The Case

A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had a prolonged three-month hospitalization for COVID-19 pneumonia-associated complications including acute-on-chronic hypoxic respiratory failure and atrial fibrillation with rapid ventricular rate. He was eventually discharged to a skilled nursing facility (SNF); however, he was readmitted approximately three times in the subsequent five months for repeated hypoxic respiratory failure events and even required an episode of mechanical ventilation.

At the SNF, advanced care planning (ACP) discussions were appropriately initiated; however, these discussions were challenging due to multiple factors: the patient was considered to lack capacity, was divorced without a next of kin, and was undergoing conservatorship. The palliative care team was consulted at the SNF and documented appropriateness for hospice, but they recommended an ethics consultation due to lack of capacity and next of kin. The ethics committee found that transition to hospice was appropriate, given the patient’s pattern of behaviors and consistent refusal to comply with many aspects of medical care. The plan was to transition the patient to hospice the following day. These recommendations were verbally communicated, but not documented in the chart.

Unfortunately, the patient developed acute hypoxic respiratory failure that night, prior to transition to hospice. He was transferred to the hospital and admitted. He passed away three weeks later in a hospital.

The Commentary

By Garima Agrawal, MD, MPH, Pouria Kashkouli, MD, MS, and and Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA

The period following discharge from the hospital is an especially vulnerable time for patients. Hospitalizations have become progressively shorter despite the increasing complexity of patients, and as a result, patients are often discharged with ongoing care needs. The quality of the discharge process and effective transitions of care are critical in minimizing gaps in care and preventing unnecessary hospital readmissions.

The patient in the described case was an unfortunate victim of discontinuity of care. The patient’s care and, more significantly, his ACP discussions were fragmented across multiple admissions and care settings from the hospital to the SNF. While the SNF in this case should be commended for their efforts to develop an ACP for this patient with limited capacity, unfortunately, they failed to document and write orders for hospice in the chart leaving the nursing staff no option but to send the patient to the hospital when he experienced acute respiratory failure. Clear communication and most importantly, timely documentation were critical for this medically complex patient who needed frequent hospitalizations. Because such communication was lacking, the quality of care was compromised.

Limitations to Advanced Care Planning

Advanced care planning (ACP) is a process in which patients discuss healthcare wishes and values with their surrogate decision maker and healthcare provider.¹ Ideally, this discussion helps ensure that future healthcare practices across the illness continuum are congruent with the patient’s healthcare preferences to reduce time and associated costs and suffering in acute care settings.

Repeated informal conversations are essential so broad goals and global preferences can evolve into specific decisions as triggered by health crises.² Not surprisingly, vulnerable populations with limited health care access have the lowest rates of ACP engagement. These populations include, but may not be limited to, patients who identify as racial, ethnic, or sexual minorities, have limited health literacy, or are unhoused or incarcerated.³

Unfortunately, the common practice is to discuss goals of care urgently in an acute care clinical context where patient-provider relationships are often underdeveloped. In this setting, clinicians may not be perceived as knowledgeable about an individual’s case, trustworthy, and persuasive, amplifying the existing ACP barriers.⁴ These situations may contribute to family disagreements and requests for treatments that the physician believes to be futile. Furthermore, 45-75% of terminally ill adults are incapacitated in the acute care setting, often leaving difficult decisions to uninformed and unclearly identified proxies.² If a proxy decision-maker cannot be identified, the hospital ethics committee becomes involved and may even request the court to appoint a guardian.⁵ Not only is the guardianship process slow, but public guardians are often unavailable. In these situations, decisions for the unrepresented patient fall to the medical provider. Providers tend to err on the side of full restorative care to avoid legal implications of the alternative, resulting in prolonged and costly healthcare with unclear goals.

Optimal Transition-of-Care is Critical for High-Risk Patients

When compared to their counterparts who go home from the hospital, patients discharged to SNFs are often more medically complex with greater burden of disease.⁶ They are often frequent utilizers of acute care, require longer hospitalizations, and need considerable post-discharge medical care.⁷ Furthermore, they often have complicated psychosocial issues that make outpatient care coordination even more difficult.

