Photo courtesy of Dr Shi graphic from Getty Images
Photo courtesy of Dr. Shi; graphic from Getty Images
Q&A | December 21, 2022 | FREE
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Honest talk about SNFs

Discharge to a skilled nursing facility is a moment for serious discussion of prognosis, a geriatrician says.

Discharge to a skilled nursing facility (SNF) can feel like a successful conclusion of care to a hospitalist, but for patients, the travails may have just begun.

Statistics show that returning to the hospital or moving to a long-term care facility are both common outcomes from a SNF stay, yet it's rare for hospitalists and patients to discuss these possibilities, experts say. Two geriatricians and a physical therapist recently teamed up to try to change this dynamic with a Viewpoint published in the November JAMA Internal Medicine.

Their article, “Advancing Communication and Decision-making for Older Adults Discharged to Skilled Nursing Facilities—Not Where but Why?,” calls on hospitalists to treat a SNF discharge as an opportunity to talk to patients about their long-term prognosis and plans.

To learn more, ACP Hospitalist recently spoke to lead author Sandra Shi, MD, MPH, a geriatrician and researcher at the Marcus Institute for Aging Research and Harvard Medical School in Boston.

Q: What sparked your interest in outcomes from SNF care?

A: When I was working in the hospital side as a resident, I had always assumed that folks would go to rehab and get better and then they would go home. It wasn't until I was a geriatrician, working in nursing facilities and really seeing many of these patients not do well, that I started looking at the literature and I realized that it's well established that these patients often don't do well. They are readmitted one in five times, and only about half of them make it home right away.

Q: How did that data change your perspective?

A: To me, that was a big shock. I first of all felt guilty that I did maybe oversell rehab a little bit when I was trying to discharge patients from the hospital: “You'll go to rehab, you'll get stronger, and then you'll go home.” This is just not the reality for half of patients. I felt like I was almost sending patients to rehab under false pretenses—that it was short-term and that they were going to get much stronger. The reality is even for the lucky half who get home, most still need home care assistance.

Q: Do you think hospitalists are also unaware of this?

A: I would think so, because other than the patients that are rehospitalized, unfortunately, they don't see what happens. It is something that is probably not on the radar for most people, and I don't blame anyone. The analogy I use when I speak with residents and fellows is that when I was an ICU resident I always thought, “Oh, I tidied up this person so well, they're going to go to the floor and do great.” And then when you're the floor resident accepting the person you're like, “What was the ICU thinking? There's no way this person is stable.” Sometimes it's just that shift in perspective that makes the difference.

Q: How should this new perspective change hospitalists' practice?

A: One of my coauthors is a physical therapist. On the inpatient hospital side, when she's doing evaluations, she felt they mostly wanted to know, “Dispo? OK, needs to go to SNF. Done.” And so she would say, “Maybe we should be having another conversation because, functionally speaking, I don't know if this person is ever really going to be able to go home safely.”

Q: How do you decide which patients this applies to?

A: First and foremost, by involving the rehabilitation team or physical therapist or occupational therapist. When we consult PT/OT, we treat it as a one-time assessment, almost like a pregnancy test: yes or no. You should treat it like any other consult service: “I understand you've recommended SNF, and I think that's totally appropriate. But what do you think is a realistic expectation for functional recovery for the family?” Listen to your instincts. Your instinct is probably telling you if this person is somebody that's not going to have the best-case outcome.

Q: What do you say in those conversations?

A: First and foremost, acknowledging that uncertainty with families, saying, “We're all rooting for them. We are hoping for best-case scenario. I think best-case scenario is this. I think the most likely scenario is this.” I use ranges: “I think you'll probably be there for two to three weeks, and my guess is that when you go home, you're still going to need some level of support. How much support will depend on how the next few weeks of rehab go. It might be very little, or it might actually be 24-hour care.”

I want to normalize that recovering from a hospitalization is a slow process, and even if they aren't able to go home or go back to gardening or shoveling snow, or whatever it was they were doing before, that doesn't mean that they didn't work hard enough. I think that's something that most [hospitalists] will feel comfortable saying because I think most people recognize that it's actually pretty normal. … But sometimes with how quickly we're trying to get people in and out of the hospital, we don't set people up with that expectation, and then they feel like it was a failure in some way.

We start telling patients and families basically as soon as they're assessed, so we can prepare them. A lot of patients are only in a SNF for two weeks, which isn't a lot of time for families that are working full-time jobs to put together 24-hour care even for a week or two. …. Maybe involve palliative care, geriatrics, and other folks who could help navigate those challenging conversations.

Q: Should these patients not be going to SNFs?

A: It's so hard to predict these things, and you want to give everyone a chance. You want to give everyone a trial of rehabilitation, yet recognize that based on the data we have, they are a high-risk population. … Most of the time [hospitalists] know that this person is not going to do well, but what else are you going to do with them? They can't stay in the hospital. It's not that I'm saying they should not go to a SNF. It's more about starting the conversation.

The SNF does give us the opportunity to address some of those social determinants that I think hospitalists feel really challenged to address, like prior authorizations, making sure that they get in to see a subspecialist. If you're not really sure where this is heading, you can always call the SNF and say, “Look, I'm sending this person over. They're being discharged. I understand they're maybe not the greatest rehab candidate. … We also discussed with them that they might be going home needing a little bit more help from their children, but a challenge was that the daughter might not be available during the daytime or they couldn't afford this medication, so we started working on a prior authorization and a referral. If you could just make sure that the patient is plugged in by the time they leave the SNF in three weeks, then that would be great.” At the SNF, because there are social workers and case managers on the same team following that patient for the entire time, sometimes they're able to better address some of those social determinants of health.

Q: Is there any other advice you'd give hospitalists on this issue?

A: Keeping continuity is always going to be helpful. SNFs are always happy to have contact with the hospital. But it's such a different environment that it's hard sometimes to kind of picture what it's like on the other side.

I do think that the transition is going to evolve on both ends. Everyone is just trying to do their best for the patient, but that can be hard sometimes when you have limited time and resources. I want everyone to feel better connected, because I think we're all seeing the same problem and saying the system doesn't seem set up to give us a good solution.