“They Need to Have an Understanding of Why They're Coming Here and What the Outcomes Might Be.” Clinician Perspectives on Goals of Care for Patients Discharged From Hospitals to Skilled Nursing Facilities

Abstract

Context. The number of patients discharged from acute care hospitals to skilled nursing facilities (SNFs) is rising. These patients have increasingly complex needs and many experience poor outcomes while under SNF care, including hospital readmissions. Patients' goals of care (GoC) are viewed as a factor contributing to unplanned hospital readmissions from SNFs. However, clinicians' perspectives of GoC for hospitalized patients discharged to SNFs are not well-described. Objectives. To explore how clinicians view GoC for hospitalized patients discharged to SNFs. Methods. Qualitative study using semi-structured interviews and thematic analysis. Results. Forty-one clinicians from one acute care hospital and two SNFs completed interviews ranging in length from 14 to 52 minutes (mean ¼ 32 minutes). Of the sample, 22% were nurses, 20% physicians, 15% were from care management, and 15% were from social services. Respondents viewed patients' GoC for continuing treatment at the SNF as important, but acknowledged that they were infrequently discussed during hospitalization. Many respondents felt that patients and families had unrealistic GoC for SNF care. Factors that contributed to unrealistic GoC included patients' limited knowledge of disease processes, prognosis, and treatment options; and inconsistent or insufficient communication of GoC among hospital and SNF clinicians, the patient, and family members. Respondents associated a lack of GoC or unrealistic GoC with patients' dissatisfaction with SNF care, unplanned transitions to hospice, and hospital readmissions. Conclusions. Respondents reported that GoC conversations infrequently occurred during hospitalization, contributing to unrealistic patient and family expectations for SNF care and poor patient outcomes. Interventions are needed that facilitate timely, accurate, and consistent GoC discussions across care continuums.

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

“…(3) What are the pressure points for clinicians in justifying patient referral to SNFs? Codes were developed inductively through group discussion until saturation was reached; coding consistency checks were made throughout the coding phase, and discrepancies were resolved by team discussion …”

“…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.…”

Building trust and facilitating goals of care conversations: A qualitative study in people with heart failure receiving home hospice care

“…One of the most important findings from this study was the role of trust in building and maintaining goals of care conversations, which is consistent with findings from previous studies conducted in clinical and long-term care settings. [18][19][20][21] Specifically, we found that having good relationships, active listening with empathy, and language concordance were all significant facilitators to building trusting relationships between persons with heart failure, family caregivers, and healthcare providers for effective goals of care conversations. This finding is similar to those documented by previous studies conducted in long-term care facilities 22 and home health settings.…”

“…This finding is consistent with a previous study that explored provider perspectives on goals of care for hospitalized persons discharged to skilled nursing facilities. 20 Feder and colleagues reported that goals of care were often not discussed during hospitalization, which contributed to sick persons' limited awareness of their disease trajectory and unclear care goals. The lack of discussion around goals of care resulted in disconnected delivery of care due to difficulty initiating goals of care conversations in the long-term care facility.…”

“…The lack of discussion around goals of care resulted in disconnected delivery of care due to difficulty initiating goals of care conversations in the long-term care facility. 20 Many studies pointed out that the lack of goals of care conversations were related to difficulty predicting prognosis and identifying when and how goals of care conversations should occur, healthcare providers' limited time and lack of training necessary to discuss goals of care, and lack of willingness to discuss goals of care among both patients and providers. 19,20,24 The absence of goals of care conversations before referral to hospice inhibits appropriate decisionmaking about patients' end-of-life wishes, preferences, and quality of life.…”