Hospitals and SNFs are jointly responsible for the outcomes of the patients transitioning between them, and while clinicians in both care settings agree on the general principles of care transitions, their roles and responsibilities remain unclear.⁸ Variability in hospital transitional care processes, limited linkages between hospital and SNF providers, and SNF staffing and turnover levels contribute to adverse events within the first few weeks after hospital discharge.⁹ Indeed, 23% of patients discharged to SNF are readmitted to the hospital within 30 days, a measure that is seen as a surrogate for suboptimal quality of care.

The transition of care for medically complex patients to and from the SNF is unarguably critical; however, care providers in these settings have identified several significant challenges, including:^6,10

• increasing complexity of patients with extensive psychosocial and specialized medical needs, requiring time-sensitive sharing of information and frank discussions with patients and caregivers;
• difficulties in identifying the right discharge care setting (home versus SNF), given variation in staffing, quality, and rehospitalization rates across SNFs;
• rising financial pressure leading to tension between hospital providers frustrated by nursing homes that decline their patients and nursing home providers complaining about premature discharges; and
• incomplete medical record transfers, often omitting ACP documents, together with other barriers to effective communication, such as frequent rotation of care teams, long wait times during the transfer process, and lack of knowledge of the resources available at the SNF.

In the face of these challenges, a safe transition from the hospital to SNF is a difficult task.

Poor Information Sharing Compromises Quality of Care

Medical information that is incomplete, delayed, or difficult to use results in high-risk discordant care and avoidable readmissions.¹¹ Although hospitals and SNFs may both use electronic health records (EHRs), what is documented and shared is at their individual discretion, which may be impacted further by lack of standardization of the data fields in their EHRs. Additionally, the lack of standardized workflow across care facilities contributes to suboptimal communication. For coordination of palliative care transitions across medical facilities, active communication is essential to avoid the shortcomings of EHR documentation.¹² ACP preferences are always changing, especially in the setting of healthcare crises. Often these preferences are communicated in informal discussions and may not be formally documented, which makes reliance on chart review inaccurate.³ For this reason, it is critical during the transition of care that clinicians take the initiative to participate in active communication, feedback loops, and warm handoffs.

Partnerships between hospitals and surrounding SNFs are an effective approach to resolve communication barriers between levels of care. By prioritizing easy communication channels and facilitating warm handoffs, the quality of the care transition is expected to improve.¹³ The patient described in the case would have benefited from better communication much earlier in his case trajectory to prevent the frequent rehospitalizations that were not improving his quality of life. An ACP is essential to provide person-centered care for all older adults, particularly those patients with cognitive impairment. Therefore, ACPs should be addressed at the first opportunity when an older adult is admitted to the SNF and not left until a patient is critically ill. In this case, the EHR documentation at the SNF should have captured the ACP discussions and included a written order for hospice care. The SNF provider should also participate in direct verbal communication during transition back to the hospital letting them know that hospice was being considered, which may have prevented an additional 3 weeks of hospital level care for this patient. Hospitals and SNFs are strongly encouraged to develop formal partnerships specifically aimed at strengthening communications and improving patient outcomes.

Take-Home Points

• Advanced care planning should be implemented and documented in a timely manner, updated as conditions change, and shared across transitions.
• High-quality patient care requires well-coordinated transitions of care with clear communication between care facilities. Optimal transitions are critical for high-risk patients who are transferred between SNFs and hospitals.
• Direct communication complements documented communication (e.g., EHR) and is necessary for patients who are going through palliative care transitions.
• Partnerships between hospitals and surrounding SNFs are an effective way to reduce communication barriers.

Garima Agrawal, MD, MPH
Associate Physician Diplomate
Division of Hospital Medicine
UC Davis Health
gagrawal@ucdavis.edu

Pouria Kashkouli, MD, FACP
Clinical Professor Hospital & Palliative Medicine
Department of Internal Medicine, Division of Hospital Medicine
UC Davis Health

Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA
Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health
Co-Editor-in-Chief, AHRQ PSNet

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