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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: J Clin Nurs. 2021 Jul 8;31(5-6):726–732. doi: 10.1111/jocn.15932

Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study

Heather Brom 1, Colleen V Anusiewicz 2, Idorenyin Udoeyo 3, Jesse Chittams 4, J Margo Brooks Carthon 2
PMCID: PMC8741822  NIHMSID: NIHMS1729253  PMID: 34240494

Abstract

Aims and objectives:

We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation.

Background:

Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid.

Design:

We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study.

Methods:

Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August–31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit.

Results:

Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01).

Conclusions:

Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid.

Relevance to clinical practice:

Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.

Keywords: case management, emergency service hospital, health care quality, access and evaluation, medicaid, patient discharge, transitional care

1 |. INTRODUCTION

Access to primary care or specialist services is recommended for all individuals following hospitalisation, yet less than half of all hospitalised adults are seen by a community-based provider within 7–14 days of discharge (Goodman et al., 2011). A lack of post-hospitalisation follow-up is particularly concerning for individuals insured by Medicaid, who are more likely to face economic barriers to healthcare services compared to those from higher economic strata and experience worse post-hospitalisation outcomes. For example, Medicaid beneficiaries are admitted to the hospital over 8 million times annually (Collaborative Healthcare Strategies et al., 2014; Ferro et al., 2019; McDermott et al., 2017) and are more apt to experience a 30-day readmission and emergency department (ED) utilisation following discharge compared to those that are commercially insured (Brom et al., 2020). Reasons for readmissions and ED visits following discharge for individuals with Medicaid vary and often include exacerbation of chronic conditions, abdominal pain, urinary tract infections and lack of access to ambulatory care (Collaborative Health Care Strategies et al., 2014; Duseja et al., 2015). Rehospitalisations and ED utilisation within the days and weeks following a hospitalisation may occur due to clinical decompensation but may also indicate a lack of comprehensive discharge planning and care coordination during the acute admission (Goodman et al., 2011; Mortensen & Song, 2008). In their 2016 report, “System Practices for the Care of Socially At Risk Populations,” the National Academy of Medicine suggests integrated post-discharge support for individuals from economically disadvantaged backgrounds (i.e., Medicaid insurance). This care should also include assistance with identifying appropriate post-discharge care services (National Academies of Sciences, 2016).

In acute care settings, nurses, including those at the bedside, case managers and discharge planners may be involved with placing referrals, scheduling post-discharge appointments and sharing clinical information across providers. Subsequently, they are well-positioned to advocate for individuals with additional social and economic needs and play an important role in their care coordination (Brooks Carthon et al., 2019). Results of some studies suggest that care coordination for individuals insured by Medicaid is often fragmented leading to gaps in care continuity and poor post-hospitalisation outcomes, including ED utilisation and rehospitalisation (Jiang et al., 2016; Parekh et al., 2018; Trudnak et al., 2014). Despite these growing concerns, few studies have examined whether connection to post-acute community-based services reduces unfavourable post-hospitalisation outcomes, such as ED utilisation, among those insured by Medicaid.

2 |. BACKGROUND

2.1 |. Post-acute care services

Follow-up care post-hospitalisation is an important component of transitional care. Evidence suggests that when patients are seen by a primary care provider within 74 days post-discharge, they have fewer readmissions (Wiest et al., 2019). Increasingly, specialty care is also needed to manage complex health conditions. Specialists add to the care team by providing expert management for chronic conditions such as heart failure, chronic kidney disease, psychiatric disorders and cancers. Referrals to specialty care for individuals insured by Medicaid have increased over the past several decades (Barnett et al., 2012; Cook et al., 2007). Additionally, home care services have been shown to improve post-acute outcomes (Alliance for Home Health Quality & Innovation, 2015), including readmissions for individuals insured by Medicaid (Brooks Carthon et al., 2021). Home care nurses assist with patient education, medication reconciliation and referral to other community-based services to meet both health and social needs.

