Social determinants of health (SDOH), including economic instability, transportation challenges, health literacy, and limited social support, are critical contributors to high hospital readmission rates among patients with congestive heart failure (CHF) (Endra, et al 2023). At the Kent Medical Center, these factors were addressed through multiple programs that incorporated financial assistance, transportation services, patient education, and community health worker (CHW) support.
Balaban et al. (2015)
demonstrated that patient navigator interventions significantly reduced hospital readmissions among high-risk populations by addressing SDOH barriers such as transportation and medication access. Similarly, Bradley et al. (2013) found that effective hospitals utilized discharge planning and follow-up coordination to reduce CHF readmissions by engaging patients and families early. These findings support Kent Medical Center’s inclusion of tailored discharge instructions and follow-up services to ensure continuity of care and a higher rating of the hospital.
Culturally tailored interventions also play a vital role in reducing readmissions among diverse populations. Betancourt et al. (2016) emphasized the importance of addressing cultural and socioeconomic factors, including health literacy and social support, in CHF management programs. At Kent Medical Center, the use of CHWs to conduct home visits and provide education reflects this approach, fostering better patient understanding and self-management.
Moreover, the Care Transitions Intervention introduced by Coleman et al. (2006) demonstrated the efficacy of enhancing patients’ self-management skills and connecting them to resources post-discharge. This model aligns closely with the education and support methods implemented at Kent Medical Center, where patients were given the opportunity to learn and teach back and used visual aids to reinforce CHF management practices.
The program’s outcomes, including a reduction in CHF readmission rates and improved patient satisfaction, showed the impact of addressing SDOH on health outcomes. These findings are similar to results from initiatives like the Community-Based Care Transitions Program, which utilized CHWs and culturally appropriate education to improve care transitions and reduce readmissions (Bradley et al., 2013).
While the Kent Medical Center program achieved some success, integrating technology, including telehealth services, can enhance its impact by addressing transportation barriers and improving access to care. Expanding CHW roles to include mental health and stress management support can help improve holistic health outcomes (Betancourt et al., 2016).
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