Point of View: Reducing Readmissions Using Patient Perspective and Social Determinants of Healthcare

“Potentially preventable readmissions” have been connected to insufficient or ineffective discharge strategies. Case managers have long made the connection between Social Determinants of Healthcare (SDoH) and increased risk for readmission through anecdotal observation. Failure to create overarching strategies to address the gaps caused by SDoH continues to impact the care continuum’s ability to adequately equip the patient for success post-discharge.

A review of literature demonstrates that addressing the patient’s “point of view” through survey of risk focused on SDoH has been successful at creating better linkage and access to care/services needed by patients to self-manage their health. Using a survey tool based on the “PRAPARE” survey (used in outpatient settings), CM RN & SW can identify and address gaps in self-management; linking patients to resources in the community on an individual basis and use the data to build out the “resource library” for the population as a whole. This project has been designed to identify the needs of the high-risk patient population but can be easily adapted to any patient population.

Recognizing that responsibility for the patient in this healthcare environment does not end at the discharge from the hospital, conclusion of service or end of the appointment, identifying patient’s extra-medical needs that may impact successful self-management of health, drawing from the resources of the patient's entire community is indeed a necessity to provide the patient with excellent patient-centered care, promote client self-advocacy and independence in alignment with the CMSA Standards of Practice.

Learner Outcomes:

At the end of the presentation, the learner will be able to:

  • Discuss the current state of Readmissions Reduction Initiatives.
  • Describe the impact of Social Determinants of Healthcare on Readmissions.
  • Analyze data collected in “Point of View” project and determine how to utilize data gathered to impact patient care on individual and population levels.

This content will apply to the following Ethical Principles (Commission for Case Manager Certification 2015) Principles.  Board certified Case Managers will:

  • Principle 2 respect the rights and inherent dignity of all of their clients.
  • Principle 5 maintain their competency at a level that ensures their clients will receive the highest quality of service

This content will apply to the following Ethical Principles and Standards (National Association Code of Ethics, 2017). 

  • Ethical Principles:
    • Service 
    • Social Justice
    • Dignity and Worth of the Person
    • Competence 
  • Ethical Standards:
    • 1: Social Workers’ Ethical Responsibility to Clients
      • 1.01 Commitment to clients
      • 1.02 Self-determination
      • 1.04 Competence
      • 1.05 Cultural Awareness and Diversity
      • 1.08 Access to records
      • 1.12 Derogatory Language
      • 1.16 Referral for Services
    • 3: Social Workers’ Ethical Responsibility in Practice Settings
      • 3.04 Client Records
      • 3.07 Administration


Colleen MorleyColleen Morley DNP, RN, CMCN ACM-RN is the Director of Case Management Services for West Suburban Medical Center in Oak Park, IL and Westlake Hospital in Melrose Park, IL under the Tenet System.

Colleen has over 19 years of nursing experience. Her clinical specialties include Med/Surg, Oncology and Pediatric Nursing.  Her passions in nursing include the promotion of professional development and continuing education and studying the readmission issue to develop solution programs.

She is active with CMSA Chicago; currently serving as President-Elect for 2017-19 and has been on several national-level committees for CMSA (Education, Awards), ACMA (Membership) and AAMCN (Education and Membership). Additionally, she currently holds the position of Director on the ANA-IL Board of Directors, serving as Legislative Committee Chair and PAC Trustee.