Enhancing outcomes for geriatric patients with evaluation of the social determinants of health

BACKGROUND: Homebound geriatric patients face multiple healthcare access barriers, with social determinants of health (SDOH) significantly impacting clinical outcomes. Despite evidence supporting the use of SDOH screening, systematic assessment remains underutilized in geriatric home care settings. 

PURPOSE: This Quality Improvement project enhanced healthcare outcomes for homebound geriatric patients by implementing systematic SDOH screening using the PRAPARE assessment tool and establishing community resource referral pathways. 

METHODS: An 8-week pre-post implementation study was conducted at a homebound geriatric practice in the Southeastern United States. Advanced Practice Providers used the PRAPARE screening tool during routine patient visits. The study measured screening rates, identification of social determinants of health (SDOH) diagnoses, and community resource referrals through descriptive statistics and pre-post comparative analysis. Chi-squared tests examined associations between patient demographic characteristics and the likelihood of receiving SDOH diagnoses. 

RESULTS: The project completed 654 SDOH screenings, marking a 70% increase from baseline levels. Twenty-one distinct SDOH diagnoses were documented, with education and literacy issues being most prevalent (56.5%), followed by housing and economic challenges (44.0%). All identified diagnoses prompted specific community resource referrals, with 45.6% of patients receiving referrals to community services. Post-implementation data revealed a 58% improvement in SDOH identification rates compared to the pre-intervention baseline. 

CONCLUSIONS: Systematic SDOH screening through the PRAPARE tool substantially enhanced the identification of social health barriers among homebound geriatric patients. This quality improvement initiative validates the value of incorporating structured SDOH assessment into standard geriatric care practices, improving patient-centered care delivery and optimizing resource connections. Future efforts should focus on expanding screening protocols and developing stronger community partnerships.