Transitions of Care in Underserved Patients: A Literature Review

Background:

Failure to transition from acute care to outpatient care has been well studied without regard to insurance status. Common experience suggests that underserved patients face unique barriers to effective post‐hospital care. These patients may have magnified risk as they often seek medical care later, present with more advanced disease, and have worse clinical outcomes. Discharging providers must provide for effective care transitions without clear indications of barriers faced by this population. To further define this area, we reviewed the literature to determine specific barriers to ideal care transitions in underserved patients in the United States.

Methods:

Literature evaluating barriers to post‐acute care from hospital to home in the underserved published from January 1^st, 1960 to October 1^st, 2013 was reviewed, Underserved was defined as patients who were homeless, lacked insurance, or had Medicaid coverage. Two reviewers determined which articles met inclusion criteria. Descriptive features of studies were abstracted along with identified barriers. These data were used to create a matrix of barriers in each subpopulation based on payer source.

Results:

Database search yielded 1,717 studies, of which twenty‐four met inclusion criteria. Studies represented populations of uninsured (21%), homeless (21%), Medicaid (13%), and combined Medicaid and uninsured patients (25%), with the remainder representing mixed populations (21%). Commonly cited barriers to care transitions included: costs (67%), access to services (50%), low health literacy (46%), housing instability (42%), and transportation (42%). Within groups, the most commonly reported barriers were cost for the uninsured and housing instability for the homeless. Patients with Medicaid equally reported barriers of cost, access to services, low health literacy, transportation, and poor social support. In the mixed group of patients lacking insurance or having Medicaid, access to services, and cost of medications and services were the most common barriers.

Conclusions:

Despite examining more than 50 years of literature we found few studies specifically evaluating barriers to post‐acute hospital care in underserved patients. Of studies identified, populations were heterogeneous. Perhaps the paucity of literature available represents the difficulty in defining this group. Notably, while barriers reported in each payer group did vary, differences are difficult to assess, e.g. absence of a barrier reported in a particular study does not indicate its true absence. Additionally, barriers may not be mutually exclusive. Based upon these findings, more research regarding care transitions in underserved patients is needed to further define areas amenable to future intervention