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Passive Social Health Surveillance and Inpatient Readmissions
Nnadozie Emechebe, MPH; Pamme Lyons Taylor, MBA, MHCA; Oluyemisi Amoda, MHA, MPH; and Zachary Pruitt, PhD
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Passive Social Health Surveillance and Inpatient Readmissions

Nnadozie Emechebe, MPH; Pamme Lyons Taylor, MBA, MHCA; Oluyemisi Amoda, MHA, MPH; and Zachary Pruitt, PhD
By collecting self-identified social needs and linking them to claims data, this study analysis reveals that social needs are associated with inpatient readmissions.

Objectives: To determine whether self-identified social needs, such as financial assistance with utilities, food programs, housing support, transportation, and medication assistance, collected using a passive social health surveillance system were associated with inpatient readmissions.

Study Design: Cross-sectional, retrospective observational study.

Methods: This retrospective observational study linked social service referral data collected from a call center–based passive social health surveillance system with healthcare claims data extracted from a managed care organization (MCO). Mixed-effects logistic regression models calculated the odds of all-cause hospital readmissions within 30, 90, and 180 days among individuals with self-identified social service needs compared with those without.

Results: Individuals who identified social service needs had 68% (odds ratio [OR], 1.68; 95% CI, 1.51-1.86), 89% (OR, 1.89; 95% CI, 1.74-2.05), and 101% (OR, 2.01; 95% CI, 1.87-2.17) higher odds of readmission within 30, 90, and 180 days, respectively, after controlling for other study variables. Examining each social service need separately, individuals had higher odds of hospital readmission within 30 days of discharge if they identified a financial (OR, 1.19; 95% CI, 1.07-1.33), food (OR, 1.32; 95% CI, 1.17-1.48), housing (OR, 1.31; 95% CI, 1.09-1.57), or transportation (OR, 1.21; 95% CI, 1.08-1.36) need compared with those without those social needs. In all study outcomes, medication assistance was not associated with readmissions.

Conclusions: An MCO created a passive social health surveillance program to more effectively integrate medical and social care. Understanding individual-level social health needs provides the insights needed to develop interventions to prevent hospital readmissions.

Am J Manag Care. 2019;25(8):388-395
Takeaway Points
  • A passive social health surveillance system—a managed care organization (MCO)’s call center–based social service referral program—enabled examination of whether self-identified social needs are associated with inpatient readmissions.
  • This study linked referral and claims data for 19,817 individuals to examine the odds of inpatient readmissions for individuals with self-identified social needs, such as food and housing insecurity, compared with those without self-identified needs.
  • Results showed that individuals with self-identified social needs had higher odds of 30-day inpatient readmissions.
  • Passive social health surveillance systems could enable MCOs to play an important role in integrating medical and social care by complementing the social health screenings of medical care providers.
Social needs, such as adequate housing, food security, and access to transportation services, affect population health outcomes.1,2 Neglecting to integrate social care with medical care may burden the healthcare system with unnecessary or unplanned utilization.2,3 Excess inpatient readmissions represent one such problem that US policy makers seek to address.4 Significant Medicare payment penalties motivate hospitals to develop strategies to curtail these readmissions. One approach includes hospital-defined algorithms that identify individuals with the greatest risk of readmission at the time of discharge.5

Social health surveillance systems, which can identify social needs and connect people to community resources, may support medical and social care integration.6 Active social health surveillance uses screening tools to directly identify patient social needs at medical facilities.7 However, medical care providers may lack the time, training, and resources to effectively conduct social health screenings or link patients to community service providers.8-11

A passive social health surveillance system—analogous to public health surveillance systems—consists of the ongoing collection, storage, and classification of social health needs information identified and reported by individuals or their caregivers. Two nationwide passive social health surveillance systems, the 2-1-1 programs6,12 and WellCare Health Plan’s Community Assistance Line,13,14 have been identified as effective approaches for identifying and tracking individual-level social health needs, including financial assistance to pay for utilities, food programs, assistance with medication, housing support, and free or low-cost transportation, among others.

The objective of this study was to determine whether self-identified social service needs collected through a passive social health surveillance system were associated with inpatient readmissions within 30, 90, and 180 days.


Study Design and Data Source

WellCare Health Plan’s Community Assistance Line, a part of its Center for CommUnity Impact, provides referrals to community-based social service organizations to individuals who contact the call center and report a social need. This cross-sectional study linked self-identified social needs collected in the social service referral program’s database with the managed care organization (MCO)’s health service claims data.

Study Population

The study examined claims and social service referral data from January 1, 2013, through October 19, 2017, from 27,189 individuals insured by WellCare Health Plan’s Medicaid managed care and Medicare Advantage programs. The sample included individuals who were at least 18 years of age with at least 1 admission to an acute care hospital. Individuals who were pregnant (n = 638), were younger than 18 years (n = 1469), were transferred to a different hospital (n = 757), had 1 admission but less than 6 months of enrollment and claims data (n = 4210), received chemotherapy (n = 88), lived outside the 13 established states of interest (n = 84), had claims data errors (n = 11), or had incomplete data on study variables (n = 115) were excluded. The final study population included 19,817 individuals from 13 states who were readmitted to 1064 hospitals.

Outcome Measures

Outcome measures consisted of 3 all-cause hospital readmissions: individuals who were admitted within 30, 90, and 180 days of prior inpatient discharge. An admission was considered a readmission only if it occurred within the stipulated time frame (eg, 30 days) and was not a transfer to a different hospital. To identify a readmission, we calculated the difference between the first and subsequent admission and categorized the individuals as having 30-, 90-, and 180-day readmissions. Individuals with a single admission and who had utilization data for at least 6 months were classified as not having a readmission.

Study Groups

The study population was further classified into 2 groups: (1) individuals with self-identified social service needs reported to the Community Assistance Line and (2) individuals without self-identified social service needs. The study further classified individuals with a self-identified need based on the presence of any of the following 5 social service needs: financial assistance for utilities, food programs, housing support, transportation, and medication assistance. Individuals contacting the Community Assistance Line with self-identified social needs either had exhausted their defined health insurance benefit for services such as food programs, transportation, or medication assistance, or the social service was not a part of the health plan benefit, such as financial assistance and health literacy programs. These 5 domains of social needs were selected based on the recommendation by CMS and their previous associations with health outcomes.15-18 The study also examined the individuals with each of these 5 aforementioned domains of social needs separately compared with individuals without them.

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