Family and patient mistrust of nursing home providers can create a barrier to care. A multidisciplinary team is needed to craft care plans and rebuild trust after something goes wrong.

That’s according to a case study presented by Cleveland Clinic geriatrician Luke Dogyun Kim, M.D., at the 2025 Annual Meeting of the American Geriatrics Society.

Kim’s case study involved an 80-year-old man residing in a nursing home. He had a history of GOLD Group E COPD, chronic respiratory failure requiring supplemental oxygen, obstructive sleep apnea, heart failure with preserved ejection fraction, benign prostatic hyperplasia (BPH), vascular dementia and anxiety. He and his family hesitated to pursue palliative care. The patient’s symptoms were attributed to nonadherence to his BiPAP machine, sleep disturbances, nocturia and polypharmacy.

The family, over the patient’s objections, requested he be admitted to the hospital after he was sent to the emergency department with increased fatigue and confusion. The case study said they were frustrated over the perceived lack of care he had received in his nursing home.

In the current environment, nursing home providers face several challenges that make it difficult to win and maintain the trust of residents and their families, Kim told Skilled Nursing News. But doing so is imperative in order to prevent a cycle of unnecessary hospitalizations and interventions that compromise patients’ goals and quality of life.

Where mistrust begins

Only around 20% of Medicare patients choose a nursing home after a hospital stay, usually a sign that something went wrong in the hospital or there has been a turn in their condition due to age, Kim said. AARP’s 2024 Home and Community Preferences Survey found 75% of adults age 50 and older want to age at home.

With these consumer preferences as the backdrop, Kim said the environment for building trust is difficult right now for several other reasons. The COVID-19 pandemic instituted a lot of additional regulations on skilled nursing providers, but those didn’t come with all the resources needed to implement them. He also cited the shift to for-profit chains from nonprofits or mom-and-pop facilities.

Census remains strong in nursing homes, but the sector is experiencing a shortage of skilled clinical staff, which can make families fearful that their loved one won’t receive the right care in a timely way.

“It’s very difficult,” Kim said. “There are recipes there – like a better nursing ratio, more frequent provider visits, and setting up goals in the beginning [as to] what can be achieved, what can’t be achieved, and a clear trajectory and what to do if things don’t happen. But again, those things require on the provider side a lot of resources and engagement. Again, in the current atmosphere it’s very hard to do.”

Medical illiteracy from family members can also contribute to mistrust. One example Kim used was radiation as cancer treatment. He said the therapy is more palliative in nature than it is curative; most advanced cancer patients need systemic chemotherapy.

“Once they come to the skilled nursing facility, their basic activities are impaired, so they do not qualify for any kind of a systemic chemo,” he said. “We commonly make a scheduled outpatient oncology visit to discuss the systemic chemo. What they hear, once they go to the appointment, is, ‘You are too weak, you need to get stronger first, you need to be ambulating, you need to be independent on the activities of daily living first.’ At a certain point, they are reaching the point that we are rehabbing them to death.”

Kim is far from the only person concerned about the “rehabbed to death” issue. Increased provision of palliative and hospice care could help, and the Patient-Driven Payment Model (PDPM) does open up the potential for nursing homes to get Medicare reimbursement for palliative services, according to a recently published article in the Journal of the American Geriatrics Society.

“From a skilled nursing facility standpoint, I think it’s about having value-based goals of care discussions with patients and their families. It takes time, and it’s hard to do,” lead author Sarguni Singh, M.D., Assistant Professor of Medicine University of Colorado School of Medicine and an American Political Science Association Health & Aging Policy Fellow, told SNN. “Through education around palliative care principles and training about how to have serious illness conversations, providers can be better equipped to have these discussions with patients and families, and maybe patients then don’t automatically get sent back to the hospital.”

In Kim’s view, some families may need a trial and error period of palliative and curative treatments, because hearing your loved one is facing a difficult treatment or is out of options can be difficult to face.

“Even if everybody is delivering the same message, it’s very hard, whether they have literacy or not,” he said. “It’s not just a matter of literacy. It’s also a psychological, emotional barrier to accept. It gets even harder if they go to a palliative care setting or long term care setting, meaning they have not just end-stage organ disease, but also they have a functional barrier, which makes it even more difficult. So again, if everybody delivered the same message and we practice as we know, I think we can make changes.”

Building trust

Having everyone on the same page with family and patient messaging goes a long way to building and rebuilding trust, Kim said. Creating a system that allows for quick, detailed communication among team members is essential.

“Most of the effective systems are able to communicate securely and circulate within the system, so if things are detected, it can be reported,” Kim said. “Usually, families rely on the nurses for the first person to contact … But in the post-acute care setting, doctors only see patients [maybe] once a week. That’s a long time [between visits], especially for the sicker population in skilled nursing. So again, there should be a system that has the best way to approach, how to communicate and how to navigate changes.”

Nursing home leaders or staff who care for their own loved ones in a facility also help engender trust, Kim said. Landing a referral can depend on word of mouth from happy families and employees who recommend the facility to others. When staff or leadership place their loved ones in another facility, it can suggest internal problems families don’t want to navigate.

Rebuilding trust when it’s broken

In Kim’s case study, a multidisciplinary team was called in to evaluate the patient and make improvements in his care plan. He received a better fitting BiPAP mask and had redundant medications removed from his prescriptions. The nursing home team received education in morphine and lorazepam administration and the patient’s breathing treatments were increased. A physical therapist was brought in to create a fall prevention and gait training program.

This strategy improved communication between the hospital and nursing home and involved the family in care decisions. The patient’s condition improved, his care preferences were honored and the family began to trust the care team.

Rebuilding trust after something goes wrong requires that clinicians acknowledge the failure and learn about the patient’s individual and family history, communicate clearly and honestly, and advocate for systemic changes that promote fairness and engagement. Dr. Kim said it’s on skilled nursing leadership to foster this environment, and that includes among staff members.

“The most simple thing is how orders are carried out,” he said. “How high is the turnover? How is a nurse managing patients without any caring, just doing the job?”

Making sure staff aren’t burned out and that turnover is low can help mitigate hospitalizations, as exacerbations and new infections are caught earlier, Dr. Kim said, which will increase trust in the system overall.