# Social Needs and Resources in the Evaluation and Enhancement of Discharge Support: The NEEDS Study

> **NIH AHRQ R01** · UTAH STATE HIGHER EDUCATION SYSTEM--UNIVERSITY OF UTAH · 2020 · $400,000

## Abstract

PROJECT SUMMARY
 Of the nearly 35 million Americans discharged to community settings after an acute hospitalization, 18%
require re-hospitalization for the same or related condition within 30 days. Research continues to document
how social needs (e.g. food and housing insecurity) and supportive resources (e.g. instrumental social support)
play important roles in health outcomes, including hospital readmissions. Yet, while assessment at admission
is required for hospital certification bodies and payers, our previous research has identified that inpatient teams
are often unaware of patients’ social needs and supportive resources, and lack of agreement on the day of
discharge between patients and nurses regarding readiness for hospital discharge (an assessment of personal
status, knowledge, coping ability, and expected support) is associated with patient coping difficulties and
hospital readmissions. These findings suggest that facilitating communication between patients, family
members, and inpatient health care providers regarding patients’ social needs and resources holds high
promise for developing more informed discharge plans, and for improving patient outcomes (e.g., readiness for
hospital discharge, decreasing readmissions). The objective of this study is to provide inpatient health care
teams with information about patients’ social needs and supportive resources, evaluating whether it facilitates
clinical decision-making, impacts readiness for hospital discharge and, ultimately, reduces hospital
readmission. The aims of this study are to 1) test the effect of assessing and communicating patients’ social
needs and supportive resources on health team- patient- caregiver- outcomes; 2) test the effect of social needs
and supportive resources assessment on discharge planning processes; and 3) examine provider and patient
experiences of social needs and supportive resources assessment. Using an interrupted time series design
and regression discontinuity analysis, we will test the effect of communicating results of a social needs and
supportive resources assessment findings to medical and surgical inpatient teams during routine discharge
planning rounds. The overall hypothesis is that inclusion of patients’ social needs and supportive resources
during inpatient care will result in higher and more congruent readiness for hospital discharge ratings (between
patients, caregivers, and members of their health team) compared to patients without social needs and
supportive resources assessment. Because patients’ social needs and supportive resources are not uniformly
or universally assessed, results of this study will provide health systems additional information about factors
placing patients at risk for poor outcomes after discharge, and identify whether integrating social needs and
supportive resource information informs and improves clinical care delivery.

## Key facts

- **NIH application ID:** 10004637
- **Project number:** 5R01HS026248-02
- **Recipient organization:** UTAH STATE HIGHER EDUCATION SYSTEM--UNIVERSITY OF UTAH
- **Principal Investigator:** Andrea Schneider Wallace
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $400,000
- **Award type:** 5
- **Project period:** 2019-09-01 → 2022-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10004637

## Citation

> US National Institutes of Health, RePORTER application 10004637, Social Needs and Resources in the Evaluation and Enhancement of Discharge Support: The NEEDS Study (5R01HS026248-02). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10004637. Licensed CC0.

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