The study identified inconsistencies among patients transitioning from hospitals and skilled nursing facilities due to social determinants of health (SDoH) and racial disparities.

A patient’s care transition experience after being discharged from the hospital or nursing facility can look very different depending on the SDoH or racial disparities they may face, according to a recent study published by JAMA Network.

For the study, a group of Michigan researchers surveyed 1,257 participants transitioning from the hospital or skilled nursing facility between October 2018 and December 2019 and how their experiences were impacted by factors such as gaps in care, access to transportation, access to medical equipment in their homes, the ability to afford basic needs, and the completion of follow-up care. The study also looked at the impact of racial disparities on patient experiences.

“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,” wrote the researchers.

Here's what they found:

  • One in five patients reported struggling with at least one SDoH, with the four most common factors including affording items such as prescriptions, medical equipment, physical therapy, and home health care; access to transportation; affording appointments and copays; and having enough help at home to assist with their care.
  • Patients who reported struggling with at least one SDoH were less likely to complete a physician follow-up appointment compared to patients who reported no SDoH concerns.
  • Patients who struggled with a lack of transportation were 70 percent less likely to complete a follow-up visit.
  • A higher proportion of Black patients reported concerns around affording medical appointments and copays, as well as basic needs such as food and heat, compared to white patients and patients of other races.
  • Black patients had a lower likelihood of follow-up care completion compared to white patients and patients of other races.