Gaps and Racial Disparities Found in Care Transitions

Researchers surveyed patients about their experiences with care transitions from hospitals and skilled nursing facilities to home.

A survey of more than 1,000 patients found inconsistencies in care transition processes from hospitals and skilled nursing facilities to home, including social determinants of health challenges and racial disparities, a new research article shows.

Boosting the quality and value of care can be achieved by improving patient experiences and outcomes while limiting costs. One strategy for achieving this goal at hospitals and skilled nursing facilities is to improve the care transition process, which includes education, medication reconciliation, follow-up appointments and telephone calls, and supportive care in the home.

The new research article, which was published by JAMA Network Open, is based on survey data collected from 1,257 patients discharged from hospitals or skilled nursing facilities (SNFs). Seventeen hospitals and six SNFs in Michigan participated in the study.

The study features several key findings.

• 11.4% of patients said they did not receive a telephone number to call for care-related questions after hospital or SNF discharge
   
• Compared to White patients and patients of other races, more Black patients did not receive a telephone number to call with care-related questions
   
• 21.4% of patients said they did not receive a follow-up phone call
   
• Among patients who did receive at least one follow-up phone call, 89.9% said the calls were helpful or very helpful
   
• 1.9% of patients said they did not receive prescribed medical equipment in the home
   
• Compared to White patients and patients of other races, more Black patients did not receive prescribed medical equipment in the home
   
• 20.8% of patients said they had at least one social determinants of health (SDOH) challenge
   
• The four most common patient SDOH challenges were inability to afford aspects of care such as prescriptions and physical therapy (7.6% of patients), lack of transportation for health-related activities such as physician appointments and grocery shopping (6.0%), inability to afford medical visits and copayments (5.6%), and lacking help at home to care for themselves
   
• Lack of transportation decreased the odds of completing a follow-up appointment by nearly 70%
   
• Patients who said they had at least one SDOH challenge were more likely to have no follow-up appointment than patients who said they did not have SDOH challenges
   
• 63.3% of patients said they had seen a physician for follow-up and another 28.1% said they had an appointment scheduled
   
• Compared to White patients and patients of other races, Black patients were less likely to see a physician for follow-up or have an appointment scheduled

"These findings suggest that health systems should recognize that care transition processes are variable, patients experience substantial social determinants of health issues, and potential racial disparities exist in postdischarge follow-up with physicians," the study's co-authors wrote.

Interpreting the data

The data shows inconsistency in follow-up phone calls, the study's co-authors wrote. "Overall, these findings show that most patients receive postdischarge follow-up telephone calls and find them valuable, but 21% of patients do not receive a telephone call, indicating inconsistencies in care transition processes."

The data shows there are disparities impacting Black patients, the study's co-authors wrote. "We also found that 1 in 10 patients reported not receiving a telephone number to call regarding their care after discharge, with a higher proportion of Black patients not receiving a telephone number to call. In addition, Black patients reported not receiving prescribed equipment more often than White patients, and these gaps persisted even after adjustment for demographic variables. … Black patients reported fewer scheduled or completed follow-ups with physicians compared with White patients and patients of other races."

SDOH play a significant role in care transitions, the study's co-authors wrote. "One in 5 patients surveyed … reported SDOH concerns, such as the inability to afford prescriptions, medical care, doctor appointments, and basic needs; transportation issues; and having adequate assistance at home. Although the healthcare industry is aware of the important role SDOH plays in patient health, awareness has not translated into improvement. In a 2019 survey of Michigan seniors, 34.7% noted their reason for not seeing a physician for follow-up was because they could not afford to, another 18.1% did not because of lack of insurance coverage, and 22.1% did not because of lack of transportation."

The data points to several areas for enhancement, the study's co-authors wrote. "There are still multiple opportunities for improvement, including (1) providing reliable, systematic care transition processes for all (follow-up telephone calls, numbers for patients to call, and delivered home medical equipment); (2) addressing patient SDOH, such as transportation; (3) scheduling and helping patients attend follow-up appointments; and (4) recognizing and reducing racial disparities in care. This information on patient challenges during the transition of care process could help hospitals and physicians tailor future care transition interventions to be specific to their patients' needs."

Related: Care Transitions Know-How Not Just for Clinicians