Selecting a Skilled Nursing Facility for Post-Acute Care: The Patient and Family Perspective Running Title: Skilled Nursing Facility Selection

Abstract

Background/Objectives

This research seeks to describe patients' experiences during the hospital discharge planning and skilled nursing facility (SNF) selection process.

Design

Semi-structured interviews, focusing on discharge planning and nursing facility selection, including how facilities were chosen, who was involved, and what factors were important in decision-making.

Setting

14 SNFs in five cities across the United States.

Participants

98 newly-admitted, previously community-dwelling SNF patients and/or their family members.

Measurement

Semi-structured interviews were qualitatively coded to identify underlying themes.

Results

Most respondents reported receiving only a list of SNF names and addresses from discharge planners and that hospital staff were minimally involved. Patients' choice of SNF was most often influenced by proximity to home and prior experience with the facility. Most respondents reported being satisfied with their placement, although many stated that they would have been willing to travel further to another SNF were it recommended. Many reported feeling rushed and unprepared, stating that they did not know where or how to get help.

Conclusion

SNF placement is a stressful transition, occurring when patients are physically vulnerable and with limited guidance from discharge planners. Therefore, most patients select a facility based on its location, perhaps because they are provided with no other information. Given CMS's proposed changes to the discharge planning process, this research highlights the value of providing patients and family caregivers with both quality data and assistance in interpreting it.

Over 20 percent of all hospitalized Medicare fee-for-service beneficiaries use skilled nursing facilities (SNFs) for post-acute care (PAC),¹ yet in their report for the U.S. Department of Health and Human Services in 2006, Shugarman and Brown highlighted that little was known about how consumers of skilled and long-term care (LTC) select facilities for that care.² Over a decade later there remains a dearth of literature focusing on PAC SNF selection, although somewhat more focuses on LTC selection. Existing research on nursing facility decision-making has found that choices are made quickly and reactively, rather than proactively.^2,3 Additionally, residents/patients themselves largely do not play a substantial role in choosing—instead physicians and family members often make nursing facility decisions.^2-4 With regard to factors that are important in this decision-making process, nursing facility quality is rarely the deciding factor, and factors that are important in nursing facility selection include location, recommendations from family and friends, prior experience, and staff treatment.^2,3,5-9

Public reporting tools and quality measures such as Medicare's Nursing Home Compare website may help guide consumer choice, but research on whether and how patients use these measures and tools to help guide choice is also limited. Although consumer response following initial implementation of Nursing Home Compare was minimal,¹⁰ research following implementation of their star rating system indicated that patients were more likely to end up in higher quality facilities.¹¹ However, research has also found that many do not use the internet to look for nursing facility information,⁵ that consumers are often unaware of resources like Nursing Home Compare,¹² and that if they are aware of or are using resources like Nursing Home Compare, the factors they are interested in such as reviews or feedback from other residents are not typically available.⁶ Additionally, patients may not have the computer, numeracy, or health literacy skills necessary to access the public reports or to make sense of information that is not easily interpreted by lay audiences (for example, how should a patient weight the relative importance of measures for pressure ulcer care versus pain management?). Indeed, there is some evidence that consumers would like more information about public reporting resources like Nursing Home Compare, as well as more guidance about the measures it includes.^6,12-14

Nursing home quality reporting may be especially important for individuals who seek PAC after a hospital event. These patients or their families/friends make choices at a crisis point when being discharged from hospitals.¹⁵ They usually have not planned for SNF placement and their choices generally are made quickly and under duress.¹⁶ Time pressure constrains individuals' ability to collect information, and this may have adverse consequences for patient outcomes.¹⁷ In addition, since PAC admissions account for a large proportion of all nursing home admissions, how consumers “choose” their post-acute setting is particularly important.¹⁸

In summary, little is known about how those needing post-acute SNF care, along with their family caregivers, select a facility. This research sought to explore patients' perceptions of the SNF decision-making process, including how they made their choices, who was involved in the process, and factors that were important to their decisions. This was accomplished through qualitative interviews with previously community-dwelling newly-admitted SNF patients recently discharged from hospitals in five cities across the country.

