Challenges faced by patients with low socioeconomic status during the post-hospital transition

Abstract

Background: Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients.

Objective: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition.

Design: We conducted a qualitative study using in-depth semi-structured interviewing.

Participants: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals.

Approach: Our interview guide investigated patients' perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis.

Key results: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.

Conclusions: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.

Figure 1.

Negative goal cycle. Low-SES patients are “set up for failure” to achieve discharge goals that are misaligned because they are confusing, unattainable or in conflict with other more pressing goals. The resulting failure leads to low self-efficacy, which may lead to poor performance on other complex health behaviors. This may place the low-SES patient even further apart from the provider at the next goal-setting episode, making it more likely that the next set of goals are misaligned and the cycle is perpetuated.