A 64‐year‐old man with alcoholism and end‐stage liver disease (ESLD) presented to the emergency department (ED) complaining of abdominal pain and swelling. In the previous 3 weeks, the patient had presented to 2 different EDs with similar complaints. With each visit, the patient had basic labs performed and was discharged with prescriptions for diuretics and pain medications. During this third ED visit, labs, abdominal ultrasound, and paracentesis were performed. He was admitted to the hospital with ascites and hepatic encephalopathy. Full workup ultimately diagnosed advanced HIV, hepatitis C, and metastatic hepatocellular carcinoma (HCC) and patient was subsequently discharged home under hospice care. Of note, this patient was uninsured, had no follow‐up care arranged after his ED visits, and had not filled his prescriptions due to finances.
Transitions of care from the hospital have become increasingly more difficult and risky. Discharged patients frequently have complex medical needs, difficulties navigating our complex medical system and limited resources. One in 5 hospitalized patients have an adverse event within three weeks of discharge, with nearly 2 of 3 events being medication‐related. More than 10% of discharged patients report worsening symptoms, whereas 40% have pending studies at discharge and another 25% have additional workups recommended, all of which suggest many patients have ongoing and acute care needs after discharge. In 2010, 49.9 million people were uninsured in the United States (16.3% of the total population). Patients with low income, no insurance, or no primary care physician obtain less follow‐up care due to the cost of health services. Such barriers are further complicated in the uninsured patient due to issues of health care literacy and unmet socioeconomic needs. In short, these patients lack a medical home or a means of obtaining comprehensive, continuous medical care. Given these barriers, as well as poor access to routine health care, uninsured patients may be at increased risk for hospital readmission. Uninsured patients are nearly 3 times more likely to make an ED visit following hospital discharge. At our urban, tertiary‐care institution, medical patients who lack timely PCP follow‐up are 10 times more likely to be readmitted (21% vs. 3%), which is magnified in those lacking insurance. As up to 60% of health care resources are utilized in rehospitalized patients, there may be cost savings if these readmissions are avoided.
Although the difficulties of transition in care are recognized across all patient groups, patients lacking insurance, the “medical home‐less,” may be at increased risk given their barriers in accessing health care after discharge, as was the case for our patient with ESLD described above. Recognition of uninsured patients as unique cases, with frequently distinct and diverse posthospital care needs, is imperative to developing a successful discharge plan for such patients.
To cite this abstract:Pino‐Jones A, Gilmer R, Misky G. The “Medical Home‐Less”: How Transitions‐of‐Care Issues May Be Magnified in the Uninsured Patient. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 364. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-medical-homeless-how-transitionsofcare-issues-may-be-magnified-in-the-uninsured-patient/. Accessed July 16, 2019.