Implementation of a Standardized Social Determinants of Health Screening Tool to Optimize Care Coordination and Clinical Outcomes for Hospitalized Patients with Type 2 Diabetes
Date of Doctor of Nursing Practice Project Completion
Spring 5-1-2026
Abstract
This quality improvement project implements a social determinant of health assessment corresponding with a specified screening tool tailored to type 2 diabetics. This tool will be used to assess patients admitted with a length of stay over 3 days and their potential barriers to compliance with outpatient treatment and then be handed off to case management to identify and implement appropriate resources. The hand-off tool will use a pre- and post-intervention strategy to assess the social determinants of health affecting 18 handpicked individuals with type 2 diabetes and identify the top determinants to improve the process for distributing resources.
The prevalence of type 2 diabetes within Harris County is highest amongst the Black (22%) and Hispanic (20%) populations (State, 2018). The background of Pasadena, TX is in a predominantly Hispanic community with a low socioeconomic status, education, and financial status, which are all contributing factors to decreased outpatient care.
The intervention was developed from previously used social determinants of health screening tools, in addition to barriers that contribute to type 2 diabetes. The key quantitative findings were used to summarize demographics, the prevalence of SDOH- social determinants of health, and increased identification. However, time constraints were being considered for health improvement measurements. The results showed that within this community, there are 23% of individuals with food insecurity, 22.2% that don’t understand their anti-diabetic medication at all, 16.7% lack insurance, 38.9% have Medicare, and 22% have Medicaid as well, which are all indicating factors contributing to potential non-compliance and hospital re-admissions.
Keywords
Type 2 diabetes, Social determinants of health, Improved patient outcomes related to social determinants of health, Screening tool, Hand-off, Compliance with diabetic care, Pasadena TX, HCA Healthcare Houston
Recommended Citation
Breanna Jemmott, "Implementation of a Standardized Social Determinants of Health Screening Tool to Optimize Care Coordination and Clinical Outcomes for Hospitalized Patients with Type 2 Diabetes" (2026). Doctor of Nursing Practice Final Project Abstract. 176.
https://digitalcommons.library.tmc.edu/dnp_abstract/176