The challenge

It can often be difficult for clinicians to identify barriers in care plan adherence stemming from social determinants of health, which can result in readmissions.

The organisation

Mount Sinai Health System, a seven-hospital health system based in New York, US, piloted a programme for highest risk patients to improve care plan adherence and prevent avoidable readmissions.

The approach

In addition to existing clinical screenings, Mount Sinai interviews patients to uncover social risk factors and then connects them to specific interventions that address barriers to care plan adherence.

The results

For patients enrolled in the programme, Mount Sinai saw a 43% reduction in hospitalisations, 54% reduction in ED visits, and saved $1.6M USD.