What are the Top Common Social Determinants of Health?

The following excerpt comes from an August 9, 2017, article by Sara Heath on Patient Engagement HIT.


The social determinants of health are the factors that affect health outside of the four walls of the hospital. Housing, social services, geographical location, and education are some of the most common social determinants of health.

These factors have a significant impact on the current healthcare landscape. As more healthcare organizations deliver value-based healthcare, they are developing strategies to drive wellness care.

Organizations are catering to patient needs outside of the hospital with the goal of keeping patients healthy in the long-run. Patients who have better health support in their daily lives may be less likely to fall ill and require an expensive medical intervention.

But what are the specific social determinants of health? Which examples are most common? And how can healthcare organizations and community partners act on these determinants?

Socioeconomic factors can encompass several different social determinants of health. Poverty can limit access to healthy food, safe neighborhoods, and good schools, among other things. Most prominently, poverty affects housing.

Although individuals can lose reliable housing for a number of reasons – trauma, violence, mental illness, addiction, or another chronic health issue – poverty remains a notable factor driving homelessness.

Hospitals treating a large homeless patient population can forge partnerships with housing departments to help drive housing in the community. Housing development partners can help place individuals who are homeless in houses and offer support that will help individuals maintain that housing.

“Access to safe, quality, affordable housing – and the supports necessary to maintain that housing – constitute one of the most basic and powerful social determinants of health,” wrote the Corporation for Supportive Housing (CSH) in a 2014 white paper.

“Supportive Housing, an evidence-based practice that combines permanent affordable housing with comprehensive and flexible support services, is increasingly recognized as a cost-effective health intervention for homeless and other extremely vulnerable populations,” CSH wrote.

Expanding housing development can also help ensure that living conditions are safe, free of asbestos, lead paint, or other environmental factors that can impair health.

Housing support can also account for other poverty-driven determinants of health, CSH said.

“Furthermore, supportive housing developments often attract or directly bring critical services to resource-barren neighborhoods,” wrote CSH. “Many supportive housing developments are increasingly featuring on-site or direct linkages to gym facilities, after-school programs, recreational spaces, food pantries, recovery support groups and full-service health clinics that benefit the larger community.”

There are countless different social support and public service gaps that are significant social determinants of health, according to Healthy People 2020, a public health organization developed as a part of the Affordable Care Act.

Issues such as race disparities, lack of social support groups, weak culture of health equity, and limited public services are all drivers of adverse health events.

Populations rely on community partners that will advocate for health equity. Examples of partners include the housing department working with homeless patients or health navigators helping a population’s surplus of single mothers.

Social support also includes efforts toward desegregation, which in turn may ensure certain races are not targeted disproportionately for the social determinants of health. One example is black patients living in poverty-ridden areas at a higher rate than their white patient counterparts.

Support for the public good means ensuring public services meet all patient needs. For instance, neighborhoods that are filled with trash need more support from public sanitation departments.

Public safety is also integral and requires the partnership of safety officers, such as fire departments and police. Police specifically can work to reduce drug issues, crime, and incidents of violence. Public safety officers can also help funnel patients out of negative lifestyles by reducing safety issues.
To learn more, read the full article.

Working with Communities to Improve Health

The following excerpt comes from an article that first appeared May 1, 2017, on the NIMHD website under NIMHD Community Health and Population Sciences Feature Articles


Improving health is not always a matter of prescribing the right medicine. Sometimes the environment needs to change. Many Americans live in neighborhoods that lack safe walking routes, grocery stores, and health facilities.

“Are there places for kids to play? Are there good farmers markets or grocery stores?” asks Irene Dankwa-Mullan, M.D., M.P.H., formerly of NIMHD and now deputy chief health officer of IBM Watson Health. Such features help people in a neighborhood live healthier lives. Along with NIMHD director Eliseo Pérez-Stable, Dr. Dankwa-Mullan wrote an editorial in the April 2016 issue of the American Journal of Public Health, “Addressing Health Disparities Is a Place-Based Issue.”

Efforts to address these problems in particular communities are called “place-based interventions.” Ideally, these interventions come from a collaboration among community members, businesses, and other stakeholders, working together with police, urban planners, and other groups to improve their neighborhood. Community members are involved to make sure the interventions are based on their values.

Examples of place-based interventions include an effort to bring a farmers market to a neighborhood without a grocery store or promoting public safety so that residents feel safe walking on the street. Walking is a simple way to improve health, but there can be many barriers to walking, a fact highlighted in the Surgeon General’s Call to Action on walking.

