1. Zangerle, Claire M. MBA, MSN, RN

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Patient care from one setting to another is complicated. Many elements come into play during the movement between healthcare practitioners and settings. This is care transitions: constant change reflecting the evolution of the patient milieu where excellent coordination and communication are essential. Embedded within care transitions is consideration of the elements that affect outcomes for a specific group of individuals. Known as population health management (PHM), this goes beyond traditional disease management to gain an understanding of both the clinical and nonclinical characteristics of a population, and the associated risks. The merger of care transitions and PHM is the cornerstone of value-driven accountable care, resulting in achievement of better quality care, lower cost, and improved patient experience.1

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Although care transitions programs are plentiful throughout acute and postacute care settings, the majority of PHM programs are in public health venues. Recently, PHM programs have emerged in these settings, minimally interacting with care transitions programs. For the best outcomes, these two initiatives must operate collaboratively and avoid siloed work. Beyond the clinical picture, the connectors between care transitions and PHM programs are the social determinants of health (SDOH)-factors and resources essential to recovery.


What are SDOH?

It's futile to treat an illness and not address the conditions that contribute to that illness. This is why it's important to understand how SDOH factor into the comprehensive picture. SDOH are economic and social conditions that affect the health of a population. Although not a comprehensive list, Table 1 shows SDOH and the potential impact they may have on one's health.

Table 1: SDOH and im... - Click to enlarge in new windowTable 1: SDOH and impact examples

Generally, it's solely the role of the case manager to incorporate SDOH into the comprehensive view of the patient as he or she transitions from one setting to another. However, it's clear that there are gaps in this model. Evidenced by the addition of a multitude of positions in acute care settings that address transitions, such as transitional care coordinators, transitions coaches, and navigators, there are alternatives to this approach. Clinical nurses have a unique perspective on the patient and are capable of leveraging this knowledge by incorporating SDOH in their practice. Collaborating with case management, clinical nurses enhance collaboration with other sectors, such as housing, transportation, and food services, to improve transitions and, thus, improve population health.


Because nurse leaders are instrumental in the development and refinement of both care transitions and PHM programs, it's our charge to ensure the connectivity of the two initiatives. Further, nurse leaders support clinical staff members and advocate for their input to affect care outcomes through leveraging their knowledge of the patient's SDOH. Elevating the importance of incorporating SDOH begins as an adopted strategy and a value-based philosophy.2


Community health needs assessment

Healthcare organizations, no matter their location or type, serve a particular community of people. Further defined within that community are specific populations. As a requirement of Section 501(r) of the Internal Revenue Code, tax-exempt hospitals have long been required to conduct a formal community needs assessment. Recent changes in legislation, including the Affordable Care Act, require hospitals to demonstrate community benefit by adopting a strategy to meet identified community health needs. These efforts are generally a collaboration between the hospital and the community health agency. The result of a community health needs assessment leads to understanding how the SDOH are influencing the health of the population.3


Nursing leadership shoulders the responsibility of formally communicating the results of a community health needs assessment to the staff. Within these assessments, data emerge regarding the SDOH of specific populations, influencing care approaches and improving care transitions. When clinical nurses address the role of SDOH in their practice, it allows for the provision of high-quality, comprehensive care.


More often than not, nurses appreciate full immersion in their patient's lives, even for the short periods of time that they interact with each other at the bedside or in other settings. This allows nurses to serve as ambassadors of health by utilizing innovative ways to guide patients to improved health outcomes. Including information from the community health needs assessment in their practice, specifically SDOH, clinical nurses can assist in the reorientation of the healthcare system to become truly patient-centered.


By including questions about SDOH in the initial assessment and ongoing patient interactions, treatment and follow-up plans through care transitions become more robust. For example, if a patient is unable to access healthy food, but the discharge plans include transitioning to a low-salt, low-fat diet, strategizing on resources to meet this need will lead to better outcomes. Through interdisciplinary collaboration, clinical nurses can identify resources that bridge the need gap.


Bringing it all together

Utilizing a holistic approach to patient care is frequently a focus in healthcare. Have we actually achieved this goal? Not yet. But through the lens of SDOH, care transitions, and PHM, we're getting closer.




1. Institute of Medicine. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: National Academies Press; 1997. [Context Link]


2. Community Health Improvement Partners. Charting the course. [Context Link]


3. Stoto MA. Population health in the Affordable Care Act era. [Context Link]