Harnessing AI for compassionate care: Identifying and supporting patients with social determinants and medical complexity

The ability to identify and address social determinants and factors which address patient complexity and vulnerability prior to a discharge from hospital is challenging in clinical practice. Yet addressing these very social determinants is critical to providing more compassionate care plans to address post discharge needs. Social needs like financial or housing security, language preference or health literacy, transportation needs, social connection can impact the transition home and lead to unnecessary visits back to the emergency department when not addressed. Karen’s project uses an advanced machine learning model to improve the capture of social needs following an admission to hospital for patients enrolled in a new model of integrated care. The use of this model is expected to enable healthcare systems to better prepare, support and improve patient outcomes and experiences for patients transitioning home from hospital admission.