response-SDOH AND SOCIAL CHANGE

Gladys Francis

Jan 13 6:18am

Reply from Gladys Francis

SOCIAL DETERMINANTS OF HEALTH AND SOCIAL CHANGE

Organizational Context and Practice Issue

The selected organization is a community-based outpatient mental health clinic affiliated with an extensive urban safety-net health system. The clinic serves adults with serious mental illness who frequently experience housing instability, limited transportation access, unemployment, and inconsistent engagement with outpatient psychiatric services. A persistent organizational challenge within this setting has been high rates of missed psychiatric follow-up appointments following inpatient discharge, which contributes to medication nonadherence, symptom exacerbation, increased emergency department utilization, and preventable psychiatric readmissions.

Evidence consistently demonstrates that ineffective transitions of care are a primary driver of poor outcomes among individuals with serious mental illness, particularly in safety-net systems where structural barriers are prevalent (White et al., 2024; Vigod et al., 2015). Despite evidence-based inpatient treatment planning, many patients lack the social and logistical supports necessary to successfully re-engage in outpatient care, undermining continuity and quality metrics.

Social Determinants of Health and Practice Change

Social determinants of health (SDOH) were central to the identified practice issue. Transportation barriers limited patients’ ability to attend scheduled follow-up appointments, while housing insecurity and unstable phone access interfered with appointment reminders and care coordination. Competing priorities related to food insecurity, caregiving responsibilities, and employment instability further reduced patients’ capacity to prioritize mental health care. Health literacy challenges also contributed to misunderstanding discharge instructions and the importance of timely follow-up (Alderwick & Gottlieb, 2019; White et al., 2024).

To address these barriers, the organization implemented a hybrid outreach and care coordination model that integrated telepsychiatry, flexible scheduling, transportation vouchers, and social work follow-up within 72 hours of discharge. Standardized SDOH screening tools were incorporated into discharge planning, with referrals to housing assistance, food programs, and community-based behavioral health services. This approach aligns with evidence indicating that addressing social needs alongside clinical care improves engagement, reduces avoidable utilization, and advances health equity (Fraze et al., 2019; Johns Hopkins Nursing Center for Nursing Inquiry [JHNCNI], n.d.).

Evidence-Based Practice Approach and Implementation Process

The organization’s change process reflected several core steps outlined in Bissett et al. (2025) and the Johns Hopkins Evidence-Based Practice Model. The problem was clearly defined using internal data on missed appointments and 30-day readmission rates. A targeted review of the literature was conducted, drawing on evidence related to transitional care models, telepsychiatry, and care coordination for individuals with serious mental illness (Vigod et al., 2015; White et al., 2024). Interdisciplinary stakeholders, including nursing, psychiatry, social work, and administrative leadership, were engaged early to enhance feasibility and buy-in.

The intervention was piloted with a high-risk patient cohort before full implementation, enabling iterative refinement of the workflows. While outcome monitoring and stakeholder engagement were strengths of the approach, formal sustainability planning and structured patient co-design were less robust. The absence of explicit long-term dissemination strategies and limited incorporation of patient advisory input represent partially missed steps within the EBP process, consistent with common gaps identified in practice change initiatives (Bissett et al., 2025; White et al., 2024).

Outcomes, Measurement, and Social Impact

Overall, outcomes were predominantly positive. The clinic observed improved attendance at post-discharge follow-up appointments, along with reductions in emergency department utilization and 30-day psychiatric readmissions. Process measures included appointment adherence rates, time to first follow-up visit, and completion of SDOH screenings. Outcome measures included utilization data, readmission rates, and patient satisfaction scores. Data were reviewed monthly and shared with frontline staff, supporting continuous quality improvement and reinforcing accountability (JHNCNI, n.d.; White et al., 2024).

Beyond clinical outcomes, the initiative contributed to positive social change by reducing structural barriers that disproportionately affect marginalized populations. Reframing missed appointments as a systems-level issue rather than individual nonadherence fostered a cultural shift toward equity-oriented care. This aligns with broader evidence demonstrating that addressing SDOH within healthcare delivery promotes social justice and improves population-level outcomes (Alderwick & Gottlieb, 2019; Fraze et al., 2019).

Lessons Learned and Practice Implications

Several key actions were critical to the initiative’s success, including leadership endorsement, integrating the intervention into existing workflows, and providing deliberate attention to SDOH through care coordination and community partnerships. Opportunities for improvement included strengthening sustainability planning, formalizing patient engagement strategies, and expanding evaluation to include longer-term outcomes. Overall, this practice change demonstrates how structured, evidence-based practice frameworks, when combined with equity-focused strategies, can facilitate meaningful and sustainable improvements in mental health care delivery (Bissett et al., 2025; White et al., 2024).

References

Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinant of health lexicon for health care systems.  The Milbank Quarterly, 97(2), 407–419. https://doi.org/10.1111/1468-0009.12390

Bissett, K., et al. (2025).  Evidence-based practice for nursing and healthcare quality improvement (pp. 208–209). Springer.

Fraze, T. K., Brewster, A. L., Lewis, V. A., & Beidler, L. B. (2019). Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals.  JAMA Network Open, 2(9), e1911514.  https://doi.org/10.1001/jamanetworkopen.2019.11514Links to an external site.

Johns Hopkins Nursing Center for Nursing Inquiry. (n.d.).  Evidence-based practice. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/evidence-based-practiceLinks to an external site.

