Opportunities in stroke care at safety net hospitals: A socioecological perspective

Safety net hospitals (SNHs) provide care to patients regardless of their insurance status or ability to pay, serving populations at the highest risk for poor stroke outcomes. These include historically marginalized racial and ethnic groups, and individuals disproportionately affected by adverse social drivers of health, including lower socioeconomic status, housing instability, and limited access to preventive care. Improving stroke care at SNHs presents a critical opportunity to strengthen care delivery for individuals with the greatest need. However, such efforts require a clear understanding of the barriers across all levels of the healthcare system. In this Perspective, the authors adopt a socioecological framework to explore patient-, community-, institution-, and policy-level influences on stroke care in SNHs. Patient-level barriers include chronic disease burden, limited health literacy, and language barriers. Community-level challenges, such as neighborhood disadvantage, transportation challenges, and food insecurity, contribute to delays in care and recovery. At the institutional level SNHs often face inconsistent access to diagnostic imaging, limited specialty support, variation in stroke center certification, and staffing shortages. At the policy level, financing structures, documentation requirements, and performance metrics may unintentionally penalize under-resourced hospitals. Findings have been synthesized in this text across these domains and highlight opportunities for research, workforce development, and stroke care delivery improvement. A socioecological approach is essential to addressing disparities in stroke outcomes and guiding multilevel strategies that ensure consistent, high-quality care for underserved populations.