Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care
- 319 Downloads
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.
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.
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.
KEY WORDSdecision-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.
- 7.Conceptual Framework-Patient Decision Aids-Ottawa Hospital Research Institute. https://decisionaid.ohri.ca/odsf.html. Accessed January 18, 2017.
- 9.Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2014. http://onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/doi/10.1002/14651858.CD001431.pub4/abstract. Accessed January 18, 2017.
- 10.Doull M, O’Connor A, Jacobsen MJ, et al. Investigating the decision-making needs of HIV-positive women in Africa using the Ottawa Decision-Support Framework: Knowledge gaps and opportunities for intervention. Patient Educ Couns. 2006;63(3):279-291. https://doi.org/10.1016/j.pec.2006.06.020.CrossRefPubMedGoogle Scholar
- 12.Jull J, Giles A, Minwaashin Lodge, The Aboriginal Women’s Support Centre, Boyer Y, Stacey D. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015;15:1. https://doi.org/10.1186/s12911-015-0129-7.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Nelson KM, Starkebaum GA, Reiber GE. Veterans using and uninsured veterans not using Veterans Affairs (VA) health care. Public Health Rep Wash DC 1974. 2007;122(1):93–100.Google Scholar
- 25.Burke RE, Juarez-Colunga E, Levy C, Prochazka AV, Coleman EA, Ginde AA. Patient and hospitalization characteristics associated with increased postacute care facility discharges from US hospitals. Med Care. 2015;53(6):492-500. https://doi.org/10.1097/MLR.0000000000000359.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Kramer A, Fish R, Min S. Community discharge and rehospitalization outcome measures. Washington (DC): Medicare Payment Advisory Commission: 2013. http://www.medpac.gov/documents/contractor-reports/apr13_communitydischarge_contractor.pdf. Accessed December 4, 2017.