Research From the Field

Caring Beyond Health Care: Lessons Learned From a Community-Based Partnership to Reduce Hospital Readmission Among High-Risk Adults


  • Raven H. Weaver
  • Cory Bolkan
  • Susan L. Robbins
  • Brooke Benton
  • Eunsaem Kim
  • Melissa Ensey
  • David Kelly


As population aging increases demands on the U.S. health care system, strong public outreach regarding community supports for older adults and clear partnerships between medical and community-based services are needed to identify, serve, and yield better health outcomes, especially for the most vulnerable populations. In this exploratory observational study, we aimed to implement a collaborative pilot project involving a cross-sector partnership between a community-based aging services organization (Area Agency on Aging) and a medical center, with the goal of reducing hospital readmissions. The medical center screened low-income, high-need, community-dwelling adults for social determinants of health (SDoH) needs prior to hospital discharge and actively referred individuals for community support. We report on the development and feasibility of the pilot implementation of a standardized SDoH screening and referral protocol. We also explored the impact of the screening intervention by examining the frequency of hospital readmissions in the 6 months pre- and postintervention. Among 99 patients screened, almost half had SDoH needs. Patients who were referred and subsequently used community-based services experienced a significant reduction in hospital readmissions. We discuss lessons learned about communication, data collection, and staffing issues that can inform future research on community-level processes and changes that can benefit a growing and diverse population of adults with complex care needs. Clinical-community partnerships contribute to sustainable practices that benefit vulnerable populations by providing care beyond the traditional health care setting—and ultimately support patients with high needs in their homes and communities.

  • Year: 2021
  • Volume: 14 Issue: 1
  • DOI: 10.54656/NWMT3812
  • Published on 27 Jul 2022