Instead of being discharged directly home, one in five hospitalized Medicare patients go to skilled nursing facilities (SNFs) for continued care and physical rehabilitation. The expectation is that soon they will return home; however, this outcome is not the case for all patients. Studies have documented racial disparities in SNF outcomes, with Black, Indigenous, people of color (BIPOC) more likely to return to the hospital from the SNF rather than go home. We found that one contributing factor to this disparity might be the lack of access to subspecialty follow-up care for patients discharged to SNFs.

Medicare Data Shows Disparities in Access to Subspecialty Care at SNFs

We analyzed data from more than 1.1 million Medicare beneficiaries who were staying in a SNF and had been treated by a medical subspecialist physician during their hospital stay. We found that during their SNF stay, BIPOC patients were less likely than Non-Hispanic White (NHW) patients to have follow-up care with a physician in the same subspecialty. Additionally, compared to NHW patients, BIPOC patients had higher rates of emergency department visits after hospital discharge to a SNF—a finding that is potentially linked to the disparity in post-discharge subspecialty care.

Removing Barriers to Access is Key

Access to subspecialty care may improve outcomes for medically complex patients with multiple chronic conditions residing in the community. Our findings suggest conversely that constrained access to subspecialty care hurts outcomes among post-acute patients in SNFs, resulting in more emergency department visits. Therefore, facilitating subspecialty follow-up during SNF stays is a potential target for policy and practice interventions to improve SNF outcomes for BIPOC patients. To inform such interventions, we need to learn more about the provider- and system-level factors that drive the disparities in subspecialty care access.

One potential barrier is transportation. Patients in SNFs depend on the facility to transport them to appointments with subspecialty care providers. Patients are generally not able to go on their own. Therefore, more generous Medicare transportation benefits could increase subspecialty care follow-up. Currently, Medicare transportation benefits are more favorable for emergency services than for follow-up care. Thus, some facilities might find it financially advantageous to send patients to an emergency room rather than outpatient appointments for subspecialty care. Expanding Medicare reimbursement for transportation to routine appointments might reduce this barrier to subspecialty follow-up and, in doing so, reduce racial disparities in post-acute emergency department visits from SNFs. Eliminating financial and regulatory barriers to care delivered via telemedicine might also help.

Another potential barrier is differences in subspecialty referrals by providers due to uncertainty, unconscious biases, or stereotyping. Unpacking the role of provider bias in differential care is complex; however, prior work suggests some strategies for decreasing its impact on care. In particular, provider training coupled with structuring or automating discharge processes can help reduce the variations in care that contribute to disparities, including in-subspecialty referrals.

The study, “Disparities in Access to Specialty Care and Emergency Department Use After Hospital Discharge to a Skilled Nursing Facility,” was published on November 8, 2022, in the Journal of Hospital Medicine. Authors include Casey Krickus, Jaya Aysola, and Kira Ryskina.


Kira Ryskina

Kira Ryskina

Assistant Professor, Department of General Internal Medicine, Perelman School of Medicine

Jaya Aysola, MD, MPH

Associate Professor, Medicine and Pediatrics, Perelman School of Medicine

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