Social Determinants of Health and their Impact on Establishing Heart Failure Care in a Clinic for the Underserved

Stephen Clarkson, M.D., MSPH
University of Alabama at Birmingham 

Heart failure (HF) is a chronic and progressive disease with considerable complexity that requires long-term management. Patient-level factors in caring for heart failure include assessing and addressing the social determinants of health (SDOH) to provide effective patient-centered care. Although associations between SDOH and heart failure have been established, questions remain about how best to implement SDOH screening tools and operationalize data in order to better address patient-level risk for adverse outcomes. Access to holistic interprofessional HF care, provided by a team that includes cardiologists, nurses, pharmacists, dietitians, and social workers, is needed to reduce disparities through providing ethical health care services, being respectful of patients and families, and considering the contributions of each team member.

The purpose of this study is to examine whether SDOH data available during an index inpatient hospitalization can be used to identify those patients most likely to miss their follow up visit at an interprofessional heart failure clinic. This work is the first step needed to develop an early intervention that can facilitate successful linkage to care for high-risk low-income patients.