Social Worker Perspectives of Social Determinants of Health Related to Hospital Readmission for Chronic Illness

Unplanned or early hospital readmission have become factors used to measure standard of care in acute care settings. Because unplanned or early hospital readmission are costly, the Medicaid Hospital Readmission Reduction Program applies fines to hospitals that have early or unplanned readmissions. Though research has been conducted to identify causes and develop interventions, recent studies have not incorporated social determinants of health (SDOH). The objective of this qualitative study was to examine the impact of SDOH on unplanned and early readmission through the lived experience and perspective of the social worker. This qualitative study used phenomenological methodology and face to face interviews with social workers. Data were gathered from interviews with six social workers and analyzed through open coding. Four themes emerged to answer the research questions in this study: (a) language barrier, (b) family support, (c) education/health literacy, and (d) role definition/collecting SDOH. Findings showed that by incorporating SDOH into the patient care and discharge plan may have a significant impact on reducing unplanned and early hospital readmission generating positive social change to both patient outcomes and experience, and costly early readmissions. Implications for positive social change include gathering and utilizing SDOH into care plans, defining and clarifying the role and duties of the social worker, and unilaterizing health care information such as SDOH for all community care partners to access.