A Social Determinants and Transitional Care Framework for Reducing Heart Failure Readmissions in Urban Safety-Net Hospitals

Abstract

Heart failure (HF) is one of the most common reasons adults return to hospital shortly after discharge,
and urban safety-net hospitals bear a heavier share of this burden than other institutions. Their patients
are more likely to live with low income, unstable housing, food insecurity, limited English proficiency,
and weak links to outpatient care, and these conditions make it difficult to obtain medications, monitor
symptoms, and attend follow-up during the weeks after discharge. Transitional care programs have
reduced readmissions in many settings, yet they have generally been designed around education and
clinical follow-up, treating social circumstances as background barriers rather than as conditions that care
can change. This conceptual study addresses that gap by developing a framework that brings the social
determinants of health into the design of transitional care for adults hospitalized with HF in urban safetynet
hospitals. The framework was built through theory synthesis and integrative review, drawing together
perspectives on the social determinants of health, multilevel influences on behavior, the experience of care
transitions, and self-care in chronic illness. The resulting model explains that unmet social needs raise
readmission risk both directly and by weakening self-care, medication adherence, and timely follow-up.
It proposes that hospitals respond by identifying social needs during admission, matching the intensity of
support to combined clinical and social risk, adapting the discharge plan to each patient’s circumstances,
sustaining contact through community health workers and early follow-up, and connecting patients to
community services until their needs are resolved. These processes are expected to reduce readmissions
and improve survival, quality of life, and costs, while narrowing the gap in outcomes between socially
advantaged and disadvantaged patients. The framework is set within the financial, organizational, and
policy realities of safety-net hospitals and recognizes that clinical severity and patient preferences shape
what care is appropriate. It is accompanied by testable propositions, construct definitions, and candidate
measures, and by guidance on implementation and evaluation in resource-constrained settings. The study
concludes that treating social risk as a modifiable part of transitional care offers a practical and equitable
route to fewer heart failure readmissions, and it provides clinicians, nurse leaders, and researchers with
a structured basis for designing, testing, and scaling such interventions.