Methods

Design and Sample

This research included 98 interviews with respondents from five different cities across the country. The research was built on a prior study that included site visits to eight US cities, which aimed to understand relationships among managed care organizations, hospitals, and SNFs through interviews with staff at these organizations. These eight markets were selected to ensure variation based on region of the country, city size, Medicare Advantage penetration rates, and the absence or presence of functioning Accountable Care Organizations. For that prior study, we selected two hospitals within each market and three SNFs that received referrals from these hospitals. For the present study, we selected those five of the previous eight cities that best represented the variation of the selection criteria to revisit, and within each city we re-recruited the three SNFs (two in the smallest city), within which to interview SNF patients and/or their informal caregivers.

In these SNFs we recruited previously community-dwelling patients who were newly admitted to SNF. Through pilot testing (with 27 patients in two Northeast states), we determined that an appropriate number of interviews per SNF would be about 7 or 8 because these could be conducted over the course of one day and would likely reach saturation. In order to recruit participants, the interviewer first worked with SNF admissions coordinators to schedule a one-day site visit. The admissions coordinator was then responsible for generating a list of potential participants, keeping in mind that we aimed for a target n of 7 or 8 per facility. On the day of the visit, the admissions coordinator provided the interviewer with the list of potential participants, all of whom were deemed by SNF staff to be capable of providing informed consent. The ability to provide informed consent, presence in the SNF for PAC following a recent hospitalization, and having been previously community-dwelling were the only selection criteria. The interviewer then individually visited and recruited each participant. Occasionally the patient was being visited by family members. In these cases, family members were also recruited to participate in the study. The interviewer described the study and its goals and participants signed a consent form that was approved by our university's Institutional Review Board.

Procedures

We interviewed 7 or 8 patients and/or family members in each of the three SNFs participating in each of the five cities, totaling about 21 interviews per city and 98 interviews total. Semi-structured interviews were conducted with these respondents, designed to characterize patients' and their families' experiences during the discharge planning and SNF selection process. The interview protocol was developed through two waves of piloting, including interviews with 27 patients in two Northeast states. During the interviews, participants were asked about their role in SNF selection and if and how they were presented with alternatives to make this decision, as well as who else was involved in the decision. They were asked about the factors most important to them, such as SNF location and quality. They were also asked about the involvement of the hospital discharge planner, including the type of information that individual provided. Finally, they were asked if they would have made a different selection if they had received a recommendation from a trusted authority, such as their physician. See Supplementary Appendix S1 for a selection of questions that respondents were asked. These interviews took place in patients' rooms, lasted about 30 minutes, and participants were compensated with $25 for their time. Interviews were audio recorded and transcribed for analysis.

Analysis

Interviews were qualitatively coded to identify underlying concepts and themes.^19-22 We developed a preliminary coding scheme based on the questions asked in the interview protocol, then modified and refined the scheme in an iterative fashion to add codes and refine code definitions. Additional codes resulted when material emerged from interviews that was unanticipated or different from the specific questions that were asked. Therefore, the resulting coding scheme reflected both the a priori codes and areas of interest from the interview questions as well as the unanticipated findings.

Initially, two members of the research team each read all transcripts from the first site and individually coded each transcript. In subsequent and repeated meetings they discussed and refined the coding scheme and coding definitions, talked about preliminary patterns they perceived in the data, and reconciled their interpretations of the first coded transcripts that each team member had prepared. Following coding of the first site, the two coders each coded the same three interviews in order to determine inter-rater reliability. Once inter-rater reliability was ensured (greater than 90 percent agreement), the two coders each coded half of the remaining interviews individually, meeting weekly to discuss emerging themes, track their prevalence across transcripts, and search for disconfirming evidence to explain discrepant information and better understand the range of responses. Throughout analysis, a comprehensive audit trail was kept, which recorded ongoing team decisions, including selection and definitions of codes and the emerging themes.^19,23-26 Coded data were entered into the qualitative software package NVivo to allow for data management.

