Journal of General Internal Medicine

, Volume 33, Issue 5, pp 678–684 | Cite as

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

  • Robert E. BurkeEmail author
  • Jacqueline Jones
  • Emily Lawrence
  • Amy Ladebue
  • Roman Ayele
  • Chelsea Leonard
  • Brandi Lippmann
  • Daniel D. Matlock
  • Rebecca Allyn
  • Ethan Cumbler
Original Research



Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization.


We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF.


Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making.


Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities.

Main Measures

We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame.

Key Results

The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome.


Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.


decision-making post-acute care hospital skilled nursing facility 



This work was supported by the National Institute of Aging, R03AG050885 (Dr. Burke, PI). Dr. Burke was also supported by a VA HSR&D Career Development Award (1IK2 HX001796).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2017_4298_MOESM1_ESM.docx (23 kb)
ESM 1 (DOCX 23.2 kb)


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Copyright information

© Society of General Internal Medicine (outside the USA) 2018

Authors and Affiliations

  • Robert E. Burke
    • 1
    • 2
    • 3
    Email author
  • Jacqueline Jones
    • 4
  • Emily Lawrence
    • 1
  • Amy Ladebue
    • 1
  • Roman Ayele
    • 1
  • Chelsea Leonard
    • 1
  • Brandi Lippmann
    • 1
  • Daniel D. Matlock
    • 5
    • 6
    • 7
  • Rebecca Allyn
    • 8
  • Ethan Cumbler
    • 3
  1. 1.Denver-Seattle Center of Innovation at the Denver VA Medical CenterDenverUSA
  2. 2.Hospital Medicine SectionDenver VA Medical CenterDenverUSA
  3. 3.Division of General Internal Medicine, Department of MedicineUniversity of Colorado School of MedicineAuroraUSA
  4. 4.University of Colorado College of NursingAuroraUSA
  5. 5.Division of Geriatric Medicine, Department of MedicineUniversity of Colorado School of MedicineAuroraUSA
  6. 6.VA Eastern Colorado Geriatric Research, Education, and Clinical CenterDenverUSA
  7. 7.Adult and Child Consortium for Outcomes Research and Delivery ScienceUniversity of ColoradoAuroraUSA
  8. 8.Department of MedicineDenver Health and Hospital AuthorityDenverUSA

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