2.2 |. Barriers to care continuity for individuals insured by Medicaid

Our interest in improving the post-hospitalisation outcomes among individuals from low economic backgrounds led us to examine if access to community-based services reduced 30-day ED utilisation. Our hospital is an academic medical centre located in a large northeastern urban setting and serves as the safety net provider for more than 300,000 local residents (Public Health Management Corporation, 2016). Approximately 58% of all patients on our Medicine Service are insured by Medicare, and 24% are insured by Medicaid. While representing less than a quarter of all patients, we found notable disparities among patients insured by Medicaid. Results from a study conducted by our team using machine learning and electronic healthcare data found that one in five (21%) individuals with Medicaid experienced a readmission within 30 days compared to 6% of commercially insured individuals. Similarly, 17% of individuals with Medicaid experienced an ED visit within 30 days of a prior hospitalisation, compared to 4% of commercially insured individuals (Brom et al., 2020).

The findings from our health system were not unique. Others have identified worse post-hospitalisation outcomes including ED use among individuals insured by Medicaid and barriers to care access. For example, using a sample of hospitals across 19 U.S. states, Trudnak et al. (2014) found that the average adult 30-day readmission rate was 12.8% costing each state on average $77 million for readmissions, which represented 12.5% of Medicaid payments for all hospitalisations. Additionally, Cheung et al. (2012) noted that compared to commercially insured individuals, those insured by Medicaid have higher ED use and more barriers to timely primary care. In a separate study, Mortensen and Song (2008) found that those insured by Medicaid experienced long wait times for an appointment, difficulty accessing a health care provider outside of the ED and high out-of-pocket costs, leading to increased ED utilisation. Similarly, Ladhania et al. (2019) noted that many providers either do not accept or accept only a limited number of Medicaid patients due to lower reimbursement rates. Finally, prior negative interactions with primary care providers, including feeling that complaints are not heard, may also lead to higher ED use and rehospitalisation among those insured by Medicaid (Capp et al., 2015). While there are clear barriers to care access for those insured by Medicaid, there are few studies that have examined if post-acute care services differ between those insured by Medicaid and commercially insured and if utilisation of post-hospitalisation community-based services influences ED utilisation among Medicaid patients (Kim et al., 2017; Mortensen, 2014).

Hospital-based nurses, including nurse case managers, need evidence to inform successful discharge transitions that cater to patient care needs (Weiss et al., 2010). Thus, the purpose of this study is to evaluate the association between ED visits within 30 days of discharge and the use of post-acute care services (primary care, home health, specialty care) and to determine if connection to these services was more beneficial among individuals insured by Medicaid. We hypothesised that access to any of the community-based services following discharge will reduce ED use within 30 days of discharge, though we suspect that the influence of receipt of care across services will differ. Using three months of discharge data from medical services at a safety net hospital, we examined patient characteristics (e.g., age, race, and comorbidities) and patterns of post-acute care service utilisation and subsequent ED visits for individuals insured by Medicaid and those commercially insured.

3 |. METHODS

3.1 |. Study design and population

Using a retrospective observational cohort study design, we obtained electronic health record (EHR) data from an academic medical centre located in a large urban area within the northeast United States. Our analysis included all adult patients between the ages of 18 and 64 who were discharged from medical services at the study hospital between 1 August 2017–31 October 2017. Older adults (≥65 years) and those insured by Medicare were excluded from this analysis. Patients who were discharged from the following medical services were included: cardiovascular medicine, endocrinology, family medicine, gastroenterology, general internal medicine, geriatric medicine, haematology/oncology, hospitalist, infectious disease, medicine, pulmonary, renal and rheumatology. Expedited approval and a Health Insurance Portability and Accountability Act waiver from our University’s Institutional Review Board were received prior to conducting this study (protocol number 829212). We adhered to The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist in reporting this study (Supplementary File 1).

3.2 |. Data collection

De-identified patient-level discharge data were obtained from our health system’s data store. The data store incorporates standardised clinical elements across multiple electronic systems to advance health care research and quality improvement throughout the health care system.

3.3 |. Measures

3.3.1 |. Outcome variable

The primary outcome of interest was an ED visit that did not result in a subsequent readmission within 30 days of the initial discharge.

