Retrospective Review of Discharge Planning Outcomes in General Hospital with Social Needed

Abstract

Discharge planning represents a critical care transition point with particular salience for patients with complex social needs. Such patients face greater risk of adverse events after discharge through processes characterized by highly coordinated, multidisciplinary care, assistance in navigating healthcare resources, and flexible, personalized planning. Yet, little is known about planning outcomes for these vulnerable groups.

This retrospective review evaluates discharge planning outcomes in a cohort of hospitalized individuals with complex social needs. Analyses examine patient characteristics, implementation of commonly recommended discharge-planning elements, and associated post-discharge outcomes—hospital readmission, emergency department (ED) visits, receipt of support services, medication adherence, and linkage to community-based social, health, and human services.