The Gaps Impeding Transition From the Hospital to Home

Some patients aren’t getting follow-up phone calls, and others lack transportation for appointments with physicians. A new study highlights problems in post-acute care.

Patients say the transition from the hospital to home needs a great deal of improvement, a recent study finds.

Researchers from the University of Michigan surveyed more than 1,200 people and reported their findings in a study published May 6 on Jama Network Open.

A majority of patients said transportation issues impeded their ability to get to follow-up appointments, the study finds. In addition, Black patients were less likely to have follow-up appointments completed or scheduled within two weeks after they left the hospital.

Social determinants of health also play a role in patients moving successfully from the hospital to home.

“Our study emphasizes the need for postdischarge contact with patients to address any gaps of care,” the authors wrote.

Healthcare providers have plenty of incentive in ensuring patients navigate the transition from a hospital to the home. Within 30 days of a hospital discharge, patients have a 1 in 5 chance of an adverse event, such as an emergency department visit or readmission to the hospital, the authors note. Hospitals can face penalties from Medicare due to readmissions.

While patients have their own individual expectations, their responses and perceptions are valuable in identifying ways to improve post-acute care, the researchers said.

Nearly 80% of patients received a follow-up phone call after discharge, and most said it was helpful.

Still, the researchers noted a “sizable proportion” (21.4%) said they didn’t receive any follow-up calls. The study found 13.2% of black participants said the calls weren’t helpful, while 8.8% of white respondents and patients of other races had a similar assessment.

In addition, one in nine (11%) of the respondents said they were never given a phone number to call if they had questions after they were discharged. Black patients were more likely to say they weren’t given a phone number than white participants and those of other races (17.5% to 11.4%).

Roughly 9 in 10 patients have either completed or scheduled an appointment. The study found 63% of patients had seen a doctor, while another 28% had an appointment scheduled.

But again, researchers found a disparity between Black participants and others.

Black patients were twice as likely as patients of other races to not have an appointment scheduled (13% to 7%). Just over half of Black patients (52%) had seen a doctor at the time of the survey, while two-thirds (67%) of patients who were white or of another race had visited a physician.

“Our analysis showed a substantial racial disparity in completion of follow-up appointments,” the authors wrote. “Unfortunately, our study was not designed to capture the reasons why Black patients attend fewer follow-up appointments after discharge.”

Roughly 1 in 5 patients (21%) reported at least one concern relating to social determinants of health. That’s significant, the authors note, because patients identifying one issue among the social determinants of health were less likely to have completed a follow-up appointment with a physician.

Although the healthcare industry is more aware of the role social determinants play in an individual’s health, “awareness has not translated into improvement,” the authors wrote.

The most common concerns cited among social determinants of health were:

  • Affordability of medications, equipment or treatment;
  • Transportation for follow-up appointments with doctors, as well as the pharmacy or grocery store;
  • Affording medical visits and copayments, and;
  • Having enough help at home to care for themselves.

“Black patients reported not receiving prescribed equipment more often than White patients, and these gaps persisted even after adjustment for demographic variables,” the authors wrote. “These care transition processes continue to be flawed from patients’ perspectives and can lead to repeat hospital utilization.”

Of the 1,257 participants, 74% were white, while 22% were Black, and 4% were listed as having another race.

The ages of participants ranged from 21 to 99, with a mean age of 70 (age data was not available for roughly a quarter of the participants).

The researchers said the study illustrates a number of areas where health systems can take action to improve the care of patients.

“Physicians should be aware of these findings and their consequences for patient experiences,” the authors wrote.