558 - A Novel Quality Improvement Project to Connect Hospitalized Children with Community Partners to Address Identified Social Drivers of Health

Ada Earp, University of Texas at Austin Dell Medical School, Austin, TX, United States; Sanyukta Desai, Dell Children's Medical Center of Central Texas, Austin, TX, United States; Alexandria Daggett, Dell Children's Medical Center of Central Texas, Austin, TX, United States; Sai R. Kaushika, University of Texas at Austin Dell Medical School, Keller, TX, United States; Abinaya Kannapiran, Dell Children's Medical Center of Central Texas, Austin, TX, United States; Sarah R. Tarrance, Dell Children's Medical Center of Central Texas, Austin, TX, United States; Adya Das, Dell Children's Medical Center of Central Texas, Allen, TX, United States; Kelly L. Kovaric, University of Texas at Austin Dell Medical School, Cedar Park, TX, United States

Background: Hospitals are required to screen all admitted patients for social drivers of health (SDoH), but patients in our hospital reported that they did not receive community aid after hospital discharge.

Objective: The objective of this study was to increase receipt of community aid within one month of hospital discharge from 0% to 30% within 12 months, by August 31, 2024.

Design/Methods: We conducted a quality improvement study at a quaternary care children’s hospital. Using the Model for Improvement, we convened a multi-disciplinary team of nurses, social workers, and physicians to create a key driver diagram (Figure 1) We included all hospitalized children admitted to the pediatric hospitalist service who screened positive for food, housing, transportation or utilities insecurity. We excluded patients who did not want a referral for community aid. Our primary measure was the % of patients who received community aid within 30 days of discharge. A secondary measure was % of patients who were contacted by a community aid organization. Data was collected by calling families 30 days after discharge and through referral data provided by our community partner (CP.) Interventions included a discharge phone call to connect patients with a CP who referred patients for community aid for their social needs. Run charts were used to analyze the measures.

Results: Over a 12 month period, of the 120 children from whom data were collected, 53% of families had more than 1 identified SDoH need, 70.8% were of Hispanic or Latino ethnicity, and there was a median patient age of 3 years. There was no change in patient comfort with screening, documentation, and referrals (data available upon request.) There were no referrals made prior to initiation of the discharge phone calls; a total of 197 referrals were made between March and August 2024. We noted a significant increase in % of patients contacted by a community organization from 0% to 81%.) (Figure 2). However, we did not note a significant change in receipt of community aid (Figure 3).

Conclusion(s): Implementation of discharge phone calls connecting patients with our CP resulted in increased contact with families after discharge without a significant impact on patients receiving community aid within one month of discharge. This discrepancy is likely due to a variety of systemic and structural barriers to timely receipt of aid for social needs. Future studies are needed to identify barriers to timely receipt of community aid after hospital discharge.

Figure 1: Key Driver Diagram
Figure 1.pdf

Figure 2: Process Measure: Contacted by a Community Organization
Figure 2.pdf

Outcome Measure: Family Received Community Aid Within 30 days of Discharge
Figure 3.pdf

Figure 1: Key Driver Diagram
Figure 1.pdf

Figure 2: Process Measure: Contacted by a Community Organization
Figure 2.pdf

Outcome Measure: Family Received Community Aid Within 30 days of Discharge
Figure 3.pdf