Background:
Hospitalized older adults are increasingly referred to skilled nursing facilities (SNFs) for post-acute care following hospitalization. However, whether hospitalized older adults are enabled to make high-quality decisions about different post-acute care options is unclear. This is important because a high-quality decision aligned with patient values and expectations may lead to a better match of needs and resources as well as improved patient outcomes.
Methods:
We conducted semi-structured interviews with 20 cognitively-intact adults 65 years of age or older at three acute care hospitals, and15 similar adults at three skilled nursing facilities to evaluate the context, process, and outcomes of their decision-making regarding post-acute care. We used purposive sampling to maximize variability in the types of patients and facilities selected. We analyzed our results deductively using the Ottawa Framework for Shared Decision-Making. The Ottawa Framework is an evidence-based approach to a high-quality, shared decision, including whether those involved in the decision: elicited the decision-maker’s values and baseline knowledge; provided an appropriate context and information for decision-making; and allowed the decision-maker time to deliberate and utilize external supports to assist in their decision.
Results:
Contextual and process factors made high-quality decision-making challenging for hospitalized older adults. In terms of context, patients discussed personal and clinical characteristics that hindered them from making “high-quality” decisions. For example, some patients expressed they were too sick or sedated to make a decision, and others noted the acute nature of their illness meant they had never considered SNF care before, and felt pressure to make a decision more quickly than they wanted. In terms of process, patients saw SNF as a way to accomplish basic needs, but felt they did not understand what their options were nor how best to achieve their goals. Rather, patients felt they had limited structured guidance from their care team to align their decision with values and expectations. Patients expressed frustration with lack of transparency in the decision-making process by hospital clinicians, and wished they knew more about SNF discharge options to be able to make an informed decision. The outcomes of these decisions left most patients feeling like discharging to SNF was their only choice.
Conclusions:
Our results indicate that there are substantial contextual and process-oriented barriers to “high-quality” decision-making regarding SNF care in hospitalized older adults. This is important because a “high-quality” decision that is aligned with patient values and expectations may lead to better match of needs and resources and improved patient outcomes. Structured decision aids that address these barriers could increase patient satisfaction and improve outcomes.