3.3.2 |. Explanatory variables

A number of studies have found a relationship between ED visits and patient demographics, social characteristics and post-acute care services; hence, they are accounted for in our analyses (Brennan et al., 2015; Duseja et al., 2015). Based on this literature, we included a comprehensive set of explanatory variables including patient demographics (i.e., age, sex, race, ethnicity), social and health characteristics (i.e., English speaking, marital status, zip code, comorbidities) and post-acute care services (i.e., primary care, home health, specialty care). Patient comorbidities were determined by the presence of 27 of 31 Elixhauser comorbidities using the International Classification of Diseases, Tenth Revision (ICD-10) codes (Quan et al., 2005). Our analysis did not include AIDS/HIV, alcohol abuse, drug abuse or psychoses comorbidities due to their omission from the data we received.

3.4 |. Data analysis

Descriptive statistics were employed to describe the sample using means for continuous and counts and percentages for categorical variables. Then, we conducted bivariate analyses to compare patient characteristics and utilisation of post-acute care services (i.e., primary care, home health, specialty care) and subsequent ED visits for patients with Medicaid compared to commercial insurance. To obtain p-values, chi-square test was used for categorical variables and logistic regression for continuous variables.

Next, we conducted a series of sequential logistic regression models to examine the association between post-acute care service utilisation and ED visit. The first model (Model 1) estimated the relationship between insurance type and ED visit. Model 2 estimated the relationship between insurance type and ED visit and includes patient characteristics (i.e., age, race, marital status, zip code and total number of Elixhauser comorbidities). Models 3 to 5 account for all prior covariates, and each post-acute care service is introduced into the model separately: Model 3 (primary care), Model 4 (home health) and Model 5 (specialty care). Only patient characteristics were included in the regression analyses if they differed significantly (p < .05) by patient’s insurance type (i.e., age, race, marital status, zip code and comorbidities).

4 |. RESULTS

4.1 |. Sample characteristics

Table 1 includes sample characteristics and compares Medicaid and commercially insured patients. During the three-month study period, there were 785 admissions of which 475 were from patients insured through Medicaid (60.5%) and 310 were from patients with commercial insurance (39.5%). The average patient age was 48.2 (±12.0) years. Most patients in our sample were Black (66.1%), not Hispanic (96.6%), English speaking (98.0%), unmarried (71.9%) and resided outside of the metropolitan area (43.3%). Compared to commercially insured patients, Medicaid patients were younger and had more comorbidities, they were more frequently black, not married and resided within the metropolitan area. The most frequent reasons for hospitalisation were infection, shortness of breath, chest pain, electrolyte imbalance and heart failure. Additionally, Supplementary File 2 describes patient characteristics by each post-acute care service utilisation.

TABLE 1.

Characteristics of the sample and comparing patients who were insured by Medicaid compared to those insured by commercial insurance

Characteristic Total sample
(n = 785)		 Medicaid
(n = 475; 60.5%)		 Commercial
(n = 310; 39.5%)		 p
Age in years, mean (SD) 48.2 (12.0) 48.8 (13.85) 54.7 (14.30) <.001
Comorbidities, mean (SD) 4.2 (2.8) 4.7 (3.06) 4.2 (2.63) .004
Male, n (%) 501 (56.0) 237 (49.9) 206 (66.4) <.001
Race, n (%) <.001
Black 519 (66.1) 393 (82.7) 126 (40.6)
White 204 (26.0) 59 (12.4) 145 (46.8)
Other 62 (7.9) 23 (4.8) 39 (12.6)
Hispanic, n (%) 27 (3.4) 18 (3.8) 9 (2.9) .521
English speaking, n (%) 769 (98.0) 462 (97.3) 307 (99.0) .086
Married, n (%) 221 (28.1) 52 (11.0) 169 (54.5) <.001
Metropolitan area, n (%) 340 (43.3) 271 (57.0) 69 (22.3) <.001
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Note: Other race category composed of Asian, Hawaiian Pacific Islander, Other, Unknown. A Pearson’s chi-squared test was used to generate p-values for categorical variables and logistic regression was used to generate p-value for continuous variables.

