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  • Review the challenges to caring for hospitalized patients with complicated social circumstances.

  • Review methods for assessing decision-making capacity.

  • Offer a definition of “patients at risk” and discuss a proactive approach to provide for their safety while hospitalized.

  • Provide treatment guidelines for acute alcohol withdrawal.

  • Highlight best practices in interdisciplinary transitions of care.

  • Discuss self-care approaches relevant to inpatient providers and staff.


Severe illness necessitating admission to the hospital can be a time of great emotional and physical vulnerability for all patients. This vulnerability is compounded when medical illness is complicated by social circumstances such as poverty, social isolation, minority status, legal difficulties, mental disability, or chemical dependence. Evidence suggests that those living at 200% below the poverty level have a higher rate of hospitalization and receive a lower standard of care while hospitalized.1,2

This chapter highlights issues and challenges that arise in the care of hospitalized socially complicated patients, including initial evaluation in the emergency department (ED), ongoing care throughout the hospital course, and transition planning from the hospital.


Health-care systems and customs vary so widely across the globe that it is difficult to compare hospitalization practices and rates from one country to the next. Access to care, the number of hospital beds, the primary care infrastructure, the management of mental illness and long-term care (LTC), and the underlying health of the population all contribute to trends in hospital care.

In the United States, one of the most notable features of hospital care is its cost: hospital costs accounted for 29% of the total resources spent in 2010, the largest single share in the care system. Yet hospital utilization accounted for only 7% of the care delivered.1 Despite no change in the age-adjusted number of hospitalizations between 1997 and 2011, inflation-adjusted hospital costs increased by 60% for all conditions.2

Poor patients have a hospitalization rate nearly twice that of the non-poor.2 Among the uninsured, regardless of age, 3 of the top 10 most common reasons to be admitted in the United States involve substance abuse or mental health conditions.1 Ironically, these higher rates of admission represent delivery of the most expensive care to those who have been deprived of more cost-effective preventive measures in the ambulatory setting.

Among the vulnerable, issues such as unstable housing, limited access to outpatient health providers, insufficient financial resources, social isolation, and a fundamental distrust of institutional intrusion into personal life make the transition from acute hospitalization to outpatient care exceedingly challenging. These factors contribute to a longer length of stay of poor patients compared with the non-poor (5.1 days versus 3.7 days, respectively).2



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