Place-based interventions have been used successfully in rural areas, disadvantaged urban neighborhoods, and Indian reservations. People who live in such places tend to have particular health problems, such as diabetes and heart disease, and working to change the place-based conditions may help address health disparities.

Communities are complicated, and figuring out the best way to improve the health of all residents in a particular place can be a daunting task. “Part of the issue is that we do not have a best practices model for place-based interventions,” Dr. Dankwa-Mullan says. The editorial in the American Journal of Public Health was part of a new series on best practices for place-based interventions. Through this series, public health professionals will be able to learn how to develop place-based interventions.

One key to success of place-based interventions is involving the community. This is similar to community-based participatory research, a way of doing research in which the community sets priorities, ensuring that communities that are asked to participate in research get answers to the questions that are most important to them.

Read the full article.

 

Talking about Health Equity

Recently, the Health Policy Research Consortium create a YouTube Series, Conversations on Health Equity,  exploring health equity with leading experts. Available videos include

 

Partnerships for Better Health Outcomes

In June, the Partnership for Healthy Outcomes: Bridging Community-Based Human Services and Healthcare issued the report “Working Together Toward Better Health Outcomes” detailing the findings from a national request for information that sought information about partnerships between healthcare organizations and community-based organizations (CBOs).  The data came from 200 respondents to the request for information with 67% of respondents from CBOs, 13% from healthcare organizations, and 9% from government agencies. The remaining respondents represented foundations, research institutions, consulting organizations, and for-profit CBOs. Responses came from all 50 states while California, New York, Colorado, Pennsylvania, and Minnesota were the most represented.

The following key findings come from the report’s executive summary.

  • There’s no one-size-fits-all formula: Respondents represented partnerships of many sizes, shapes, and contractual and funding arrangements; many were among healthcare providers and CBOs – but partners also included public health and other government agencies, private insurers, foundations, schools, supermarkets, and more.
  • Shared goals provide common ground: Most of the responding partnerships were initiated by CBOs and noted the value of developing shared goals to improve health outcomes and contain or reduce costs.
  • Most partnerships have some sort of formal agreement in place, though partner integration varied from communicating (sharing client information) to coordinating (aligning services toward better client outcomes) to collaborating (sharing staff, space, or resources) to integrating (becoming a collective entity with connected programs, planning, and funding).
  • Most commonly, partnerships provided services to impact immediate-term clinical needs, such as reducing hospital admissions or length of stay. This may be due, at least in part, to a funding environment with incentives for cost reduction. More than half of respondents reported that their partnerships include care coordination support to better organize services across multiple providers; fewer partnerships reported providing services that address underlying social determinants to improve health in the long-term. A majority (65%) of partnerships reported realizing cost savings.
  • Partnerships rely on an evolving variety of funding sources, including private foundations, healthcare systems, and government entities, and typically more than one. A number of partnerships were established through a one-time grant and have developed – or are developing – a long-term, sustaining funding model.
  • Nearly all organizations acknowledged expanding skills and capacities through partnership, particularly in network-building, improving programs, and generating new funding.
  • Advancing the field will require partners and funders to:1)Prioritize and invest time in relationship-building – the key ingredient to effectiveness; 2)Engage a wide range of stakeholders, including community members, early on and throughout the partnership; 3)Identify and fund the full cost of partnership to effectively support development and evolution; 4)Stay adaptable and nimble in an ever-shifting environment.

To learn more, download the full report.

Examining Provider Bias In Health Care Through Implicit Bias Rounds

The following comes from the July 17, 2017, article by Vidya Viswanathan, Matthew Seigerman, Edward Manning, and Jaya Aysola on the Health Affairs Blog.


In 2015, a 27-year-old patient presented to our primary care resident practice in intractable pain, having been recently discharged from the hospital following surgery for a complex shoulder fracture. The orthopedic surgeons evaluated him the day before and scheduled a second surgery but did not adequately treat his pain. The inpatient nurse had told him he would be discharged with the oral pain regimen he had been taking for the past day or so within the hospital. But upon discharge, he found himself without those prescriptions and came to our primary care practice in severe pain. When we reviewed his inpatient record to determine the reason for this discrepancy, the attending physician discovered the phrase “drug-seeking” in the record. The rationale for this statement was not provided, nor the context. When questioned by his new primary care provider about this, the patient was shocked. He tried to recollect what he may have said to result in that assumption. He had no prior history of documented substance or prescription drug abuse.

