Tearing Down SDoH Barriers to Discharge During a Pandemic

by Mary Kay Thalken, RN, MBA on Aug 26, 2020

COVID Patient StrugglingThe highly infectious nature of the coronavirus has led many to make the claim that COVID-19 doesn’t discriminate.

But that’s not entirely true.

We know, for instance, that while anyone can contract the virus, socioeconomic factors actually play a critical role in determining the likelihood of exposure. Anyone whose job by necessity dictates that they work in close quarters or in a retail setting where they’re making regular contact with outside parties, is at far greater risk of contraction than someone who is able to work remotely, in isolation.

Similarly, socioeconomic factors can play a role in continued transmission and access to care. Homes with large families living in close quarters can be a super-spreader event all their own. Among those who become ill, persons with insurance, access to high-quality care, and the proper support system are going to generally fare better than those who don’t have those things.

There’s yet another area where the social determinants of health play a role, and that’s in discharge. Someone with employer-sponsored health insurance coverage, transportation, a large home and a remote work situation is far easier to discharge than an individual who has none of those things. The social determinants of health have an outsized impact not just on COVID transmission and treatment, but in your ability to transition patients to the next step in their care journey.

Case managers who solve for the social determinants of health can therefore remove barriers to discharge, freeing up bed space and enabling the patient to progress in his or her recovery. Here’s how to tear down some of those impediments to success.


Perhaps the biggest roadblock to a successful discharge is the availability of a care setting that can accept that patient.

This can primarily happen in two ways. First is if the patient has recovered sufficiently to be discharged but still needs some type of post-acute care. You could be prevented from a successful referral due to a lack of available facilities with bed space, PACs’ inability to treat COVID patients, insurance incompatibility, a patchwork series of rules and regulations regarding COVID discharge in your area, or some combination of all of the above.

The second issue is if the patient is deemed clinically eligible to recover at home but they actually don’t have a home acceptable for COVID recovery. For instance, if they’re homeless, live in a shelter or share a small space with a large number of other people, home discharge gets much more difficult. After all, recovering COVID patients should have their own habitable space, including a bed and bathroom.

The first issue mentioned can be solved by working with your post-acute providers to gauge their ability to accept COVID patients and establish a real-time look at the number of beds available. When this still isn’t sufficient, some hospitals have turned to essentially creating their own post-acute spaces out of existing facilities, a move made possible thanks to recent flexibility from CMS.

The second issue requires a little more creativity. In some areas, local governments and community organizations have turned hotels into de facto recovery spaces, where COVID patients without the proper shelter can go to quarantine. Look into the options that exist in your area to see if this might be a possibility for some of your patients that have nowhere else to go.

Nutrition and Medication

I’m grouping nutrition and medication together because they share very similar DNA.

In order for an individual to be discharged either home or to a post-acute setting, they need to have a steady supply of both food and prescribed medications. Because the patient will be unable to go to the grocery store or a pharmacy given their condition and need to quarantine, it’s essential that something be done to help them procure these essential items.

Grocery and Medication DeliveryCase managers can and should communicate with local businesses, such as grocers and pharmacies (or online providers of food delivery and prescriptions), in order to have items ready for the patient when they arrive at their next care setting and to set up delivery of these items on a set schedule.

One important thing to note: with the cutbacks that have taken place at the United States Postal Service, it’s more important than ever to get an ETA on item delivery and to follow up to ensure the delivery occurred. This is an added step for care managers, but it’s essential in order to keep the patient’s recovery on track. A missed prescription or food drop-off could lead the individual to break their quarantine or even suffer a lapse that leads to readmission, so make sure every part of the plan is executed as it should be.


We’ve previously covered how important transportation can be in a patient’s post-acute recovery from COVID. If a patient doesn’t have the proper transportation, their discharge can be delayed, they’re at greater risk of missing follow-up appointments, and their ability to secure other resources, such as the aforementioned food and prescriptions, is compromised.

Case managers can work with local transportation providers to solve for some of these issues. First, you should have a program in place to schedule pick-ups and drop-offs with patients who need them. Ideally, you would be able to do this instantly from a secure online portal that offers a real-time view into where the transportation provider is, how long until arrival, any check-ins that need to occur along the way, etc.

But don’t stop there. If you know your patient is under quarantine or otherwise unable to secure their own transportation, then case managers can look ahead to upcoming appointments and set up pick-ups accordingly. This requires quite a bit of follow-up and even some handholding, but that’s always going to be better than readmission. And when it comes to connecting the patient with other resources, there might be transportation options in your area that can also handle grocery and prescription pick-up and drop-off.

Programs like these can help you reduce the risk of readmission and further transmission of the virus.

Support Systems

Finally, one social determinant that absolutely can’t go overlooked is human connection.

COVID is a lonely disease. The very companionship we crave when we’re ill is impossible when the act of being near family, friends and community can lead to a dangerous retransmission of the virus.

Caregiver Socially Distant Visit

When quarantine is a fact of life for the foreseeable future, you can still make a real difference as a caregiver. Whether it be setting up Zoom for an elderly patient who wants to be able to connect with her social circle, teaching someone who wants to go to church just what a Facebook Live stream is, or explaining and scheduling telehealth or even telepsychiatry appointments, you can do so much to treat the “loneliness” aspect of COVID-19.

In addition, a simple check-in by an in-home caregiver can be enough to brighten an individual’s day. You would obviously want to take precautions (masks, disinfectant, PPE, etc.), but looking in on a patient can ensure they’re continuing on the path to recovery, are sticking to prescribed guidelines from the physician and are just generally doing okay.

Addressing the social determinants of health is a step we cannot overlook during the COVID-19 pandemic. Case management teams have a variety of tools at their disposal to ensure discharged patients don’t turn into readmitted patients.

By solving for these problems ahead of time, you can even speed up discharge and patient referrals, thereby reducing avoidable days and creating a win-win scenario.

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Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.