Black patients less likely to get referral for home health care after hospital stay

When discharging Black patients from the hospital, nurses are less likely to refer them to home health care than white patients, a new University of Michigan study found.

About 22% of Black patients are referred by discharge nurses to home health care compared to 27% of white patients.

The study found that despite a higher likelihood that Black patients were unmarried, lived alone and had more chronic conditions—all risk factors for hospital readmission—they were routinely rated equally ready for hospital discharge as white patients, and slightly higher than Hispanic patients and other ethnic groups.

In other words, Black patients had to be considerably less ready to go home than white patients to have the same odds of getting a home care referral.

Olga Yakusheva, Ph.D., lead author and professor at the U-M School of Nursing and School of Public Health, said she was surprised by the prominent disparity in home health care referrals between Black and white patients, and that the disparity seemed to impact Black patients significantly more than Hispanic or other nonwhite patients.

“We as clinicians and researchers have to recognize and respect that patients and their families have essential knowledge that can inform interventions,” said co-author Abiola Keller, associate professor of nursing at Marquette University. “To effectively impact health disparities, we must authentically engage the communities most impacted in processes to co-create and implement potential solutions.”

Other significant findings:

• Black patients had the highest readmission rate at 15%, compared to 10% for white patients, 13% for Hispanic patients and 12% for other races
• Differences in home health care referrals persisted for all patients through to a score of 9 on the 10-point readiness for discharge scale
• Differences in home health referrals were highest for patients with discharge scores of 6 or lower, at 27% referral rates for Black patients vs. 33% for white patients
• All else being equal, Black patients must score two points higher on their discharge assessment to have an equal chance at a home health care referral as white patients
• In the raw data, 26%-27% of white and other ethnicity patients received referrals, followed by 22% of Black patients and 14.5% of Hispanic patients

However, after adjusting for the different risk profiles, there was no significant difference in the likelihood of a home health care referral between patients who are white, Hispanic or of another race, but Black patients were significantly lower, Yakusheva said.

“With Black patients, the difference in referral rates was observed against the combined backdrop of the elevated risk profile in addition to poor observed outcome of care,” she said. “So, for Black patients, the observed data are consistent with a potential failure of the health care system to provide appropriate care.”

Reasons for the disparity are complicated

The data doesn’t pinpoint the cause, but the disparities may happen because more Black patients turn down home health care because they have less trust in the health care system.

“Or, it could be structural bias. It is not that nurses are knowingly withholding care, but they may be sometimes miscommunicating or misunderstanding the needs of Black patients, including needs for in-home care after hospital discharge,” Yakusheva said, adding both reasons are within the purview of the health care system to address.

“Interventions to build strong connections with minoritized groups in our communities and to build mutual trust and understanding between minoritized groups and health care professionals are needed to address systemic inequities in health care.”

Researchers examined discharge records from 14,684 Medicare patients in 31 U.S. hospitals. The study appears in the journal Medical Care on Dec. 7. Co-authors include U-M doctoral student Kathryn Lee and Marianne Weiss, professor emerita at Marquette University’s School of Nursing.

Study: Racial and ethnic disparities in home health referral among adult Medicare patients (DOI: 10.1097/MLR.0000000000001945)