Vigod, S. N., Kurdyak, P. A., Dennis, C. L., Leszcz, T., Taylor, V. H., Blumberger, D. M., & Seitz, D. P. (2015). Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review.  The British Journal of Psychiatry, 207(2), 99–107. https://doi.org/10.1192/bjp.bp.114.147727

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2024).  Translation of evidence into nursing and healthcare (4th ed.). Springer.

 

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Dana Ghazzawi

Jan 13 5:26am

Reply from Dana Ghazzawi

Week 8 Main Discussion

Suburban Hospital’s perioperative services department implemented a practice change to address a persistent pattern of day-of-surgery cancellations and delays for elective surgical cases. This issue had significant operational and patient-care consequences, including wasted operating room (OR) time, staff overtime, patient dissatisfaction, and delayed treatment for individuals whose surgeries were postponed. From an evidence-based practice (EBP) perspective, this problem reflected a gap between what was known about effective preoperative preparation and what was occurring in routine workflows. Consistent with the Johns Hopkins Evidence-Based Practice (JH-EBP) Model, leaders and frontline clinicians first clarified the scope and drivers of the problem by reviewing cancellation data and identifying common reasons for delays, which is a core element of the Practice Question phase described by Bissett et al. (2025).

Social determinants of health (SDOH) were strongly embedded in this problem. Many cancellations were not due to clinical instability but rather to factors such as limited transportation, low health literacy, language barriers, unstable caregiving, and financial constraints that prevented patients from completing preoperative testing or obtaining required medications. For example, patients without reliable transportation or who depended on family members were more likely to arrive late or miss their arrival window, resulting in cancellations. Patients with limited English proficiency or low health literacy were more likely to misunderstand NPO instructions or medication holds, leading to unsafe or incomplete preparation. Others could not afford laboratory tests or imaging or had difficulty navigating insurance authorization processes, leaving them “not cleared” on the day of surgery. These SDOH-related barriers directly affected whether patients could access surgical care in a timely and safe manner, making this not only an operational issue but also an equity and population-health issue.

SDOH were partially addressed through the organization’s practice change, which introduced a more structured and proactive preoperative readiness process. This included standardized preoperative phone calls and checklists that screened for transportation, caregiver availability, medication access, testing completion, and language needs. When barriers were identified, staff used defined escalation pathways, such as referrals to social work, interpreter services, or care coordination, to resolve problems before the day of surgery. This approach reflected the JH-EBP emphasis on understanding the full context of a problem—including patient and system factors—before implementing solutions (Bissett et al., 2025). Positive social change occurred to the extent that these processes reduced preventable cancellations, improved communication with patients, and helped individuals who were previously disadvantaged by SDOH barriers to successfully receive their scheduled surgical care. However, the degree of social change depended on how consistently the workflow was applied and how well support services were resourced, highlighting the importance of sustainability and equity-focused implementation emphasized in population and specialty practice exemplars (White et al., 2024).

When viewed through the lens of Bissett et al.’s (2025) Appendix A, many of the key steps of the JH-EBP process were followed. The organization clearly identified and defined the practice problem, developed a focused EBP question about how standardized preoperative readiness processes could reduce cancellations, and reviewed evidence related to patient education, care coordination, teach-back, and barrier screening. Evidence was searched, screened, and appraised using structured methods consistent with the Evidence Phase, and best-evidence recommendations were translated into a practical workflow that included scripts, checklists, and escalation pathways. However, some steps were incompletely executed, including formal incorporation of patient and community perspectives into the design of the process and the development of a robust sustainability plan with ongoing training, accountability, and feedback loops.

Overall, outcomes were positive when the process was implemented as designed. Key actions that contributed to success included standardization of preoperative calls and checklists, early identification of barriers, closed-loop communication to ensure issues were resolved, and regular review of cancellation data. These actions are consistent with the emphasis on translating synthesized evidence into actionable practice changes found in the JH-EBP Model (Bissett et al., 2025). When outcomes were less satisfactory, it was often because SDOH screening was inconsistent, resource connections such as social work or transportation assistance were limited, or staff were not uniformly trained in the new process. Strengthening these areas would likely have improved both efficiency and equity.

Change was measured using multiple indicators. Operationally, the primary outcome was the day-of-surgery cancellation rate and the number of delay minutes attributable to preventable readiness issues such as late arrival, missing test results, or incorrect medication use. Process measures included the percentage of patients who received the standardized preoperative call, completion of teach-back, and documentation of barrier screening and referrals. Equity-focused evaluation included examining cancellation rates by language preference, insurance status, and documented transportation or social support barriers. Patient understanding and satisfaction were also monitored through feedback and teach-back success. Together, these measures allowed the organization to determine not only whether cancellations decreased, but also whether the change improved access and fairness for patients affected by SDOH, which is a central goal of evidence-based, population-focused practice (Johns Hopkins Nursing Center for Nursing Inquiry, n.d.).

References

Bissett, K., Ascenzi, J., & Whalen, M. (2025).  Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (5th ed.). Sigma Theta Tau International.

Johns Hopkins Nursing Center for Nursing Inquiry. (n.d.).  Evidence-based practice. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/evidence-based-practiceLinks to an external site.

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2024).  Translation of evidence into nursing and healthcare (4th ed.). Springer.

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