Telehospitalists' Contribution to Health Equity

Written by Andrew McWilliams

It is our shared responsibility to ensure that everybody receives the health care they need, regardless of social or economic status. Telehealth technologies can assist care providers, including hospitalists, in reaching underserved groups such as low-income people, minorities, people with limited knowledge of English, the elderly and disabled.

Many of these underserved populations live in rural areas of the U.S., where residents generally are in poorer health than those living elsewhere and have less access to treatment, partly because so many rural hospitals and health clinics have shuttered in recent years. Since 2010, an average of 18 rural hospitals have closed annually. Only 2 closed in 2021, thanks to Federal pandemic aid, but when the aid expires soon, the closures will resume

Rural hospitals receive more attention these days, but inner-city “safety-net” hospitals that care disproportionately for low-income patients and communities of color also face growing financial difficulties. Urban hospital closures so far have remained infrequent compared with rate at which their rural counterparts have been closing, but in the absence of fundamental reforms, further closures can be expected.

Of course, there are basic differences in the situation of rural vs. urban safety-net hospitals, but one of the factors driving both types of hospitals closer to the brink is patient bypass. Bypass is the tendency of relatively well-off (and insured) patients to seek care in better-equipped and better-staffed hospitals in more affluent urban neighborhoods. Poorer people are left behind to be cared for in hospitals that provide the best care they can, with their dwinding resources.

A major contributing factor to bypass, although its exact impact is difficult to quantify, is a shortage of hospitalists to manage inpatient care in the bypassed hospitals. One of the keys to maintaining a strong in-patient hospital system is to have hospitalists available 24/7 to admit, plan care and treatment, and ensure transfer of patients to the medical floor as efficiently as possible.

The shortage of hospitalists is of further concern because hospitalists can play a key role in stanching the hemorrhage of other specialists to well-off urban hospitals. Hospitalists are also important when it comes to recruiting primary care physicians into rural and other underserved communities.

These are a variety of reasons why these hospitals have difficulty recruiting and retaining hospitalists. Rural hospitals may be at more of a disadvantage in attracting hospitalists because of their remote location, but urban hospitals may suffer more from constrained resources. Telehospitalists can help these hospitals to fully staff their hospitalist departments, in order to serve their patients better and, hopefully, to improve the hospitals’ financial condition.

In this way, telehospitalists can make a significant direct and indirect contribution to health care equity, directly by improving the care that inpatients in rural and urban safety-net hospitals, and indirectly by reducing the need and the motivation for patients to bypass their local hospital. While patients may feel they will get better care in a more distant hospital, that feeling comes at the cost of increased distance from the support network of family and friends.

Another area in which telehospitalists can contribute to health care equity is by facilitating the expansion of the hospital-at-home (HaH) care model. HaH enables some patients who need acute-level care to receive care in their homes, instead of in a hospital. There has not yet been much in-depth research on the impact of HaH on healthcare equity.

However, a recent article in the Journal of the American Geriatrics Society (“Health Equity in Hospital at Home: Outcomes for economically disadvantaged and non-disadvantaged patients”, by Albert L. Siu and others) suggested that HaH is feasible for economically disadvantaged patients and that these patients, many of whom have comorbidities and complex social needs may even benefit more than non-disadvantaged patients from HaH.

The ability to provide care in the home presents a unique opportunity to treat a patient’s clinical diagnosis while observing and mitigating social determinants of health that can affect outcomes, such as food insecurity, medical equipment needs, management of chronic diseases in real-world situations. Telehospitalists are an important part of the HaH model, in which the hospitalist may only see a patient once, e.g., in the ER, while subsequent visits are conducted through a combination of telemedicine, digital diagnostics, and in-person visits by medics or registered nurses, under the remore management and guidance of a telehospitalist.

Lastly, it is widely accepted that paying insufficient attention to differences in cultural backgrounds can cause harm to a patient’s overall health. Conversely, patients tend to be healthier when their care givers take their ethnicity and race into account.

Hospitalists face added difficulties with cultural issues compared with primary care providers, because they are typically thrust into a situation of acute illness, while a primary care provider has some opportunity to establish a relationship with the patient. The use of a remote telehospitalist makes it easier to match patients, if need be, with a hospitalist who is familiar with the patient’s language and culture. Doing so can result in better care and outcomes.

Achieving health equity will require continuing, broad-based efforts to address avoidable inequalities, historical and contemporary injustices, and the social determinants of health. Telehospitalists by themselves obviously cannot solve all these problems, but they can be an important part of the solution.

Tags: Telehospitalist ,Services ,Hospital ,Impact ,Recruiting