Rapidly Improving Health-Related Social Needs Assessment Through A National Collaborative

Introduction Heart Failure (HF) is projected to impact over 8 million people by 2030. The complexity of HF is compounded by adverse effects of social determinants of health (SDOH), defined as “conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life”. A 2020 study of Medicare beneficiaries hospitalized with HF found that patients burdened by a SDOH factor were associated with almost 3 times the risk of 90‐day mortality, compared to those without these factors. The American Heart Association recognizes the adverse impact of SDOH on HF patients and is driving efforts to improve assessing and addressing these factors. Hypothesis By leading IMPLEMENT-HF (I-HF), a national quality improvement initiative with a component focused on improving organizations’ assessment of health-related social needs (HRSN), we aim to increase the number of HF patients being assessed for HRSN to improve outcomes. Methods I-HF creates a transformative learning collaborative across seven U.S regions to coordinate care and improve the assessment of HRSN. Hospitals participating in I-HF collect data in Get With The Guidelines®-Heart Failure (GWTG-HF) on whether a HRSN assessment was completed on adult patients with a principal diagnosis of HF. HRSN assessment is defined in GWTG-HF as evaluating potential barriers impacting patient's access to healthcare services and social needs post-discharge. Data was collected from Q1-Q4 2021 for a comparison of I-HF participating hospitals versus non I-HF participating hospitals. Data was continuously evaluated to identify improvement areas discussed in 1:1 site meetings, and regional and national learning collaboratives. Multiple improvement strategies were implemented including barriers and model sharing, targeted training, resource development, and quality improvement consultation. Results As a result of this initiative, 63 hospitals participating in I-HF, began focused data collection on HRSN within GWTG-HF. Analysis of total patients assessed from Q1 through Q4 2021 is shown in Figure 1. Q1 indicated I-HF hospitals assessed only 4.0% of eligible patients, Q2 = 9.4%, Q3 = 22.4%, and Q4 = 25.3%, resulting in a 21.3% absolute improvement over the four quarters analyzed, demonstrating more rapid improvement compared to the non-I-HF participating hospitals (p value = 0.007). Conclusion Early results indicate positive association of using a targeted learning collaborative model to improve assessment of HRSN. I-HF continues to connect sites sharing challenges and strategies to further improve assessment of social needs. By obtaining assessment data, hospitals and regions can better identify and connect patients to available resources and reduce barriers to access.