The patient in question was a young black male and the victim of a drive-by shooting by a stranger. He had been sitting in the passenger seat of a stationary car when it happened. Standard practice in this type of case involves long-acting oral opioid medication, with gradual adjustments of a medication regimen tailored to meet the needs of the patient. But the patient didn’t receive the standard of care, and we naturally wondered why. The answer may be implicit bias.

The literature suggests that he would be more likely to be perceived as drug-seeking when requesting pain relief, compared to his white counterpart. Bias is particularly well-documented in pain management, with black children and adults receiving less adequate pain treatment than their white counterparts in the emergency department for the same presenting condition, even when accounting for insurance status and severity of pain. Longitudinal, national data on 156,729 pain-related emergency department visits found that even among those presenting with the same condition, non-Hispanic white patients were significantly more likely to receive an opioid than all other ethnic minorities examined. Researchers using an instrument to assess implicit bias in more than 2,500 physicians found a significant implicit preference for white Americans relative to black Americans among physicians of all racial/ethnic groups except for black physicians. Another study found that physicians were twice as likely to underestimate pain in black patients compared with all other ethnicities combined and also more likely to overestimate pain in nonblack patients than in black patients.

To address the case of our patient who was inadequately treated for pain based on apparently false assumptions—and other patients who have experienced a different standard of care due to implicit bias—we believe there needs to be formal discussion of this source of clinical errors at institutions. We propose the initiation of a new kind of case conference—“Implicit Bias Rounds”—to specifically identify and discuss these cases.

How Does Bias Occur?

We conceptualized Implicit Bias Rounds based on theories on why disparities in care occur despite well-intentioned providers and despite the recognition of the importance of cognitive error as a source of diagnostic error. Providers, when faced with the need to make complicated judgments quickly and with insufficient and imperfect information, may rely on assumptions associated with a patient’s social categories to fill in the gaps with information that may be relevant to diagnosis and treatment. Physicians are at risk for relying on stereotypes or assumptions for efficient decision making, even when attempting to be objective. In addition to the assumptions providers may make about patients that are dissimilar to them, they may also unconsciously favor patients whose identity they relate to. Such affinity bias may cause a provider not to consider the possibility of a drug problem in an adolescent that appears similar to him, despite a positive urine screen for marijuana. Current efforts in medicine to combat bias may also serve to perpetuate them: Physician-anthropologist Arthur Kleinman states that one problem with traditional cultural competency training is that it may erroneously characterize culture as static and cultural understanding as a technical skill.

It is not enough to merely consider potential sources of provider bias without considering proposed strategies to mitigate that bias. Evidence tells us that simply adjusting the explicit medical curricula is not enough to change implicit bias; increasing positive role modeling for medical trainees is more effective. Strategies proposed to combat implicit bias include consciously thinking of the patient’s perspective and approaching each provider-patient interaction as a shared negotiation between worldviews. Focusing on specific and unique details about an individual, instead of his or her social category, serves to combat biases by diminishing stereotyping and promoting empathy building. Clinicians who are trained to consider the unique perspectives and experiences of their patients are more likely to show empathy toward them, the study suggests. Priming physicians with information about the relevance or irrelevance of sociocultural factors in medical care can combat cognitive errors that stem from stereotyping. A regular intervention such as Implicit Bias Rounds would serve to implement these strategies on a consistent basis.

Read the full article.

USA Health Partners with Feeding the Gulf Coast to Address Food Insecurities in Clinical Setting

The following article first appeared in the Med School Watercooler: The blog of the University of South Alabama College of Medicine on June 29, 2017.


USA Health recently partnered with Feeding the Gulf Coast to implement “Boxing Out Hunger,” an innovative program designed to improve health by addressing food insecurities in the clinical setting at Stanton Road Clinic.

“Being a board member for Feeding the Gulf Coast, I feel very strongly about what they do to help the community and, of course, I am very passionate about the work that USA Health does,” said Dr. Julee Waldrop, representing both the University of South Alabama and Feeding the Gulf Coast at a recent kick-off event. “The ‘Boxing Out Hunger’ program is truly a great partnership, and it is my hope that Feeding the Gulf Coast will be integrated into the entire health system.”

