Addressing Patients’ Social Needs after Hospitalization

Imagine being discharged from the hospital to a two-room apartment badly in need of repair. Your electricity has been cut off and you can barely remember the discharge instructions. You were told to see a specialist in a week, but it will take you 90 minutes one-way on public transportation to get there. Confused about follow-up and juggling the complexities of life, what do you do?

Patients with significant social needs are at risk for poorer health outcomes after hospital discharge. Often social needs go unaddressed during hospitalization as medical concerns take priority, yet these unaddressed social needs may lead to readmissions or unnecessary emergency department (ED) use. With funding from the Leonard Davis Institute and Penn Center for Health Care Innovation, researchers at Penn Nursing and an interdisciplinary team of clinicians at Penn Presbyterian developed an intervention to improve post-hospitalization outcomes among these patients.