disproportionately impact underserved communities. This project improves the care provided to BH patients who are admitted to 9 hospitals in the largest healthcare network. After the COVID pandemic, the volume of patients with acute Serious Mental Illness (SMI), substance use, and alcohol use disorders increased creating an urgency.

Measurement: A fishbone diagram was used to visualize brainstorming ideas and examine cause-and-effect relationships. During this time the team was able to determine the reason why patients were getting readmitted. The information was also used to develop an improvement plan to address the needs identified.

Analysis: SPSS software was used to analyze the data and the McNemar test was used to analyze paired nominal data non-parametrically. The test involved a dichotomous nominal variable and an independent variable with two dependent groups. A correlation coefficient was calculated to determine significance.

Implementation: A TOC model to identify, enrolled, and followed patients was created. The program offers interventions like coordination, transportation, medications, calls, equipment, etc. Several obstacles were overcome including leadership engagement, establishing trust, and managing resources. This project can be duplicated by following the workflow that will be shared in this model.

Research Director at HMH
Research Director – HMH

Speaker Type: 60 Minute Session On-Demand

Clinical Lead Manager at HMH
Clinical Lead Manager – HMH

Speaker Type: 60 Minute Session On-Demand

Director of Community Health Quality Improvement at HMH
Director of Community Health Quality Improvement – HMH

Speaker Type: 60 Minute Session On-Demand

Senior Vice President and Associate Chief Quality Officer at HMH
Senior Vice President and Associate Chief Quality Officer – HMH

Speaker Type: 60 Minute Session On-Demand