4.2 |. Comparison of ED use and post-acute care services utilisation across insurance types

Approximately 9% of patients had an ED visit within 30 days of discharge from the study hospital. Individuals with Medicaid more frequently used the ED (12.4%) compared to those commercially insured (4.2%; p < .001). The most used post-acute care service was specialty care (46.7%) followed by primary care (18.6%) and then home care (16.6%). Home care services were more frequently used by Medicaid patients (20% compared to 11.3% for commercially insured patients, p = .001), and specialty care was more frequently used by commercially insured patients (53.9% compared to 42.1% for Medicaid patients, p = .001). There was no statistically significant difference in frequency of primary care utilisation between the two insurance groups (Table 2).

TABLE 2.

Post-hospital utilisation comparing patients who were insured by Medicaid compared to those insured by commercial insurance

Characteristic, n (%) Total sample
(n = 785)		 Medicaid
(n = 475; 60.5%)		 Commercial
(n = 310; 39.5%)		 p
ED visit 72 (9.2) 59 (12.4) 13 (4.2) <.001
Primary care visit 146 (18.6) 95 (20.0) 51 (16.4) .212
Home care visit 130 (16.7) 95 (20.0) 35 (11.3) .001
Specialty care visit 367 (46.7) 200 (42.1) 167 (53.9) .001
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Note: Pearson’s chi-square was used to generate p-values.

4.3 |. Association between insurance type and post-acute care services utilisation

Using logistic regression models, we examined if the relationship between ED visit and insurance type was influenced by post-acute care service utilisation (Table 3). Model 1 demonstrates the relationship between insurance type and ED utilisation, which showed that patients with Medicaid were over three times more likely to experience an ED visit within 30 days post-hospitalisation compared to patients insured commercially (OR 3.34, 95% CI: 1.74–6.01). When patient characteristics were also accounted for (Model 2), there was a reduction in the odds of ED visits for Medicaid patients compared to those with commercial insurance (OR 2.11, 95% CI, 1.03 = 4.35). As shown in Models 3–5, utilisation of home care and specialty care was associated with a statistically significant lower odds of ED visit. In Model 5, the association between insurance type and ED visits was no longer significant once the utilisation of specialty care was accounted for (OR 1.92, 95% CI: 0.92–4.00).

TABLE 3.

Likelihood of ED visit post-hospitalisation, comparing Medicaid and commercially insured patients, accounting for patient characteristics and post-acute care service utilization

Model 1
Unadjusted		 Model 2
Adjusted for patient characteristics		 Model 3
Adjusted for patient characteristics and primary care		 Model 4
Adjusted for patient characteristics and home care		 Model 5
Adjusted for patient characteristics and specialty care
OR (95% CI) OR (95% CI) OR (95%CI) OR (95%CI) OR (95% CI)
Medicaida 3.34*** (1.74, 6.01) 2.11* (1.03, 4.35) 2.15* (1.04,4.44) 2.25* (1.09, 4.66) 1.92 (0.92, 4.00)
Primary care – – 0.57 (0.28, 1.16) – –
Home care – – – 0.17** (0.06, 0.50) –
Specialty care – – – – 0.01*** (0.001,0.08)
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Note: Patient characteristics include age, race, marital status, residing in metropolitan area and total number of Elixhauser comorbidities). Abbreviations: CI, confidence interval; OR, odds ratio.

a

Reference group is commercial insurance.

*

p < .05,;

**

p < .01,;

***

p < .001.

5 |. DISCUSSION

In this study, we examined whether there were differences in utilisation of post-acute care services among individuals insured by Medicaid and commercial insurance and whether those differences explained ED utilisation in the month following hospitalisation. Our results suggest that when compared to commercially insured individuals, those insured by Medicaid were more likely to visit the ED post-hospitalisation. Further, individuals insured by Medicaid were more likely to use home care but were less likely to see a specialist when compared to individuals with commercial insurance. Specialty care was the only post-acute care service that completely diminished the relationship between insurance type and ED utilisation 30 days post-hospitalisation.

