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

Burke RE, Jones J, Lawrence E, Ladebue A, Ayele R, Leonard C, Lippmann B, Matlock DD, Allyn R, Cumbler E. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. Journal of general internal medicine. 2018 May 1; 33(5):678-684.

Related HSR&D Project(s)

• CDA 14-411 – Improving Transitional Care for Veterans Discharged to Post-acute Care Facilities

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Abstract:

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