According to Kim Lawkis, nutrition programs director for Feeding the Gulf Coast, one in six adults and one in four children struggle with food insecurity. “Feeding the Gulf Coast was selected as one of only five food banks in the U.S. to participate in Feeding America’s Health Care Pilot Program,” she said. “This pilot focuses on our organization expanding access to fresh, healthy products and working with health care partners to help implement programs that directly address food insecurity and top priorities in their community health plan.”

The program — which is unique to our area — seeks to fill a nutritional gap that exists for many patients who visit Stanton Road Clinic. Through phase one of the partnership, Stanton Road Clinic will distribute 1,000 healthy pre-packaged boxes to food insecure patients that contain an assortment of shelf-stable ingredients such as canned produce, protein, dairy, and grains. The food box is intended to meet the immediate needs of patients at the clinic and educate them on the importance of a healthy diet. Recipe cards are also included in the food boxes, which provide tips for preparing the food.

Beth Poates, a social worker with USA Health, will determine eligibility for food boxes by screening all new and self-pay patients for food insecurity. If the patient screens positive for food insecurity, they will receive a food box that is tailored to their health concerns.  Patients who do not screen positive will be referred to the closest food bank.

Owen Bailey, chief executive officer for USA Health, said a visit to Boston Medical Center’s Food Pantry several years ago sparked his interest in implementing the “Boxing Out Hunger” program at USA Health. “Using their success as inspiration, it is my hope that USA Health and Feeding the Gulf Coast can create similar success in Mobile to address nutrition-related illnesses and improve the outcomes for our patients,” he said.

According to Ali Shropshire, CRNP, family nurse practitioner and nurse manager for Stanton Road Clinic, the connection between adequate nutrition and health and healing is clearly documented in the medical literature. “We believe that the ‘Boxing Out Hunger Program’ will increase our patient compliance, decrease blood pressure, decrease blood sugar and overall decrease hospital utilization,” she said. “I am proud of the tremendous progress we have made and the opportunity to work with our new partner Feeding the Gulf Coast in achieving these goals.”

Dr. Errol Crook, director of the Center for Healthy Communities and professor and Abraham Mitchell Chair of internal medicine at the USA College of Medicine, said patients visiting Stanton Road Clinic often have insecurities that go beyond health. “Stanton Road Clinic is a community clinic, but we define community in a very broad sense,” he said. “We have patients who walk or take the bus here, but we also have patients who come from other counties. In addition to health, many of our patients experience insecurities in safety, shelter, and clothing. We are very happy to now have a way to address one of those insecurities, and by doing so we hope to one day be able to address the other major insecurities they experience.”

Read the full article.

Health Insurance Coverage, Doctor-Patient Relationship, and Health Care Utilization

A recent study published in Preventive Medicine Reports explored the effect of health insurance coverage and doctor-patient relationships on the likelihood that an individual would receive diagnostic tests for diabetes and cardiovascular disease. Using data collected from 230 participants in the Labor Market Health Care Survey (LMHCS), the study examined three questions:

  • How does health insurance affect the likelihood of having a regular health care provider?
  • How does health insurance coverage affect the likelihood of receiving tests for cardiovascular disease?
  • To what extent does having a regular health care health care provider mediate the effect of health insurance coverage on receiving the diagnostic tests?

The research team, led by Dr. Kenneth Hudson, the LMHCS was a multi-wave longitudinal study of adults 18 and older living in nine high-poverty census tracts in a county of approximately 400,000 residents. For the study, high poverty census tracts were defined as those where 50% of the households have incomes below the poverty threshold. Interview participants were selected through a two-stage random sample. To be included in the study, an individual had to be over 18 years of age. While data collection began in 2006, about 90% of the data in this study were collected since 2013. The research team interviewed participants every 2 to 3 years when they could be located. During interviews, participants provide information on their household composition, employment history, health status, health care utilization and income. Of the 230 participants in the study, about half were under the age of 40.

Analysis of the data included 3 dependent variables:

  • Whether or not participants have health insurance from any source
  • Whether or not the participant has a regular health care provider and knows their doctor’s name
  • Whether or not participants receive diagnostic tests for blood pressure, cholesterol levels and blood sugar levels.

In terms of health insurance coverage, only 12% of participants reported having coverage through an employer, 7% purchased coverage from the private market, and 5% had coverage through a family member. About ⅓ of participants had coverage through Medicare or Medicaid. The final ⅓ did not have any type of insurance coverage.