Our findings have implications for discharge planning for individuals insured by Medicaid. Less than half of individuals insured by Medicaid were able to access specialty care within 30 days of hospitalisation. However, the specialty care needs of individuals insured by Medicaid has substantially increased over the past two decades (Anderson et al., 2018). The increased demand for specialty consultations is further compounded by barriers to care experienced by patients with Medicaid, including transportation to appointments, hours of appointment, childcare and provider availability (Anderson et al., 2018; Cheung et al., 2012; Kim et al., 2017; Ladhania et al., 2019). In 2011, approximately one-third of specialty care providers either limited or were unwilling to accept referrals for patients insured by Medicaid (Anderson et al., 2018). The limited access to specialty care often delays treatment, which can lead to increased use of urgent care and ED visits and may result in avoidable rehospitalisations (Anderson et al., 2018; Weisz et al., 2015). In our sample, individuals insured by Medicaid had a higher number of comorbidities, which suggests the need for more chronic care and specialty care co-management. Because Medicaid insurance is provided to economically disadvantaged individuals with incomes 138% below the Federal Poverty Level, other health-related social needs, such as co-pays or a lack of transportation, may also influence access to post-acute specialty care. Given the complex social and chronic disease management needs of individuals insured by Medicaid, increased attention and focus is needed to help secure specialty care appointments and creative solutions to address co-occurring social needs.

5.1 |. Limitations

Our findings should be interpreted with the following limitations in mind. The setting was a single health system in a large urban area. Therefore, results may not be generalisable to other settings. In using EHR data, we were only able to assess utilisation within our health system and reports of and reasons for ED utilisation and post-acute care services may be underreported. We were also limited to discrete data available to us in the EHR and could not obtain additional details about patients’ social needs that may be included in providers’ narrative notes. Despite these limitations, we were able to demonstrate associations between the likelihood of ED visits and insurance status and post-acute care service utilisation. Future research should examine whether these findings are evident when using multi-site samples or administrative claims data.

6 |. CONCLUSIONS

The days and weeks following a hospitalisation are a period of vulnerability as patients recover from acute illness. Connection to appropriate post-acute care services is essential to ongoing monitoring of their conditions and addressing any decompensation in health status following hospitalisation. Connection to specialty care services is especially important for individuals insured by Medicaid and is associated with fewer ED visits in the month following hospitalisation.

7 |. RELEVANCE TO CLINICAL PRACTICE

Nurses at the bedside and those in case management are key in identifying patients’ post-discharge needs, facilitating referrals and scheduling appointments. During this discharge planning processes, the plan of care should meet the needs of individuals insured by Medicaid, who may require additional support in accessing post-acute care services. In addition, discharge preparation for individuals insured by Medicaid should include improved communication between the inpatient and post-acute care teams (Baldino et al., 2020). This communication should not only focus on securing an appointment, but also ensure the outpatient provider is completely informed about the hospitalisation and any social or clinical issues that may complicate the patient’s care (Jackson et al., 2013), including access to medical equipment and barriers to filling prescriptions (Mansukhani et al., 2015). Tailored discharge planning that assures the continuity of care between acute and specialty care services has the ability to reduce disparities in access to post-acute care services among individuals insured by Medicaid and those who are commercially insured. In the event that an ED visit is required post-hospitalisation for individuals insured by Medicaid, this same level of attention to care continuity should be completed. This may consist of the ED nurse, or case manager, communicating across care settings to ensure greater continuity of care.

Supplementary Material

Supplemental Data File1
Supplemental Data File 2

What does this paper contribute to the wider global clinical community?

  • Nurses are poised to create tailored discharge plans to meet patients’ needs, particularly for those who are low income and may need additional supports in accessing post-acute care services.

  • Ensuring continuity for low income individuals transitioning from hospital to home and increasing communication across all providers and care settings will ensure successful care transitions for patients and reduce unnecessary emergency department utilisation.

Funding information

This work was supported by the National Institutes of Health - National Institute of Nursing Research (T32-NR0714, Aiken, PI) and the University of Pennsylvania Leonard Davis Institute of Health Economics Workgroup on the Care of Socially Disadvantaged Patients

Footnotes

CONFLIC TS OF INTEREST

The authors have no conflicts of interest to declare.

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section.

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Supplemental Data File 2
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