Social determinants of health come to light in hospital at home

Social Determinants of Health (SDOH) has become one of the most frequently used terms in healthcare, appearing in PowerPoint presentations, articles, and conferences, much like the Quadruple Aim. It is foundational to every healthcare strategy.

However, there have been many attempts to define the acronym without arriving at a final consensus. For instance, some prefer to describe it as social drivers of health, social factors, or social influencers of health, while others debate the inclusion of the word “social.” I often see a similar push to rebrand “patient experience” as “human experience”… UGH!

Alright, now that we’ve addressed that, whatever we call SDOH, its basic tenets remain the same:

Then came the high-acuity Hospital at Home (H@H) movement.

I had the thrill of organizing one of the first H@H leadership summits. Virtually every frontline healthcare professional who transitioned from their brick-and-mortar wards to H@H settings shared that it was the first time they could visualize the patient’s SDOH firsthand.

The common theme was that even the most detailed admissions inventory forms fail to capture the true social determinants of health compared to witnessing them firsthand in a patient’s home.

Patients might not always be entirely honest on a clipboard form about eating high-caloric foods or drinking alcohol (I count myself in that group). But seeing the contents of cupboards in a multi-generational, low-income housing project located in a food desert—pork rinds, candy, and bourbon—tells a different story.

The deeper vetting done prior to H@H patient admissions allows for the identification of physical and less obvious factors that either hinder or improve outcomes compared to traditional hospital settings.

Many of these admission criteria are evolving as H@H matures. For example, a physician mentioned they needed to add a question about road conditions to their qualification forms. In rural areas, the mountainous roads could not accommodate the small vehicle one of their key care team members drove, like a Mini Cooper!

So, what are some of the soft H@H admission considerations that should be evaluated before high-acuity care begins at home?

SDOH hospital at home considerations

Patient and family willingness

Consent: The patient (and family, if applicable) must consent to receiving care at home, fully understanding the care plan and responsibilities.

Comfort level: The patient and caregivers should feel comfortable with the concept and logistics of home care, including the use of any required medical equipment.

Home environment suitability

Safe living conditions: The home should have essential facilities like clean water, electricity, and temperature control, and it should be free of hazards that could compromise the patient’s safety.

Space for medical equipment: Depending on the patient’s needs, the home may need to accommodate medical equipment (e.g., oxygen tanks, IV equipment).

Access to emergency services: The home must be in an area where emergency services can easily access the patient if their condition worsens.

Support Systems

Caregiver availability: A caregiver (family member or professional) may be required to assist the patient with daily activities or certain aspects of care.

Access to technology: H@H programs often rely on telemedicine and remote monitoring devices. Patients need reliable internet access and the ability to use necessary technology (with support if needed).

Healthcare resources

Provider availability: The H@H program must ensure regular nursing visits, physician oversight (via telemedicine or in-person), and other necessary medical services.

Logistics for delivering care: The program must have the capacity to provide medications, lab work, imaging, and other diagnostics or treatments in a timely manner at the patient’s home.

Payer and insurance considerations

The current wild card is whether the H@H waiver program for reimbursement will be renewed this year. Its renewal would be a game changer for the scalability of H@H and for the comfort of patients who qualify.

Coverage: Insurance coverage for hospital-at-home services varies. Programs may only accept patients whose health plans cover this form of care.

Cost-effectiveness: The care must be cost-effective for both the patient and the healthcare system compared to traditional inpatient care.

Regardless of the reimbursement mechanism, H@H is here to stay, thanks to improved outcomes, reduced readmissions, and significantly lower infection rates. Most importantly, both patients and clinicians agree that it offers a much more satisfying care environment. In a healthcare workforce struggling with burnout, the ability to recruit and retain talent who can now engage directly with their patient’s SDOH is incredibly powerful.