SHM Converge Scientific Abstract ePoster Gallery-Implementing Inpatient Screening for Unmet Social Needs in an Amc

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This study examined the feasibility of screening for social needs during an inpatient internal medicine hospitalization, an area less studied than outpatient primary care screening. Because social determinants of health strongly affect outcomes, the team tested whether hospitalized patients could be screened for unmet needs and whether positive screens could be acted on by the care team.<br /><br />The project took place on a 25-bed Massachusetts General Hospital medical unit from December 2021 to March 2022. Adult, English-speaking, non-LTAC, non-hospice patients were screened at the bedside by nurses using an SDOH questionnaire (n=88). Positive results were shared with nursing and case management, followed by chart review to assess documentation and response.<br /><br />Participants were mostly older adults (mean age 67), and the cohort was 78% White, 45% female. Common admission reasons included infectious disease, GI bleed, cirrhosis, COPD/asthma, and DVT/PE. Many patients reported recent or ongoing resource needs, including food, housing, transportation, medication costs, and utility bills.<br /><br />Key findings:<br />- 25% of patients identified unmet needs not previously known to the clinical team.<br />- 98% of patients with unmet social needs had a social work consult placed within 2 days.<br />- Patients with at least one unmet social need had a baseline readmission rate of 29% and were 1.4 times more likely to be readmitted.<br />- Only 6% of social needs were reflected in discharge summaries.<br /><br />The study concluded that inpatient units may be an underused setting for universal social needs screening, but successful implementation requires better workflow integration, dedicated screening resources, stronger partnerships with community agencies, and improved EHR documentation. Limitations included exclusion of non-English-speaking patients, a single-unit setting, and the small sample size.

Asset Subtitle

Jocelyn A. Carter

Meta Tag

Author List Ada A. Amobi, Brammy Rajakumar, Jocelyn A. Carter, Sammer Marzouk

Category Innovations

Concept Social Determinants of Health

Concept Unmet Social Needs

Concept Social Needs Screening

Concept Readmission

Concept Inpatient Outcomes

Distinguished Non-Finalist

Presenter Organization Massachusetts General Hospital

Presenting Author Jocelyn A. Carter

Track Transitions of Care

Keywords

social needs screening

inpatient hospitalization

social determinants of health

unmet needs

internal medicine

social work consult

readmission risk

EHR documentation

resource insecurity

hospital workflow

Social Determinants of Health

Unmet Social Needs

Social Needs Screening

Readmission

Inpatient Outcomes