In relation to health care utilization, 45% of participants reported not having a regular provider. 17% reported having a regular health care provider but did not know their doctor’s name. The remaining 38% had a regular provider and could report the doctor’s name. Around half of the participants reported having cholesterol, blood sugar and blood pressure tests in the last 2 years.

Through the analysis, Dr. Hudson and his team found that participants with health insurance coverage were more likely to have had recent tests for diabetes and cardiovascular disease than those without coverage. However, they also found that having a regular health care provider mediates the effects of insurance coverage, especially when the participant could report the name of their doctor.

Read the full study.

Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults

The following comes from a Commonwealth Fund summary of research first published in Health Affairs Web.


Synopsis
Low-income adults in Arkansas and Kentucky who obtained coverage under the Affordable Care Act’s Medicaid expansion had better access to primary care and preventive health services, lower out-of-pocket costs, improved medication compliance, and improved self-reported health status than did low-income adults in Texas, which did not expand Medicaid. Among adults with chronic conditions, ACA coverage was associated with better disease management and medication compliance and a significant increase in self-reported health status.

The Issue
Congress is currently weighing the future of the Affordable Care Act. Since becoming law, the ACA has helped more than 20 million Americans enroll in health insurance coverage, and national studies have noted improvements in coverage, consumer satisfaction, and access to care. In this Commonwealth Fund–supported study, researchers compared Kentucky, which expanded Medicaid as prescribed by the ACA; Arkansas, which obtained a waiver to use federal Medicaid funds available through the ACA to purchase private marketplace insurance for low-income adults; and Texas, which did not expand Medicaid coverage. Looking at these three states, the authors assessed ongoing changes in health care use and self-reported health among low-income adults, including those with chronic conditions, after three full years of the ACA’s coverage expansions.

Key Findings

  • By the end of 2016, the uninsured rate in Arkansas and Kentucky—the two expansion states—had dropped by more than 20 percentage points compared to Texas, the nonexpansion state. In 2016, the uninsured rate was 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.
  • Low-income adults in Kentucky and Arkansas who gained coverage experienced a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket costs, and a 23-point increase in the share of those who reported they were in “excellent” health.
  • Results were similarly positive for people with chronic illnesses who gained coverage because of the ACA. Low-income patients with diabetes, heart disease, hypertension, and stroke who gained coverage were 56 points more likely to report having regular care for their condition than were chronically ill adults in Texas, 51 points less likely than those in Texas to skip medications because of the cost, and 20 points more likely to report being in excellent health.

See the full summary.
See the original article.

 

Medicaid’s Role in Providing Access to Preventive Care for Adults

The following excerpt is from a Data Note by Leighton Ku, Julia Paradise, and Victoria Thompson published by the Kaiser Family Foundation published on May 17, 2017.


Medicaid, the nation’s public health insurance program for people with low income, covers 74 million Americans today, including millions of low-income adults. The Affordable Care Act (ACA) expanded Medicaid to nonelderly adults with income up to 138% of the federal poverty level (FPL), and, in the 32 states (including DC) that implemented the expansion, more than 11 million adults have gained Medicaid as a result. Chronic illness is prevalent in the adult Medicaid population. Preventive care, including immunizations and regular screenings that permit early detection and treatment of chronic conditions, improves the prospects for better health outcomes. This Data Note focuses on Medicaid’s role in providing access to preventive care for low-income adults.

Why is preventive care for adult Medicaid Enrollees Important?

Adults in Medicaid have high rates of preventable and controllable conditions. Nearly one-third (30%) of non-elderly adult Medicaid beneficiaries report that they are in only fair or poor health – roughly double the percentage of low-income privately insured and uninsured adults who report fair or poor  health (Figure 1). Medicaid adults also have significantly higher rates of chronic conditions and risky health behaviors that may be amenable to preventive care. One in 10 adult enrollees has a diagnosed mental illness; 7 in 10 are overweight or obese, and almost 1 in 3 smoke tobacco.

