Opportunities Exist to Better Integrate Health-Related Social Needs and Social Determinants of Health into Discharge Assessment and Planning

The VA Office of Inspector General (OIG) conducted a review to evaluate (1) VHA and medical center leaders’ awareness and incorporation of social determinants of health (SDOH) and health-related social needs (HRSN) into inpatient medical unit discharge assessments, planning, policies, and templates; and (2) VHA’s efforts to address SDOH/HRSN with tools and community resources. The OIG determined there were no national policies or procedures that integrated SDOH/HRSN into discharge assessment and planning. Although the OIG found three national reference documents incorporating SDOH/HRSN, these documents were not considered formal guidance and were largely unknown to leaders responsible for discharge assessment and planning within inpatient units. Most medical center staff developed their own discharge policies and procedures addressing SDOH/HRSN, according to an OIG survey. The OIG also identified national templates incorporating SDOH/HRSN for primary care social workers but no template for discharge planning within medical units. VHA leaders recognized the impact of incorporating SDOH/HRSN into a screening tool and launched the Assessing Circumstances and Offering Resources for Needs initiative. The templated screening expands VHA’s capability to collect and capture SDOH/HRSN data in the electronic health record. As of July 2023, only two medical centers used the tool within inpatient medical units. The VHA Office of Health Equity developed health mapping tools to assist staff in identifying and addressing health disparities within their communities; however, few medical center leaders reported using these tools. Almost half of the surveyed leaders did not participate in formal partnerships with community resources to address SDOH. The OIG made five recommendations to the Under Secretary for Health regarding the development of national policy on incorporating SDOH/HRSN into discharge assessment and planning, implementation of a standardized template, evaluation of barriers to assessing SDOH/HRSN at discharge, use of health equity tools, and establishment of community resource partnerships to address SDOH.