Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives lowvalue health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account. R educing avoidable hospitalizations and emergency department (ED) visits is a major target for cost control and quality improvement in the health care system. Hospitalizations for ambulatory care-sensitive conditions 1 -that is, acute conditions that could have been prevented or mitigated by effective ambulatory care 2 -cost approximately $30.8 billion annually.3 At each stage of care, patients with low socioeconomic status (SES) are at higher risk for being hospitalized for ambulatory care-sensitive conditions than patients of higher socioeconomic status.1-7 Low-SES patients are twice as likely as high-SES patients to require urgent ED visits, 4,8 four times more likely to require admission to the hospital, 1-3 and more likely to return to the hospital after discharge 6,7,9,10 and require multiple hospitalizations for any given illness.11 At the same time, they use 45 percent less ambulatory 12 and preventive care 13,14 than high-SES patients. Un-and underinsurance drive low-SES patients' preferential use of inpatient health services in part. 1,[15][16][17][18] But even in countries with near-universal health insurance coverage, lowvalue use persists among low-SES patients. 19This suggests that factors beyond insurance shape preferences for inpatient versus ambulatory care.The relative underuse of primary care and overuse of hospital-based care among low-SES patients, which we call "low-value use," has two negative consequences. First, these patients are less likely to gain the health benefits of primary care, 20,21 exacerbating health disparities.

IMPORTANCE Addressing the social determinants of health has been difficult for health systems to operationalize. OBJECTIVE To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. DESIGN, SETTING, AND PARTICIPANTS This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. INTERVENTION Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. MAIN OUTCOMES AND MEASURES The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. RESULTS Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, −3.1 days; 95% CI, −6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, −0.3; 95% CI, −0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, −0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, −0.17; P = .04). CONCLUSIONS AND RELEVANCE A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health.

BACKGROUND:Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the posthospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients. OBJECTIVE: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition. DESIGN: We conducted a qualitative study using indepth semi-structured interviewing. PARTICIPANTS: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals. APPROACH: Our interview guide investigated patients' perceptions of hospitalization, discharge and the posthospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis. KEY RESULTS: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.CONCLUSIONS: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.