Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care

Burke, Robert E.; Jones, Jacqueline; Lawrence, Emily; Ladebue, Amy; Ayele, Roman; Leonard, Chelsea; Lippmann, Brandi; Matlock, Daniel D.; Allyn, Rebecca; Cumbler, Ethan

doi:10.1007/s11606-017-4298-1

Cited by 32 publications

(58 citation statements)

References 27 publications

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“…At the macro level (external factors outside of patients and clinicians), issues with cost and quality in PAC are well described, but evidence is mounting that the micro level (day‐to‐day decisions made by patients and clinicians) is equally important in determining how PAC is used and how reforms might affect individual choices. Studies demonstrated the key role patients, caregivers, and clinicians play in PAC decision making on a case‐by‐case basis . It seems plausible that reforms to control PAC costs at the macro level may have substantial effects on these individual case‐by‐case “micro” decisions, potentially creating maladaptive changes where patients are discharged quicker and sicker, resources are rationed, and patients and caregivers have mounting concerns about the right level of care.…”

Section: Discussionmentioning

confidence: 99%

“…Studies demonstrated the key role patients, caregivers, and clinicians play in PAC decision making on a case-by-case basis. 10,11,13 It seems plausible that reforms to control PAC costs at the macro level may have substantial effects on these individual case-by-case "micro" decisions, potentially creating maladaptive changes where patients are discharged quicker and sicker, resources are rationed, and patients and caregivers have mounting concerns about the right level of care. These patterns may perversely contribute to increased rehospitalizations from PACs 26 and a continued increase in healthcare spending.…”

Section: Hospital Physicianmentioning

confidence: 99%

“…Costs play a significant role in decision making, and prior research suggests both providers and patients are uncertain about critical aspects of PAC that inform decision making . Perceived costs may drive decision making about PAC and could represent an important lever for improving decision making and the value of PAC delivered.…”

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confidence: 99%

“…Costs play a significant role in decision making, [7][8][9] and prior research suggests both providers and patients are uncertain about critical aspects of PAC that inform decision making. [10][11][12][13][14][15] Perceived costs may drive decision making about PAC and could represent an important lever for improving decision making and the value of PAC delivered. Indeed, many payment reforms involving PAC-from first-dollar cost sharing in Medicare Advantage plans, 16 to Bundled Payments for Care Improvement, to Medicare Spending per Beneficiary metrics-are intended to address costs through changes in decision making and processes of care between the hospital and PAC.…”

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confidence: 99%

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Perceived Costs of Care Influence Post‐Acute Care Choices by Clinicians, Patients, and Caregivers

Ayele

Jones

Ladebue

et al. 2019

J American Geriatrics Society

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Background/Objective Older adults frequently receive post‐acute care (PAC) after hospital discharge, but little is known about how perceived costs influence PAC choices. This research study sought to understand how clinicians, patients, and their caregivers evaluate the cost of skilled nursing facility (SNF) care in their decisions about whether to utilize SNFs after hospital discharge. Design Guided by principles of social constructivist theory, we conducted a qualitative interpretative study using semistructured interviews with clinicians, patients, and caregivers. Setting The study took place in three SNFs and three hospitals located in an urban area. Purposive sampling was used to maximize variability in SNFs, hospitals, units within hospitals, and staff. Participants A total of 104 participants made up the study: 25 hospital clinicians, 20 SNF clinicians, 20 hospital patients, 15 SNF patients, 14 hospital caregivers, and 10 SNF caregivers who were directly involved in patients’ transition from acute hospitalization to SNFs. Measurements Central themes related to how perceived costs of care influence PAC choices. Results Clinicians, patients, and caregivers did not understand the nuances of SNF insurance coverage or out‐of‐pocket costs. They felt constrained by insurance coverage in their discharge disposition choices and faced delays in hospital discharge due to insurance authorization processes. Some clinicians reacted to these constraints by “documenting failure,” sending patients home to “fail” so they could justify SNF to insurers. Others changed their recommendations to provide patients “some” postdischarge care, even if inadequate, because of cost constraints. Clinicians discussed conserving resources to take maximal advantage of insurance‐covered SNF days. Overall, cost constraint resulted in patient safety concerns, clinician professional dilemma, and moral distress. Conclusion Improving patient and caregiver understanding about costs and constraints of PAC would improve decision making. There is a need for improved comprehension of cost and insurance coverage of SNF care for informed patient and provider decision making at the time of hospital discharge. J Am Geriatr Soc 67:703–710, 2019.

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Section: Discussionmentioning

confidence: 99%

Section: Hospital Physicianmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Perceived Costs of Care Influence Post‐Acute Care Choices by Clinicians, Patients, and Caregivers

Ayele

Jones

Ladebue

et al. 2019

J American Geriatrics Society

Self Cite

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“…T his qualitative study by Burke et al 1 describes the degree to which people are enabled to make high-quality, postacute care (PAC) decisions. They conducted interviews with hospitalized older adult patients (n = 32) and their caregivers (n = 22), while the individual was in the hospital waiting for placement or after they were placed in a skilled nursing facility.…”

mentioning

confidence: 99%

Capsule Commentary on Burke et al., Evaluating the Quality of Patient Decision-making Regarding Post-acute Care

Penney

2018

J GEN INTERN MED

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T his qualitative study by Burke et al. 1 describes the degree to which people are enabled to make high-quality, postacute care (PAC) decisions. They conducted interviews with hospitalized older adult patients (n = 32) and their caregivers (n = 22), while the individual was in the hospital waiting for placement or after they were placed in a skilled nursing facility. Transcripts were analyzed inductively for themes, which were then deductively grouped under broad concepts from the Ottawa Decision-Support Framework (ODSF).Their work joins research and policy discussions about how, when, and where to transition patients out of the hospital, while avoiding unnecessary costs and ensuring appropriate level of care and accountability. 2, 3 While some studies have focused on how clinicians make decisions about PAC, 4 this paper fills a gap by focusing on the factors which influenced the decision-making processes of patients and their families. In discussing how to mediate the challenges participants shared, the authors state that providing patients with information is insufficient. Frequently, we think we empower patients by giving them information and Bchoice^(e.g., Medicare's Nursing Home Compare); however, this neglects how patients and families are often circumscribed in their ability to make sense of and meaningfully act on information provided, particularly in uncertain and changing circumstances, and limited resources. 5 One limitation is that although patients and caregivers were interviewed at different time points (in hospital or in a PAC facility), the differing time points were not discussed or considered in the analysis. The work is strengthened by the authors' use of the ODSF as a conceptual framework for evaluating post-acute care decision-making and consideration of the perspectives of patients and caregivers.As the authors note, their findings have direct clinical implications. They usefully suggest conversations about PAC be modeled off Bgoals of care^discussions, wherein patient and family values, goals, and preferred roles in decision-making are highlighted in order to tailor transition of care discussions.

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The Need to Realign Health System Processes for Patients Discharged From the Hospital—Getting Patients Home

Mor

2019

JAMA Intern Med

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Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care

Cited by 32 publications

References 27 publications

Perceived Costs of Care Influence Post‐Acute Care Choices by Clinicians, Patients, and Caregivers

Perceived Costs of Care Influence Post‐Acute Care Choices by Clinicians, Patients, and Caregivers

Capsule Commentary on Burke et al., Evaluating the Quality of Patient Decision-making Regarding Post-acute Care

The Need to Realign Health System Processes for Patients Discharged From the Hospital—Getting Patients Home

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