Link Found Between Stroke Patient Readmission Disparities and Minority Status
Black stroke patients are more likely to be readmitted to the hospital than white stroke patients, but this gap closes in hospitals with better nurse staffing levels, investigators found.1
“When we hear about nursing staffing and ratios, we hear that nurses are caring for too many patients, and patient safety is at risk or in peril,” says J. Margo Brooks Carthon, PhD, RN, FAAN, lead study author and Tyson Family Endowed Term Chair for Gerontological Research and associate professor of nursing at the University of Pennsylvania School of Nursing.
“My research looks at historically vulnerable patients, who — when entering hospitals — typically come with increased comorbidities or medical conditions and increased severity of illness,” Carthon says.
These patients could experience better outcomes if hospitals allocate nursing resources in a way that appropriately addresses their additional, extenuating concerns and issues.
“If you look at nursing staffing ratios in hospitals where Black and white ischemic stroke patients are cared for, the average nurse-patient ratio for Black and white stroke patients was essentially the same,” Carthon explains. “But even at that equal level of staffing, you saw disparities in Black and white patients and readmissions.”
This disparity disappears in hospitals with the richest staffing resources and where nurses are caring for two patients per shift.
“This is an important point: What are the system levers we can deploy to eliminate inequities?” Carthon asks. “If our goal was systemic equality, we could say we reached it because Black and white patients have equal staffing ratios. But the goal is equity because some patients need more resources; they have more clinical and social needs.”
The study results suggest hospitals need to intensify nursing care for some patients, depending on their clinical presentation. “Black patients may come in with a different set of social and cultural vulnerabilities, so we need to think about allocation of resources to more appropriately address those care needs,” she explains. “Allocation of staffing could be thought of as a systemic intervention to address systemic inequities.”
Focus on Systemic Inequities
Addressing systemic inequities requires studying the allocation of resources, including nurse staffing. “Nursing is the largest resource in healthcare settings,” Carthon says. “When nurses are caring for too many patients and resources are not supporting nursing care, then care is missed, like discharge instructions.”
When inadequate nurse staffing reduces the ability for nurses to provide adequate care, that has particular implications for ethnic and racial minorities because they have greater care needs. “The consequences of missed care [for minorities] will be greater,” she says.
This is not the same as saying all Black patients need extra care, and it does not refer to racial/ethnic medical issues. The data showing that minority patients are affected by lower nurse staffing levels points to systemic factors that affect patients’ overall health, such as social determinants of health.
“We need to look at the full picture of how they’re more likely to have social needs,” Carthon says. “When people are pressed for time, they prioritize medical issues over social issues. Electronic medical records are just beginning to address social determinants of health.”
Without a stronger focus on social determinants of health in nursing and case management, it is questionable how well nurse case managers integrate social determinants of health assessments in care planning, especially when they are caring for too many patients.
“When you address social determinants of health, are you empowered to do anything about it?” Carthon asks.
Nurses are trained to assess social needs and provide care. But if they work in a health system where they do not have the bandwidth to do so adequately, care transitions can suffer.
“Are they able to connect the dots between what’s going to happen in terms of post-discharge care and specialty care?” she asks. “Do patients have transportation to get to their appointment? Do they really understand the needs of their chronic disease management?”
For case managers to perform the work they have been trained for requires system-level investment in the workforce so they can partner with patients in holistic care, Carthon says.
Case management and care transition work is happening in both acute care and in community care, where case/care management teams are working in concert with one another. They think about both clinical and social needs.
“We bolster and intensify our case management services,” Carthon says. “Case managers are talking to each other, creating systems that are interoperable to create communication across sectors.”
Health systems can improve continuum of care work through innovative programs. A collaboration between healthcare research organizations and providers can address solutions to healthcare disparities. For example, one hospital found stark inequities for patients insured by Medicaid, Carthon says.
“They are more likely to be readmitted and return to the emergency department within 30 days,” she explains. “We asked nurses, case managers, social workers, community health workers, home health workers, and patients about their experience [in continuum of care] and the patient’s recovery journey.”
They found there was a breakdown in communication and coordination, and many social needs were never addressed.
A solution is a clinical pathway that includes the community. Case managers can initiate the referral and identify Medicaid patients who are hospitalized and need a home care referral.
“That’s a big deal because prior to this, only one in five people insured by Medicaid received a home care referral,” Carthon says. “It was because case managers applied to Medicaid patients the Medicare regulations that a person had to be homebound.”
But under Medicaid rules, a person who is discharged from the hospital can receive home care. Providers and case managers did not know the difference.
“We said we have to do something because we are not doing what we need to, and people are falling through the cracks,” she says. “One out of five patients were not receiving the social support and clinical intensity they needed in their home environment.”
Under a program to address this issue, case managers identify patients in need of home care services and assist with a referral. Also, hospitalists and discharging hospital physicians will accept responsibility for patients and extend their role until patients are connected to primary care.
“The home care nurse can call the hospitalist with any problems until the person receives primary care and primary care is the ongoing gatekeeper,” Carthon says. “In that intersection between the hospital and primary care, which can last two to four weeks until the patient gets a primary care provider, you have someone to help.”
The burden on hospitalists is low. In at least one experience with this care continuum project, hospitalists were willing to bridge the care gap for up to one month.
“It’s a great solution,” Carthon says. “Case managers initiate the referral and are involved in weekly case conferences. Patients continue to get skilled nursing through home care and have intensive oversight and case management.”
Case managers are represented at weekly interdisciplinary acute care/community case conferences, which provides a feedback loop.
REFERENCE
- Carthon JMB, Brom H, McHugh M, et al. Racial disparities in stroke readmissions reduced in hospitals with better nurse staffing. Nurse Res 2021; Sep 15. doi: 10.1097/NNR.0000000000000552. [Online ahead of print].
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