Health Policy$ense

Post-Acute Stays in Skilled Nursing Facilities: Patient Experiences

Reported Gaps in Physician Communication

What kind of care do patients expect after they are discharged from a hospital to a skilled nursing facility (SNF)? And how do those expectations align with care they actually receive from physicians and advanced practitioners? We know surprisingly little about the patient care experience in these post-acute settings, even though 1.5 million people in the U.S. are discharged to them each year. One fourth of those people die or are readmitted to the hospital within 30 days. Patients with Alzheimer’s disease or related dementias are at an even higher risk of rehospitalization.

Nancy Hodgson
Nancy A. Hodgson, PhD, RN, FAAN, is an LDI Senior Fellow, and Professor in the Department of Biobehavioral Health and Anthony Buividas Term Chair in Gerontology at the University of Pennsylvania School of Nursing.

We do know that many different models exist for physician practice in SNFs, ranging from in-house, full-time physicians on staff to open-staff models in which physician generalists from the community see SNF patients. Some data suggest that advanced practitioners who specialize in SNF care may be associated with better patient outcomes, but we don’t know what SNF patients expect from their providers and what they experience. So we decided to ask them.

We interviewed 50 patients receiving post-acute care in a SNF. Because we were also interested in the expectations and experiences of patients with cognitive impairments, we interviewed six family caregivers of these patients. What we found was enlightening and should inform efforts to redesign and improve post-acute care.

First, most participants could not identify the practitioners in charge of their care at the SNF; in fact, almost all participants could not name this provider or misidentified the provider. Confusion about the roles of different health care professionals was common, as one participant stated:

“I'm not sure who makes decisions about my medications at [this facility]. I know there is a plan, and they asked me different things, if I need this or that or the other, but I don't know who is actually–whether it's the nurse, whether it's a supervising physician. I assume it's a supervising physician, but I don't know.”

This confusion was often associated with distress and disempowerment, as patients felt unsure of the right person with whom they should communicate about their care. One patient summarized this distress, saying:

“I don’t know [if there is a separate doctor or nurse practitioner who coordinates my care in this facility]. I don’t know. I feel kind of stupid not knowing.”

Many participants expected that the attending physician who oversaw their care at the hospital would continue managing their care at the SNF, and felt disappointed when this did not happen.

Second, patients reported dissatisfaction with the frequency and quality of communication with their physicians. Most patients reported that they expected to see their doctor most days, and were disappointed when they did not. Patients also felt that physicians were rushed and dismissive in their communication, and that physicians did not actively explore patients’ preferences for care. Some reported that this inadequate communication led to disorganized and delayed care. One participant said that she felt like a “supervisor” to hospital staff in managing her own medication regimen:

“I think that [the physician] can stay on top of stuff a little bit more. I know they have a lot of patients here and I know they’re really busy, but I just feel like I’m like their supervisor and I’m keeping on top of them and making sure they do their job...I don’t want to have to be burdened with that mindset that I need to stay on top of these people in order for them to do what I need to have done.”

Not surprisingly, patients reported a more positive SNF experience overall when they felt that they received individualized physician care. When reflecting on her father’s SNF stay, one family caregiver said the following of her father’s physician and his regard for his personal preferences:

“And [the physician is] very understanding of my father and how he thinks. And thinking so much about my father and then specifically understanding of his needs, like the vegan element, things like that.  Some people really shake that off like it’s not important – he has to eat – but for a man who spent his life that way, it is important.” 

We did not find significant differences between the experiences and expectations of people with and without cognitive impairment, though participants with cognitive impairment were less aware of the gaps in their knowledge related to their SNF care.

These findings have important implications for post-acute practice and policy. SNFs provide services aimed at improving patients’ functional status so they may safely transition back into their homes and communities. Patient outcomes in these settings vary considerably, and it is likely that the gaps in physician care and communication we discovered play an important role in these outcomes.

Post-acute care is receiving more attention from policymakers and payers. Our findings suggest that they consider regulatory processes and reimbursement policies that promote increased SNF patient access to their physicians. Such initiatives could improve patient and caregiver satisfaction with SNF care.

This study, Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities, was published in BMC Geriatrics in November 2020. Authors include Kira Ryskina, Kierra Foley, Jason Karlawish, Joshua Uy, Briana Lott, Erica Goldberg, and Nancy Hodgson.