Effects of Social Determinants of Health on Outcomes of Older Patients in a Long-term Acute Care Hospital and Experiences of their Family Members

Abstract

AbstractBackground: Older adults (≥ 65 years) with chronic critical illness (CCI) who are discharged to long-term acute care hospitals (LTACHs) often experience suboptimal outcomes, including prolonged hospitalizations, increased readmissions, and a high mortality rate. As a result, their families may experience psychosocial and emotional challenges, including higher risks for depression, anxiety, grief, and post-traumatic stress disorder (PTSD). Although clinical factors influence patient outcomes, social determinants of health (SDoH) have critical yet poorly understood effects on outcomes in the LTACH population. This dissertation examined the association between SDoH, clinical risks, and outcomes among older adults with CCI in a LTACH and described the experiences of and challenges facing family members serving as caregivers for this population. Methods: The Center for Latino Adolescent and Family Health (CLAFH) framework guided this 3-study dissertation: a scoping review, an exploratory mixed-methods study, and a quantitative secondary data analysis. The scoping review was guided by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and included studies that examined the underlying social conditions that contribute to patient outcomes (N = 5). Five family members and four health care providers (HCPs) (N = 9) participated in the mixed-methods study. A direct content analysis of the interview transcripts was conducted using a priori codes from the Adaptive Leadership Framework for Chronic Illness (ALFCI). Electronic health records were analyzed for older adults with CCI discharged to a LTACH from January 1, 2014, to December 31, 2024 (N = 802). Latent profile analysis identified distinct clinical risk profiles, and nested logistic regression models examined associations among SDoH, clinical profiles, and 30-day composite outcome.Results: Findings indicate that the current literature focused on SDoH within the LTACH setting has predominantly concentrated on only three of the five established domains: social and community context, economic context, and health care access and quality. Race was a key demographic variable in three studies that examined its association with outcomes such as mortality, morbidity, readmission rates, and health care costs. Moreover, the following four themes were identified in the interview transcripts: family members’ adaptive challenges, adaptive work, HCP-described family adaptive challenges, and HCPs’ technical work. Family members’ adaptive challenges included communication challenges, care expectations, and individual challenges, and their adaptive work included voicing concerns, advocating for their loved ones, setting expectations, and coordinating with other family members. Health care providers’ technical work focused on communication strategies and collaborative work with family members. The secondary data analysis identified five clinical risk profiles, with patients in Classes 4 and 5 exhibiting increased risk. Model 4, comprising SDoH and clinical risk profiles, demonstrated improvements in calibration, discrimination, and explanatory power for predicting the 30-day composite outcome compared to Models 1, 2, and 3. Medicare insurance and living in large rural communities were independently associated with the outcome. Conclusions and Implications: This dissertation explored both social and clinical risks associated with outcomes among older adults with CCI in LTACHs and described their family caregivers’ experiences. The findings of this dissertation support the conclusion that clinical risks alone are insufficient for risk stratification and underscore the importance of considering social context when examining disparities in health outcomes. Given the limitations in methodology and in the literature exploring SDoH in the LTACH setting, more research is needed to establish causal pathways and describe the spatiotemporal relationships among SDoH capital, exposure, susceptibility, family caregiver adaptive challenges, and work, and how these factors contribute to disparate outcomes among older adults with CCI.