Integrating Social Determinants in a 30-Day Congestive Heart Failure Readmission Assessment Tool

Affiliated with two Ivy League medical schools, New York-Presbyterian Hospital (NYP) is one of the largest hospitals in New York City. Of NYP’s 44,764 patients discharged from January – May 2015, 3,509 (7.8%) were readmitted within 30 days. Among the 1,024 Congestive Heart Failure (CHF) patients, however, 161 (15.7%) were readmitted within 30 days. Many CHF readmissions can be prevented through improved follow-up care and collaboration among healthcare providers. A strong indicator of whether NYP is doing its best to manage high-risk patients and improve transitional care is the correlation between preventable 30-day readmissions, follow-up care, and collaboration. Social determinants of health play a crucial role in hospital readmissions. Current stratification tools, utilized to assess the level of risk for readmission, do not integrate these social determinants. The Capstone team designed a CHF Readmission Risk Assessment Tool for NYP with an emphasis on social determinants.