Title : Cancer patient discharge planning applying social determinants of health: Practice in the context of the national cancer center korea
Abstract:
The South Korean government announced the “Community Care Basic Plan” in 2018, emphasizing the importance of hospital medical social work teams in supporting the community integration of individuals in need of care. In particular, developing discharge plans that incorporate social determinants of health is essential to facilitating the healthy reintegration of cancer patients who require long-term and complex interventions.
The Medical Social Work Team at the National Cancer Center Korea has been conducting discharge planning consultations and medical social work interventions for cancer patients using a social needs screening tool since April 2019. The tool, originally proposed by Health Leads, has been translated and adapted to the Korean context. This questionnaire consists of simple questions about aspects of life that influence the patient's physical, social, and mental health. The screening tool used at the National Cancer Center includes 12 items: “financial stress,” “utility needs,” “food insecurity,” “transportation issues,” “housing instability,” “social isolation,” “social support,” “mental health,” “health literacy,” “employment,” “violence,” and “caregiving burden.” The questions are answered with 'yes' or 'no' and are designed to capture the respondent’s perceived need for support.
The National Cancer Center’s Medical Social Work Team provides psychological counseling, discharge planning, referrals to community resources, and develops and implements programs for patients with a variety of psychosocial concerns. When medical staff identify psychosocial issues in cancer patients during treatment or prior to discharge, they refer patients to the Medical Social Work Team through the EMR system. Medical social workers then provide counseling to the patients and their families. Since April 2019, the Medical Social Work Team has performed social needs screenings using this tool for referred cancer patients who have given their consent. The data collected are analyzed and used to guide patient support strategies.
From April 2019 to December 2024, a total of 443 patients were screened for social determinants that impact health. The data analysis revealed the following: of the 443 patients, 62% were male and 38% were female, and 62% were aged 60 or older, reflecting South Korea’s demographic shift toward becoming a super-aged society by 2026. Patients were found to have an average of 4.5 unmet and often complex social needs. The top 12 social needs were ranked as follows: financial stress (82.4%), social isolation (60.7%), housing instability (53.5%), food insecurity (43.1%), mental health concerns (40.9%), lack of caregiving resources (33.6%), transportation issues (33%), low health literacy (26.4%), utility needs (25.1%), employment difficulties (24.2%), caregiving burden (17.4%), and exposure to violence (10.8%).
Based on the data collected on unmet social needs, tailored medical social work interventions were carried out with patients. To mitigate financial stress, financial assistance was provided, and counseling and community resource referrals were offered for issues such as housing instability, lack of caregiving resources, and transportation challenges. For mental health concerns, informational booklets featuring a range of psychosocial resources were developed and distributed. By identifying patients’ unmet social needs and associated risk factors, and by connecting them with appropriate support services, we aim to contribute to improving the health and overall quality of life of cancer patients.
