Abstract 14483: Association Between Four Selected Social Determinants of Health and Readmissions for Patients in the Grady Heart Failure Program, 2018-2019

Abstract

Introduction: African Americans have a higher prevalence of heart failure (HF) than white Americans due in part to social determinants of health (SDOH). The Grady Heart Failure Program (GHFP) at Grady Memorial Hospital (GMH) in Atlanta aims to reduce readmissions for primarily low income, underinsured, African American patients with congestive HF. The GHFP addresses barriers to access to care through a community health worker, mobile health visits, transportation support, and low-cost medication. This study examines whether four key SDOH variables from Healthy Planet, a population health module in GMH’s electronic medical record, are associated with readmissions for GHFP patients. Methods: We analyzed data on demographics (race, sex, ethnicity) and SDOH variables (homelessness, financial resource strain, inability to afford medications, and issues with transportation to medical appointments) from Healthy Planet linked to HF-related readmissions from the GHFP’s dashboard. A total of 420 patients in the GHFP were included in this analysis from May 2018-April 2019. We evaluated the relationship between SDOH variables and any HF-related readmission and any 30-day HF-related readmission within the 12-month study period using Fishers exact tests. Results: Of the 420 patients, 92% were non-Hispanic African American, 62% were male, and 22% were uninsured. In the year prior to their first GHFP consult, 22% experienced homelessness, 49% had financial resource strain, 30% were unable to buy needed medications, and 46% had difficulty with transportation to medical appointments. A total of 76 patients (18%) were readmitted (range 1-5 readmissions), and 26 (6.2%) were readmitted within 30 days (range 1-4 readmissions within 30 days) over 12 months. No SDOH variables were associated with any 30-day HF-related readmission. Transportation issues were associated with any HF-related readmission ( P =0.04). Conclusions: While the majority of GHFP patients experienced SDOH-related barriers to care, none were associated with any 30-day readmissions and only transportation issues were associated with any readmissions. Future studies and models will examine whether the GHFP’s efforts to address social needs have led to a decline in 30-day readmission rates.