clinician, nurse checks seniors' heart with stethoscope

New research suggests that patients transitioning from hospitals and skilled care to home care settings often have different experiences, with social determinants and racial disparities potentially playing roles.

The study entitled “Patients Perspectives on Care Transitions from Hospital to Home,” was published in the May 6 issue of the JAMA Network.

Michigan researchers surveyed 1,257 participants who were transitioning from hospitals and skilled nursing facilities to the home from October 2018 to December 2019. The study identified “inconsistencies in the care transition process.”

According to the study, 20% of participants reported social determinants of health issues, and transportation issues decreased the odds of completing follow-up appointments by 70%. In addition, Black patients had fewer follow-up visits scheduled or completed within the first two weeks following discharge.

“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 post-discharge follow-up with physicians,” the authors wrote in the study’s abstract.

The study identified “substantial racial disparity” in completion of follow-up appointments. “In addition to disparities in follow-up appointments attended, Black patients were less likely to receive the number of someone to call with questions after discharge and were less likely to receive their medical equipment,” the authors wrote.

Researchers concluded that there were several opportunities to improve the transition process for patients, including providing reliable, systematic care transition processes for all, addressing social determinants of health such as lack of transportation, scheduling and helping patients attend follow-up appointments, and recognizing and reducing racial disparities in care.