How Social Determinants of Health Impact Transitional Care

What Is Transitional Care and Why Is It Important?

Transitional care refers to the coordinated services that support patients as they move between healthcare settings. It’s essential because it:

Reduces hospital readmissions
Improves safety and continuity
Enhances patient satisfaction
Addresses both clinical and social needs

Continuity of care in transitional settings is essential for ensuring that patients receive comprehensive support during critical health transitions, minimizing gaps in treatment and enhancing overall outcomes. In today’s value-based environment, transitional care—when implemented with equity in mind—serves as a cornerstone for improved patient outcomes and more sustainable health care delivery. Learn more about our Transitional Care framework.

Understanding Social Determinants of Health

The World Health Organization defines SDOH as “the non-medical factors that influence health outcomes.” These include:

Economic stability (e.g., income, employment, housing)
Education access and quality
Health care access and quality
Neighborhood and built environment
Social and community context

These elements shape health behaviors and influence whether individuals can adhere to discharge instructions, attend follow-up appointments, or manage chronic conditions such as congestive heart failure or cognitive impairment.

Social Determinants of Health factors contributes to healthy people

Social Determinants of Health and Transitional Care

Transitional care services (TCS) are designed to ensure continuity and coordination of healthcare as patients move between different care settings—such as from hospital to home or from acute care hospitals to rehabilitation services. While these services are clinically focused, their effectiveness is deeply influenced by factors that extend beyond traditional medical care. Social determinants of health (SDOH)—the conditions in which people are born, live, work, and age—play a critical role in the success or failure of transitional care across diverse health care settings.

The Interplay Between SDOH and Transitional Care

Economic Stability and Housing Insecurity

Patients without stable housing are at a disadvantage from day one. No refrigeration for medications? No place to recover safely? Transitional care simply cannot succeed under these conditions. Patients who lack stable housing face significant challenges in post-discharge recovery. This is particularly critical for individuals with complex care needs, who may require assistive devices, medications, or ongoing restorative care.

Why it matters:
Discharge planning that fails to address housing or transportation can result in poor patient outcomes. Case management and social work are essential to link patients to housing assistance and community-based supports during the discharge process. Housing support must be built into the discharge plan—not added as an afterthought.

Transportation: The Hidden Barrier

A patient misses their follow-up appointment—not because they didn’t want to go, but because they couldn’t get there. This scenario plays out every day across healthcare systems. Limited access to transportation services impedes follow-up appointments, especially for patients being discharged from acute care facilities. These missed visits increase the risk of complications and readmissions.

Why it matters:
Transportation programs integrated into transitional care services drastically reduce missed appointments and complications. Programs that include transportation solutions improve coordination of care.

Low Health Literacy and Education: When Words Fail

A prescription label or discharge summary might seem clear to clinicians—but for patients with limited health literacy, these instructions can be overwhelming or misunderstood. A growing body of evidence shows that patients with limited health literacy are more likely to experience complications during care transitions.

Why it matters:
Simplified communication, teach-back methods, and culturally tailored education significantly reduce preventable complications. To improve quality of care, health professionals must provide clear, accessible communication.

Food Insecurity and Nutrition Deficits

A patient recovering from heart failure is advised to follow a low-sodium diet—but doesn’t have access to nutritious food or even a kitchen. Comprehensive discharge planning for patients recovering from acute illness should include screening for food insecurity, especially in older people or patients with dietary restrictions related to blood pressure or diabetes.

Why it matters:
Nutrition services, food delivery programs, and community partnerships can transform recovery outcomes by making dietary instructions actionable. Connecting patients with food delivery programs or nutrition education can enhance quality of life and reduce preventable complications post-discharge.

Mental Health and Social Isolation

Depression, anxiety, or simply the lack of a caregiver can derail a recovery plan. Patients without emotional or social support are more likely to fall through the cracks. Social support is a known protective factor in reducing hospital readmissions. Lack of family or caregiver support places high-risk populations—such as older adult patients or those with heart failure—at greater risk.

Why it matters:
Including behavioral health screening and caregiver engagement in transitional care helps keep patients connected, engaged, and empowered. Involving family caregivers and conducting behavioral health assessments supports stronger patient satisfaction and engagement, especially for patients recovering in different locations or those with limited access to care.

