Leveraging the Transitional Care Model Intervention to Identify and Mitigate Adverse Social Determinants of Health.

Adverse social determinants of health (SDoH) often contribute to poor patient health outcomes after hospitalization. Although transitional care interventions can help prevent negative outcomes as patients transition from hospital to home or other health care settings, using a one-size-fits all approach may overlook chances to improve outcomes for older individuals with chronic illnesses, especially minority older adults who are disproportionately affected by adverse SDoH. Using the lens of the 5 domains of the Healthy People 2023 SDoH framework, we show how SDoH can be integrated in an evidence-based transitional care intervention such as the transitional care model (TCM) to prevent adverse events (eg, avoidable emergency room visits and rehospitalizations after discharge). This flexible and adaptable approach can help improve outcomes for patients as they transition from hospital to home or other health care settings. We highlight opportunities for transitional care intervention teams and health care systems to identify and address SDoH factors using the TCM, an evidence-based and adaptable intervention demonstrated to reduce adverse events, health disparities, and health inequities.