How to Improve Post-Acute Care After Patient Hospitalization

Close to 40% of adult patients receive post-acute care (PAC) when they are discharged from a hospital. That can include receiving help at home or going to a specialized facility, including a skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital. The PAC discharge process, however, is often rushed, ill-informed, prone to errors, and disempowering to patients and caregivers who may receive little guidance, new research from UC San Francisco shows.

Additionally, insurance coverage determinations greatly limit discharge options, resulting in longer hospital stays, shorter PAC durations, and leading to the use of cheaper but potentially less effective PAC.

In a narrative review published Jan. 20 in JAMA Internal Medicine, experts from UC San Francisco aim to cut through the confusion and provide an overview of PAC settings and treatment considerations to help hospital-based clinicians more effectively collaborate with patients, caregivers, and care teams to facilitate better PAC transitions.

“Hospital-based clinicians have a responsibility to understand the different types of PAC settings and actively participate in discharge planning to continue delivery of optimal, patient-centered care,” said first author, James Deardorff, MD, a geriatrician and UCSF assistant professor of Geriatrics. “They have an in-depth understanding of a patient’s complex medical needs and should proactively advocate for specific PAC settings and assist in selecting an appropriate PAC facility, especially for patients with insurance restrictions.”

In the review, the authors offer best practices for facilitating PAC transitions. They advise clinicians to recognize PAC needs as early as possible to engage in discussions about discharge preferences, while remaining flexible to change course if sufficient recovery enables the patient to return back home. With PAC use rising due to pressure to shorten hospital stays, discharge planning is often opaque and influenced by external factors such as insurance coverage and geography. The authors believe discharge planning to PAC should be guided by clinical needs, caregiver support, and values and preferences of patients and caregivers.

Better handoffs with goals of care

To optimize the process, discharge planning should be an interdisciplinary team-based approach that includes hospital-based clinicians and leverages each team member’s unique skill sets and expertise. Clinicians can improve PAC decision planning by synthesizing their knowledge of a patient’s medical needs and prognosis with the assessments of a patient’s rehabilitative and social needs from therapists, case managers, social workers, and nurses.

To reduce errors during the hospital-to-PAC transition, clinicians can help facilitate better transitions through discharge summaries that provide accurate information for medication reconciliation, post-hospital medical needs (e.g., wound care, lab-work), specialist follow-ups, functional and mental status at time of discharge, and goals of care. A hospital-facility “doc-to-doc” conversation also improves continuity and reduces adverse events post-discharge.

While its goals are often preserving and restoring health, PAC admissions are frequently a challenging time for patients.

“Going to a PAC facility can be a pivotal time for people with serious illness who might not recover but instead are withering away and dying slowly,” said study author Anil Makam, MD, MAS, a hospital medicine physician and UCSF associate professor in residence. “The hospital-to-PAC transition represents an opportunity for clinicians to revisit prognosis with patients and families, engage in goals-of-care conversations, discuss the need for advanced directives, and also any future care planning.”

In addition, the authors encourage hospital-based interdisciplinary teams to discuss tradeoffs and provide education around the capabilities and constraints of PAC. PAC settings vary in their eligibility requirements and in the intensity and complexity of services they provide. For example, while skilled nursing facility admissions may decrease rehospitalizations compared to home health care, they are more costly and may not improve patient functioning. For patients whose PAC needs can be met across different settings, they recommend the less intensive and least restrictive PAC setting when evidence suggests equivalent recovery.

The authors note that better transparency and research are needed to help inform decisions for individuals enrolled in Medicare Advantage, commercial insurance, and Medicaid plans. They also believe clinical trials are needed, such as those ongoing for home health care.

Additional Author: Robert E. Burke, MD, MS

Funding: This work was supported by grants from the National Institute on Aging (R03AG082859, K76AG094730, and P30AG044281 to Dr. Deardorff), the National Center for Advancing Translational Sciences (KL2TR001870 to Dr. Deardorff), and the Agency for Healthcare Research and Quality (R01HS027600 to Dr. Burke).

About UCSF Health: UCSF Health is recognized worldwide for its innovative patient care, reflecting the latest medical knowledge, advanced technologies and pioneering research. It includes the flagship UCSF Medical Center, which is among the nation's top specialty hospitals, as well as UCSF Benioff Children’s Hospitals, with campuses in San Francisco and Oakland; two community hospitals, UCSF Health Stanyan and UCSF Health Hyde; Langley Porter Psychiatric Hospital; UCSF Benioff Children’s Physicians; and the UCSF Faculty Practice. These hospitals serve as the academic medical center of the University of California, San Francisco, which is world-renowned for its graduate-level health sciences education and biomedical research. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. Visit www.ucsfhealth.org. Follow UCSF Health on Facebook or on Twitter.