Transitional Care and Healthcare Equity

Addressing Disparities in Access and Outcomes

Transitional care isn’t just a medical process—it’s a justice issue. Historically marginalized communities face deeper and more complex barriers during care transitions. Structural racism, language barriers, income inequality, and geographic isolation all increase the risk of poor outcomes. Transitional care plays a critical role in advancing health equity, particularly for historically marginalized patient populations. During periods of transition—such as after an episode of hospital care—individuals face elevated risks that are often compounded by structural disparities.

Populations impacted by racial, linguistic, or economic barriers often experience fragmented health care services, poor follow-up, and worsened health outcomes. These groups are more likely to lack access to quality health care providers or rehabilitation services.

Transitional care in these communities must include:

Culturally and linguistically appropriate services (CLAS)
Referrals for housing and transportation
Health education tailored to appropriate literacy levels
Integration with trusted health professionals and community-based organizations
Screening and response tools for SDOH risks embedded in every care transition

Integrating Social Determinants of Health

Effective transitional care models recognize that treating the medical condition is not enough. Addressing SDOH—such as food insecurity, caregiver absence, or unsafe home environments—is essential to supporting vulnerable populations, especially Medicaid patients with chronic conditions. The value of transitional care is seen in our ECM services, read about our Enhanced Care Management and transitional services.

Multidisciplinary teams at the center of these models include:

Social workers
Peer support specialists
Housing and legal resource navigators

These teams are supported by insights from randomized controlled trials, systematic reviews, and data from across the nation.

Policy and Program Alignment

Federal and state agencies are advancing equity-based models of care:

CMS links payment incentives to reductions in disparities in hospital care
California’s ECM and Community Supports target high-risk individuals with complex needs
Medicaid 1115 waivers fund pilots for foster youth, unhoused populations, and justice-involved patients

These policy shifts aim to improve patient outcomes and reduce health care costs.

Health policy advances Transitional Care

What Presidium Health Is Doing to Address SDOH and Advance Equity Through Transitional Care

At Presidium Health, we believe that advancing health equity begins with reimagining transitional care from the ground up. Our programs are designed not just to reduce readmissions but to bridge the systemic gaps that disproportionately affect vulnerable, high-risk patients.

Multidisciplinary, Equity-Driven Care Teams

Presidium Health deploys multidisciplinary care teams trained to assess both clinical and social risk factors. These teams—comprised of nurses, care coordinators, social workers, behavioral health specialists, and community health workers—identify barriers such as food insecurity, housing instability, or limited caregiver support early in the discharge planning process.

Comprehensive SDOH Screening and Navigation

We embed comprehensive SDOH screening into our care transitions workflow. These screenings are standard practice- not optional extras. Patients are connected to vetted, culturally aligned resources in real-time through our community partner network.

Integrated Medical and Social Care Coordination

Presidium's model integrates clinical care (e.g., medication management, chronic disease monitoring) with social supports (e.g., food delivery, home environment assessments). Our goal is not only to facilitate safe discharges, but to ensure continuity across levels of care—especially for patients with complex care needs or limited family support. We break the silos between the social services and clinical teams.

Cultural Competence and Community Trust

We prioritize cultural humility in all patient interactions. Our staff reflects the linguistic and cultural diversity of the populations we serve. Through ongoing training and community partnerships, we help reduce medical mistrust and empower patients in their care journey.

Measuring Equity and Impact

We don't just track clinical outcomes—we measure: SDOH resolutions rates and referrals, patient-reported barriers and satisfaction, engagement rates, and improvements in long term quality of life. Our data supports a scalable, replicable model to reduce disparities and improve care transitions for individuals at the intersection of medical and social vulnerability.

Technological Access and Remote Support

Understanding that digital inequity affects follow-through, Presidium provides: Telehealth access with language support, mobile-enabled communication tools, and remote monitoring for chronic conditions like heart failure. This ensures consistent engagement even when patients face transportation or mobility barriers.

State and Federal Program Alignment

Presidium actively participates in CalAIM's ECM and Community Supports programs, targeting individuals with acute illness, behavioral health challenges, housing instability, and transitions of care needs. This includes spear-heading a technology-based pilot program aimed at improving transitions of care for underserved populations.

Looking Ahead: Toward Equity-Centered Transitional Care

Transitional care has the power to improve lives- when done right. That means looking beyond discharge instructions and into the realities of people’s lives. Whether it’s helping an older adult safely recover at home or ensuring an individual has access to healthy food and follow-up care, addressing SDOH is what transforms good care into great outcomes. The transitional care landscape is shifting toward equity, context, and quality of life. Presidium Health’s Transitional Care is leading the transformation- one transition, one patient, and one community at a time.