THE INFLUENCE OF SOCIAL CAPITAL ON SUCCESSFUL COMMUNITY DISCHARGE AFTER POST-ACUTE CARE AMONG MEDICARE BENEFICIARIES

Health equity, in which high standards of care are provided to individuals regardless of individual characteristics, is a goal of the healthcare system. Social risk factors such as socioeconomic position, cultural contexts, and community factors may negatively affect health outcomes despite high standards of care. This dissertation focuses on structural social capital—the sum of resources available from the community structure—as a social risk factor in the community context that may affect health outcomes. This was done by examining the association between successful discharge to the community at 30 days and county-level social capital among Medicare beneficiaries who were discharged from post-acute care facilities for lower limb fracture and joint replacement services from 2013–2014. The analyses were retrospective and cross-sectional. Manuscript 1 looked at all patients in the United States, accounted for the nested structure of the data where patients were nested within counties, and regressed the binary outcome—successful discharge to the community—on patient- and county-level characteristics. Manuscript 2 was an ecological study in which the unit of analysis was Texas Hospital Referral Regions (HRRs). We calculated the silhouette index, a proxy of how homogenous or disparate levels of social capital are among counties within Texas HRRs. We then regressed the percent of successful discharges to the community on the silhouette index and other HRR-level characteristics to see if there was an association between social capital disparity in Texas HRRs and the percent of beneficiaries with successful discharge to the community in each HRR. Manuscript 3 examined only patients with Texas HRRs, accounting for patients nested within HRRs. We used logistic regression to regress the outcome on the HRR-level silhouette index to see if social capital disparity was associated with successful discharge to the community. The findings of this dissertation show that the effect of social capital on health outcomes varies by diagnosis group and level of geographic analysis. Additional research should be cognizant of how the effect of social capital on health may vary depending on how social capital is defined, the amount of social capital that is available, and the geographic level of analysis.