Post-Acute Care Remains a Mystery for Hospital Doctors

Care transitions have become critically important for long-term care providers’ finances, but the world of skilled nursing facilities and home heath settings remains a mystery to many doctors at hospitals — and a pair of hospitalists think there are steps they can take to remove some of the confusion.

Christine Jones of the University of Colorado School of Medicine and Robert Burke of the Denver Veterans Affairs Medical Center outlined three problems with post-acute care (PAC) transitions and offered potential solutions in the May 15 issue of Annals of Internal Medicine.

Deficiencies in hospitalist knowledge about care practices and patient outcomes in a SNF have some obvious pitfalls that can lead to unsafe transitions.


“Hospital clinicians may not be aware that SNF physicians are allowed up to 30 days to complete an initial patient evaluation and that SNFs are only required to have a registered nurse (RN) available for eight hours per day,” the authors wrote. “Thus, hospitalists may have unrealistic expectations about the degree of monitoring and management provided in these settings.”

To combat this, Jones and Burke suggested that trainee education include some experience in both home health and SNF settings. They also recommended asking hospitalists to assume a larger leadership role in decision-making for PAC.

“We believe that it is the hospitalist’s responsibility to lead the multidisciplinary team and create the optimal post-discharge care plan,” Jones and Burke wrote. “To do this well, hospitalists need to learn about important aspects of PAC (for example, how patients qualify, and which PAC settings are appropriate for specific needs).”


Another problem for care transitions is the fact that PAC clinicians frequently don’t get all the information they need to provide the best care. To combat this, Jones and Burke recommended finishing structured communication from the hospital to the clinicians in PAC before discharging a patient. This information should include data particularly needed by the clinicians— but this information isn’t always part of traditional discharge summaries.

Hospitalists also get short-changed on communication, which in turn limits their ability to improve care transitions, the authors wrote. One solution could be having hospitalists and trainees lead joint hospital-PAC reviews of patients who are readmitted, with the goal of finding gaps in transitional care.

It’s not the first time Burke has focused on the opacity of PAC for discharged hospital patients. He and other researchers developed a scoring system to predict adverse outcomes for Medicare patients discharged to a SNF from a hospital. Those findings were published in the Journal of the American Geriatrics Society.

“This line of research has really come from my own uncertainty actually about what happens to the older adult that I discharge to skilled nursing facilities,” Burke told Skilled Nursing News at the time. “One of the problems that I’ve noticed is that there doesn’t seem to be any way of evaluating these patients. I got no feedback about the people that I discharge for how they did.”

Written by Maggie Flynn

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