Background: In the acute care environment, healthcare workers interface with patients who have limited access to medical care and a high prevalence of social determinants of health (SDoH) barriers.1 The inpatient setting presents a key intervention point where the social needs of vulnerable populations might be addressed. Standard inpatient medicine care teams, however, lack the [...]

Background: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet [...]

Background: In 2011, ~3.3 million adult 30-day US hospital readmissions generated $41.3 billion in hospital costs. $8.26 billion (20%) of this was considered preventable. Numerous studies demonstrate relationships between hospital readmissions and social determinants of health (SDoH). Lack of education, socioeconomic status, and lack of social support have all been cited as core contributors to [...]