Date of Degree
Summer 2025
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Lydia Forsythe
Second Advisor
Dr. Corinne Cochran
Third Advisor
Dr. Melanie Brewer
Abstract
Problem: Unmet social needs contribute to hospital readmissions and extended inpatient stays, placing strain on care coordination and hospital throughput. Social Determinants of Health (SDOH), such as housing instability, lack of transportation, or food insecurity, are often unaddressed in clinical workflows. At the project site, a gap in effectively integrating SDOH into the discharge planning process led to delayed discharges and increased length of stay (LOS). Additionally, 41.20% exceeded the Geometric Mean Length of Stay (GMLOS), surpassing the organizational benchmark of 40.17%. Gaps in standardized assessment and communication of SDOH data limited the ability to plan timely discharges and connect patients with needed resources.
Aim of the Project: To improve discharge planning and reduce the percentage of patients exceeding GMLOS by increasing the completion and discussion of SDOH assessments during Multidisciplinary Rounds (MDR).
Review of the Evidence: Literature supports integrating SDOH screening into clinical practice to address barriers to discharge and reduce avoidable hospital utilization. Evidence also emphasizes that standardized communication of social risk data among care teams improves coordination, reduces readmissions, and supports patient-centered care.
Project Design: A quality improvement (QI) project using the Plan-Do-Study-Act (PDSA) model and the OhioHealth Change Management (OHCM) framework guided implementation and evaluation. The initiative took place in a 24-bed medical-surgical unit.
Intervention: The Core 5 SDOH assessment tool was implemented at admission, and SDOH findings were integrated into daily MDR. Staff were trained in identifying social needs, documenting findings, and initiating referrals.
Significant Findings/Outcomes: Post-implementation, 63% of patients had completed SDOH assessments, and 72% of completed assessments were discussed in MDR. Six patients screened positive, and all received care management consults. While GMLOS increased slightly to 41.55%, MDR efficiency was maintained at an average of 1.69 minutes per patient. The project identified workflow inconsistencies and underreporting of social risks, signaling areas for future improvement.
Implications for Nursing: This initiative demonstrates the feasibility and clinical value of embedding SDOH assessments into nursing practice and interdisciplinary care. Nurses play a vital role in identifying social barriers early and advocating for appropriate interventions. Standardizing SDOH workflows enhances care coordination, supports equity, and improves readiness for discharge contributing to more efficient and holistic patient care.
Recommended Citation
Beck, Erika, "Patient-Centered Approach to Decrease Length of Stay" (2025). Doctor of Nursing Practice (DNP) Scholarly Project. 30.
https://fuse.franklin.edu/dnp-project/30
Rights
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