Preventive care can reduce disease and avoidable use of high-cost services. Increased access to screening for diabetes, cancer, depression, and o ther chronic conditions, and counseling to address behavioral risk factors, have the potential to reduce disease and prevent exacerbations of conditions that can be medically managed. Improved health may reduce the use of avoidable hospital and other high-cost care, and reduce Medicaid spending. For example, smoking can cause heart disease and other chronic illnesses that one study estimated may be responsible for more than $75 billion in Medicaid costs. Medicaid coverage of smoking cessation services, including quit lines and medications, has the potential to mitigate both the health and cost impacts of smoking. Obesity, a major driver of preventable chronic illness and health care costs, affects about two-thirds of low-income adults. Findings from one study indicate that severe obesity in adults cost state Medicaid programs almost $8 billion in 2013, suggesting that “effective treatment for severe obesity should be part of each state’s strategy to mitigate rising obesity-related costs.”

What Preventive Services Does Medicaid Cover for Adults?

Coverage of most adult preventive services has historically been optional for states. Medicaid coverage of preventive services for children has long been strong, as states must cover comprehensive preventive services at no cost for children in Medicaid under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. In contrast, historically, coverage of adult preventive care has been largely optional for states, with some exceptions – states must cover pregnancy-related care and family planning services without cost-sharing. In addition, within federal guidelines, states can charge adults cost-sharing for preventive services.

The ACA expanded coverage of adult preventive care. An important thrust of the ACA was an emphasis on preventive care. In particular, the ACA included recommended preventive services without patient cost-sharing as one of the 10 “essential health benefits” (EHBs) that most health plans are now required to cover. The required preventive services are based on the recommendations of independent, expert clinical panels and include, for adults: 1) screening and counseling services (e.g., cancer screening, diet counseling); 2) routine immunizations; and 3) preventive services for women. The EHB requirement applies to Medicaid benefits for adults who are newly eligible due to the ACA expansion, but not “traditional” Medicaid adults, for whom most preventive services are optional for states and can require cost-sharing within federal guidelines. To incentivize states to cover the EHB preventive services for all Medicaid adults, the ACA provided for a one percentage point increase in the federal Medicaid match rate for these services in states that opt to cover all of them without cost-sharing.

Read the full data note.

 

‘Connectivity’ as the Key to Healthy Communities

The following excerpt originally appeared in in an article by Shannon Firth in MedPage Today  on May 11, 2017 summarizing a panel discussion that had taken place on May 9, 2017.


Keeping people connected to resources necessary to maintain good health — not least of which is other people — is a vital but often neglected factor in modern healthcare, policy experts and scholars said here Tuesday.

Transportation is an “underappreciated” health problem, said Dayna Bowen Matthew, JD, a nonresident senior fellow at the Brookings Center for Health Policy, at a panel discussion hosted by the Brookings Institution on Tuesday.

She noted that interstate highways aren’t always a means of connecting people to each other and to resources: in cities, they create barriers as well.

A grid of superhighways can mean a person living in a city’s southeast quadrant must take two buses and time off from work to reach a well-intentioned “food solution” in the northwest quadrant.

“That community’s not connected,” said Bowen Matthew, who is also a professor at University of Colorado Law School and the Colorado School of Public Health, and author of Just Medicine: A Cure for Racial Inequality in American Health Care.

Those families across town from farmers’ markets and other fresh food resources will rely on the more accessible options instead, which may be fast food.

Tuesday’s discussion focused heavily on the social determinants of health — nonmedical factors that greatly influence a population’s health such as transportation, housing, access to food — but one thing unites these influences: connectivity.

Social Networks are Key

The National Health Service in England has a “district nurse,” an individual responsible for keeping watch over certain neighborhoods, explained, Stuart Butler, PhD, a senior fellow in economics for the Brookings Institution.

Growing up in England, Butler’s mother ran a post office, which was a key source of “intel” for the district nurse on the community residents’ well-being. If Butler’s mother hadn’t seen someone for a few days, the nurse would learn of this and ride her bicycle to the person’s home.

Decades later and an ocean away, Matt Brown, RN, a geriatric nurse navigator at Sibley Memorial Hospital in Washington, learned quickly about the importance of follow-up phone calls to ensure smooth transitions back to the community.

During his first such call as part of a senior-focused transition project, he spoke to a patient who had just returned home after being hospitalized for pneumonia.

In the course of the phone call, the patient reluctantly admitted he had fallen and couldn’t get up off the floor of his home. Brown convinced him to call 911, rather than wait for the patient’s wife to come home. When the ambulance arrived, Brown spoke with the emergency medical technicians to confirm his patient was okay.

To further reduce the risk of injuries, the Sibley Innovation Hub has offered a short training course focused on transitions after certain surgeries, which they are now supplementing with animated patient education videos.

Read the full article.