Social Environment Key to Less Rehospitalization Risk for Home Health Care Patients

“Social environment factors” play a big role in whether a senior who’s receiving home health care following a hospital discharge is likely to be readmitted within 60 days, finds a study published in Advances in Nursing Science.

Those factors can include the patient’s living situation and the amount of care provided by a family member or an informal caregiver.

“Understanding how social environmental factors contribute to home healthcare patients being rehospitalized would be assist in improving care for patients and in helping agencies deliver more cost-effective care while at the same time managing Medicare spending,” said Hong Tao, RN, PhD, of  the University of Wisconsin Milwaukee and colleagues in the report. 


More than one in five patients in the study of 1,268 seniors receiving home health care ended up back in the hospital following discharge, most within the first 20 days. Approximately 20% of hospitalized Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, the cost of which accounts for one-sixth of the total Medicare budget, according to a recent study. 

Patients’ recoveries in Dr. Tao’s study were linked to the social environment in which they resided and the effects of certain factors. The seniors’ ability to take care of themselves was influenced by their living arrangements and by the type and amount of informal care they received, the researchers found.

What’s needed for an optimal recovery is a balance between a patient’s clinical condition and his or her ability to provide self-care, they said. Those who were less able to care for themselves, whether because their condition had worsened or their care needs were more demanding, were linked to a higher risk of rehospitalization.


Getting care and assistance from informal caregivers also had an important impact on seniors’ self-care ability and rehospitalization, said the researchers. Those living by themselves were less likely to be rehospitalized, a correlation the study believes may result from a better ability to function independently and care for themselves. 

Understanding the correlation between a patient’s social environment and risk for rehospitalization could help reduce unnecessary readmissions, improve care quality, and cut costs, researchers believe.

“[Our] findings may help home healthcare nurses to recognize those patients who are in need of certain services that may reduce hospitalization, such as those that lack the support of the patient’s family or assistance from paid informal caregivers,” they write, as patients with good social environmental support are “more likely to have a higher functional ability and thus remain in their homes, the first choice of most patients.

Written by Alyssa Gerace