Discharge Follow-Up of Patients in Primary Care Does Not Meet Their Care Needs: Results of a Longitudinal Multicentre Study

TL;DR

A study in Spain found that primary care follow-up after hospital discharge is inadequate, especially for vulnerable patients, leading to delayed and insufficient care.

Contribution

The study identifies specific gaps in post-discharge primary care coordination for vulnerable patients in a real-world setting.

Findings

Primary care follow-up after hospital discharge is delayed and insufficient for vulnerable patients.

Functionally impaired patients receive fewer home visits and face delays in care.

Low presentiality and infrequent consultations are observed despite increased patient complexity.

Abstract

Adequate coordination between healthcare levels has been proven to improve clinical indicators, care costs, and user satisfaction. This is more relevant to complex or vulnerable patients, who often require increased care. This study aims to evaluate the differences between hospital discharge follow-up indicators, including number of general practitioners’ (GPs) and community nurses’ (CNs) consultations, presentiality of consultations, type of first post-discharge consultation, and time between hospital discharge and first consultation. Vulnerable and non-vulnerable patients were compared. A longitudinal retrospective study was carried out in the north of Tenerife on the post-discharge care of patients discharged from the Canary Islands University Hospital (Spanish acronym HUC) between 1 January 2018 and 31 December 2022. The results obtained show deficiencies in the care provided to patients by primary care (PC) after being discharged from the hospital, including delayed first visits, low presentiality of those visits that were less frequent even with increased patient complexity, scarce first home visits to functionally impaired patients and delays in such visits, and a lack of priority visits to patients with increased follow-up needs. Addressing these deficiencies could help those most in need of care to receive PC, thus reducing inequalities and granting equal access to healthcare services in Spain.