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Disparities after Discharge


By Lev Malevanchik, MD, and Sachin J Shah, MD, MPH

Patients with limited English proficiency (LEP) commonly face barriers in communicating with their clinicians and understanding their treatment plans. These barriers are particularly problematic in the hospital, where patients with LEP are more likely to suffer adverse events and have higher mortality and readmission rates than English proficient (EP) patients. 

One of the most vulnerable times in a patient’s hospitalization is at discharge, when they transition from the monitored setting of the hospital to their home. One way that hospitals have been identifying and tracking issues that arise during this care transition is with automated phone calls. Our hospital started a care transitions outreach program in March 2017, and now each patient discharged home from the hospital gets a phone call within 72 hours asking them about how they are doing in six domains:

  • difficulty getting prescriptions
  • medication concerns
  • questions about follow up care
  • questions about discharge instructions
  •  new or worsening symptoms
  • any other clinical issues not already addressed

We used data from 2018-2019 to evaluate whether the program’s technology and processes reached patients with LEP and EP equally. We also measured the disparities in post-discharge issues between the two populations. The results are detailed in the December 2021 issue of The Joint Commission Journal on Quality and Patient Safety.

Of the nearly 14,000 patients discharged home from our hospitals, 11% had LEP. Our program reached 81% of patients with EP and 76% of patients with LEP. When looking at the post-discharge issues, we found that patients with LEP suffered worse outcomes across all six domains.

The reasons for these disparities include in-hospital and post-discharge issues. In the hospital, patients with LEP lack:

  •  access to professional interpreters
  • adequate informed consent for their procedures
  • sufficient explanations by their providers

 At the time of discharge, few have a professional interpreter at the bedside to assist with discharge instructions. After hospital discharge, it may not be surprising that patients with LEP report all post-discharge issues at higher rates. 

Improving Outcomes for Patients with LEP
To improve outcomes for patients with LEP, we must first identify them and correctly label their preferred language in the electronic medical record. Next, hospital systems must provide adequate interpretation (phone, video, in-person) and hire bilingual clinicians. Then, at a minimum, clinicians must use professional interpreters at discharge. Although written translation technology can play an increasingly important role as technology improves, currently, it is not accurate enough to translate reliably. Separately, programs like Meds-to-Beds which brings important post-discharge medications to the bedside before a patient departs home can help patients with LEP avoid difficulties at the pharmacy. Lastly, multilingual post-discharge phone call programs can identify and address issues for patients with LEP. These methods of improving care for patients with LEP are established but require health system leadership buy-in and financial resources.

Patients with LEP deserve the same care that we provide our EP patients. When care is not equitable, disparities after discharge occur. Our study showed that we can reach patients with LEP after discharge with an automated calling program to identify issues. It is past time to fix these disparities.

Lev Malevanchik, MD, is an Assistant Professor in the Division of Hospital Medicine at the University of California, San Francisco (UCSF). Dr. Malevanchik’s research focuses on improving the care of patients with LEP by working to improve access to interpretation services.

Sachin J Shah, MD, MPH is an Assistant Professor of Medicine at UCSF. Dr. Shah’s research aims to improve the care and outcomes of older vulnerable adults.