Vulnerable Patient Intensified Protocol to Reduce Readmission Disparities After Coronary Artery Bypass Grafting: Design, Implementation, and Lessons Learned from a Quality Initiative

Our findings demonstrate that a social-risk-informed care model is feasible in a hospital-based CABG readmission prevention program. Vulnerable patients can be identified through the standardized collection of SDOH, insurance status, and race/ethnicity data. Insurance status may be an excellent proxy to ascertain social risk and is readily accessible. Other healthcare organizations should consider regional demographics for possible SDOH risk. Our findings may support other initiatives to improve the collection of SDOH and demographic information. The VPIP CABG readmission prevention program could be adapted for other conditions and settings to achieve equitable care.