Black Medicare patients less likely to be referred for home health care, finds study

At discharge from the hospital, Black Medicare beneficiaries are less likely to be referred for home health care (HHC), compared to white patients, reports a survey study in Medical Care.

The disparity in referral for HHC among Black Medicare patients appears greatest among those with low "readiness for discharge" scores, according to the new research led by Olga Yakusheva, Ph.D., of University of Michigan School of Nursing and School of Public Health.

Does race affect decisions about home health visits for Medicare patients?

Home health care is an important option for older adults being discharged from the hospital. Home health visits provide essential continuity of care to reduce the risks of adverse outcomes and readmissions.

Previous studies have suggested that patients from racial and ethnic minority groups are less likely to receive HHC. The researchers examined how nurse assessments of patients' readiness for discharge affect referral to HHC services for patients of different racial and ethnic minority groups.

The study included data on 14,684 Medicare beneficiaries discharged from US hospitals drawn from a previous clinical trial. For each patient, nurses completed a standard assessment of readiness for hospital discharge based on factors including physical status, knowledge, coping ability, and expected support.

Differences in readiness scores and decisions about HHC referral were compared among racial/ethnic groups. About 69% of patients were White and 10.7% were Black. (The rest were of Hispanic or "other" or unknown race and ethnicity.) Black patients were significantly younger: average age 61 years, compared to 73 years for White patients.

Despite similar readiness for discharge, Black patients less likely to receive HHC

Scores on the readiness for discharge assessment were similar among racial/ethnic groups. For both Black and White patients, the average readiness score was about 8.2 (on a 0-to-10 scale). This was despite differences in certain higher-risk characteristics: Black Medicare beneficiaries were less likely to be married, more likely to live alone, and had more chronic conditions than their White counterparts.

Yet Black patients had significantly lower rates of HHC referral. Only 22.4% of Black patients were referred to HHC at discharge, compared to 26.7% of White patients. Overall, HHC referral rates were 32% for patients with a readiness for discharge score of 10 versus 22% for those with a score of 6.

Across the range of readiness scores, the likelihood of HHC referral decreased gradually as the readiness score increased. The difference in HHC referral between Black and White patients was greatest for patients assessed as least ready for discharge: among those with readiness scores of 6 or less, the HHC referral rate was 26.8% for Black patients, compared to 32.6% for White patients.

That finding raises concern that "the least ready and potentially most at-risk or sickest Black patients are systematically under-referred for HHC services," the researchers write.

Dr. Yakusheva and colleagues emphasize that their study cannot determine "the underlying source of the disparity" in HHC referrals among Medicare patients. Potential causal factors include mistrust, cultural appropriateness of readiness assessments, patient preferences, and ineffective communication between patients and clinicians, as well as "unintentional but ultimately harmful" bias on the part of health care providers.

All of these factors "are well within the scope of influence of our health care institutions," Dr. Yakusheva and co-authors write. They conclude: "Health care systems should commit to mechanisms for engaging with stakeholders from diverse races and ethnicities to co-create solutions for systemic structural injustice in health care settings."