Keeping vulnerable populations out of the hospital

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The conditions in which you live, learn, work and play can all affect your overall health, according to the Centers for Disease Control and Prevention.

USF College of Public Health doctoral student Nnadozie Emechebe is lead author on a recent study published in The American Journal of Managed Care examining how the social determinants of health impacted vulnerable populations being admitted to the hospital for care.

Doctoral student Nnadozie Emechebe, B. Pharm, MPH. (Photo by Caitlin Keough)

In, “Passive Social Health Surveillance and Inpatient Readmissions,” Emechebe looked at how call-center referral data managed by WellCare Health Plans—a managed care organization—to determine if there was an association between self-reported social needs and hospital readmissions.

“To provide some context, WellCare Health Plans provide referrals to community-based social service organizations to individuals who contact the call center and report a social need,” Emechebe said. “These social needs include financial assistance to pay for rent and utilities, food programs, assistance with medication, housing support, free or low-cost transportation, among others.”

The study attempted to highlight the potential of utilizing call-center referral data, a system Emechebe said we like to call passive social health surveillance, as a compliment to social needs screening to identify individuals with unmet social needs.

According to Emechebe, health care plans receive a medical claim each time its members interact with the health care system.

This study linked referral and claims data for 19,817 individuals to examine the odds of inpatient readmissions for individuals with self-identified social needs, such as food and housing insecurity, compared with those without self-identified needs.

Results showed that individuals with self-identified social needs had higher odds of 30-day inpatient readmissions.

“Thus, by linking data on social needs with medical claims data, we were able to examine whether the identified social needs were associated with hospital readmissions,” he said.

His findings indicated that a managed care organization created a passive social health surveillance program to more effectively integrate medial and social care, but that understanding individual-level social health needs is paramount.  

“While the association of social needs on health outcomes is well established, the integration of social care into medical care remains a challenge because it’s difficult to collect this information,” he said. This study highlights a potential tactic non-clinical organizations can deploy to identify individuals with these social needs.

The next step would be to determine the benefit of including social needs data in predictive models for readmission, according to Emechebe.

(Photo source: Wikimedia Commons)

“These models are set up to determine individuals who could be at risk of readmissions and, at the moment, they typically include patient demographics and some clinical information,” he said. “Therefore, it would be important to examine if incorporating data on social needs provides additional predictive power to these models.”

Emechebe, who is earning his PhD in eepidemiology, said he’s grateful his work is published.

“It’s always a proud moment to see months of hard work bear fruit. However, this is special because it’s my first published work as a lead author and I’m grateful to Dr. Pruitt for the opportunity and mentorship,” he said.

He hopes his research sheds some light on the need for non-clinical organizations to invest in addressing unmet social needs.

“That could consequently improve the health of individuals with these unmet non-medical needs and increase the efficiency of our health system,” he said.

Story by Anna Mayor, USF College of Public Health

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