Roman Ayele1,2,3, Jacqueline Jones1,3, Amy Ladebue1, Emily Lawrence1, Patricia Valverde1, Chelsea Leonard1, Ethan Cumbler4, Rebecca Allyn5, Robert E Burke6,7. 1. Denver-Seattle Center of Innovation at Eastern Colorado Healthcare System, Denver, Colorado. 2. Department of Health Systems Management and Policy, Colorado School of Public Health, Aurora, Colorado. 3. The College of Nursing is its own school at the University of Colorado College of Nursing, Aurora, Colorado. 4. Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado. 5. Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, Aurora, Colorado. 6. VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania. 7. Section of Hospital Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Abstract
BACKGROUND/ OBJECTIVE: Older adults frequently receive post-acute care (PAC) after hospital discharge, but little is known about how perceived costs influence PAC choices. This research study sought to understand how clinicians, patients, and their caregivers evaluate the cost of skilled nursing facility (SNF) care in their decisions about whether to utilize SNFs after hospital discharge. DESIGN: Guided by principles of social constructivist theory, we conducted a qualitative interpretative study using semistructured interviews with clinicians, patients, and caregivers. SETTING: The study took place in three SNFs and three hospitals located in an urban area. Purposive sampling was used to maximize variability in SNFs, hospitals, units within hospitals, and staff. PARTICIPANTS: A total of 104 participants made up the study: 25 hospital clinicians, 20 SNF clinicians, 20 hospital patients, 15 SNF patients, 14 hospital caregivers, and 10 SNF caregivers who were directly involved in patients' transition from acute hospitalization to SNFs. MEASUREMENTS: Central themes related to how perceived costs of care influence PAC choices. RESULTS: Clinicians, patients, and caregivers did not understand the nuances of SNF insurance coverage or out-of-pocket costs. They felt constrained by insurance coverage in their discharge disposition choices and faced delays in hospital discharge due to insurance authorization processes. Some clinicians reacted to these constraints by "documenting failure," sending patients home to "fail" so they could justify SNF to insurers. Others changed their recommendations to provide patients "some" postdischarge care, even if inadequate, because of cost constraints. Clinicians discussed conserving resources to take maximal advantage of insurance-covered SNF days. Overall, cost constraint resulted in patient safety concerns, clinician professional dilemma, and moral distress. CONCLUSION: Improving patient and caregiver understanding about costs and constraints of PAC would improve decision making. There is a need for improved comprehension of cost and insurance coverage of SNF care for informed patient and provider decision making at the time of hospital discharge. J Am Geriatr Soc 67:703-710, 2019. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
BACKGROUND/ OBJECTIVE: Older adults frequently receive post-acute care (PAC) after hospital discharge, but little is known about how perceived costs influence PAC choices. This research study sought to understand how clinicians, patients, and their caregivers evaluate the cost of skilled nursing facility (SNF) care in their decisions about whether to utilize SNFs after hospital discharge. DESIGN: Guided by principles of social constructivist theory, we conducted a qualitative interpretative study using semistructured interviews with clinicians, patients, and caregivers. SETTING: The study took place in three SNFs and three hospitals located in an urban area. Purposive sampling was used to maximize variability in SNFs, hospitals, units within hospitals, and staff. PARTICIPANTS: A total of 104 participants made up the study: 25 hospital clinicians, 20 SNF clinicians, 20 hospital patients, 15 SNF patients, 14 hospital caregivers, and 10 SNF caregivers who were directly involved in patients' transition from acute hospitalization to SNFs. MEASUREMENTS: Central themes related to how perceived costs of care influence PAC choices. RESULTS: Clinicians, patients, and caregivers did not understand the nuances of SNF insurance coverage or out-of-pocket costs. They felt constrained by insurance coverage in their discharge disposition choices and faced delays in hospital discharge due to insurance authorization processes. Some clinicians reacted to these constraints by "documenting failure," sending patients home to "fail" so they could justify SNF to insurers. Others changed their recommendations to provide patients "some" postdischarge care, even if inadequate, because of cost constraints. Clinicians discussed conserving resources to take maximal advantage of insurance-covered SNF days. Overall, cost constraint resulted in patient safety concerns, clinician professional dilemma, and moral distress. CONCLUSION: Improving patient and caregiver understanding about costs and constraints of PAC would improve decision making. There is a need for improved comprehension of cost and insurance coverage of SNF care for informed patient and provider decision making at the time of hospital discharge. J Am Geriatr Soc 67:703-710, 2019. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
Entities:
Keywords:
constraints of insurance; cost of care; post-acute care
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