Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans.

Objectives: (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index.

Data sources and setting: We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program.

Study design: We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk.

Data extraction: We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022.

Principal findings: The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA.

Conclusions: Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.