Results

Participant Characteristics

A total of 98 interviews were conducted with patients and their family members in five cities. For 90 of the interviews the patient was the only respondent, while eight interviews were conducted with the patient and a family member. Sixty patients were female and 38 were male; 84 patients were White, 11 Black, and 3 of another race. Seventy-eight of the patients entered the hospital on an emergency basis (most commonly the result of a fall, n=30, cancer, n=8, and infection, n=7), while 19 had planned hospitalizations (most commonly for joint replacements, n=9), but only 9 of these 19 reported choosing their SNF in advance. In 66 of the interviews the patient served as the SNF decision-maker, in 19 cases a family member or friend of the patient made the decision, and in 12 the SNF decision was made by hospital staff. Thirty-five patients had prior stays in the same SNF, while 45 patients had never had any SNF stay before. See Table 1 for a tabular representation.

Table 1. Respondent Information.

Characteristic	n (%)
Patient Gender
Female	60 (61)
Male	38 (39)
Patient Race
White	84 (86)
Black	11 (11)
Other	3 (3)
Emergency Hospitalization	78 (80)
Falls, Accidents, Broken Bones, Concussions	30 (31)
Cancer	8 (8)
Infection	7 (7)
Heart Attack, CHF	6 (6)
Stroke	6 (6)
Pneumonia	5 (5)
Amputation	4 (4)
Other	12 (12)
Planned Hospitalization	19 (19)
Joint Replacement	9 (9)
Back Surgery	3 (3)
Other	7 (7)
Planned SNF-Stay	9 (9)
SNF Decision-Maker
Patient	66 (68)
Family Member or Friend	19 (19)
Hospital Staff	12 (12)
Prior Stay in Same SNF	35 (36)
No Prior SNF Stay	45 (46)

^*One respondent refused to answer cause for hospitalization

Themes Identified

During the course of the interviews, respondents discussed many aspects of the SNF decision-making process, and several themes emerged during coding. Of particular note is that although we sought to understand all aspects of experiences, respondents largely reported experiences of a negative nature. Very few respondents reported that they had positive experiences in SNF decision-making. The aspects of the process that respondents reported on fell under three themes: the overall SNF decision-making process, factors that were important in selecting a SNF, and other aspects of the transition. First, respondents described the overall decision-making process, stating that they had very little time to choose a SNF, that in order to choose a SNF they received lists from discharge planners that included just names and addresses of local SNFs, and that discharge planners and physicians were minimally involved in the selection process. With regard to the second theme, respondents described the factors that were important to them in selecting a SNF: many patients selected facilities that they had previously been to, that family/friends had been to, or that were located close to their homes, although a few respondents indicated choosing facilities because they had better and/or more staff, were clean, or had more amenities. Respondents also discussed other aspects related to the transition process (the third theme), including that they would have been willing to travel further for a higher quality facility. Respondents also highlighted the value of having friends and family to help with the decision-making process, and most respondents felt unprepared and unassisted during the process. Further description of these concepts follows, and illustrative quotes are included in Tables 2, 3, and 4. Table 2 includes quotes that relate to overall SNF decision-making; Table 3 includes quotes that describe factors that are important to patients in decision-making; Table 4 includes quotes that describe other aspects of the transition process.

Table 2. Quotes Describing the Overall SNF Decision-Making Process.

Sub-Theme	Example Respondent Quotations
Rushed Decision-Making	They wanted to move me out the same day. And so I had to decide so that they could go forward to see if they could get a bed. (patient, Northeast) There is a push and a shove associated with it. On the medical side they were encouraging a fairly rapid transition and on the administrative side they seemed to be encouraging a VERY rapid transition. (patient, Northwest) We didn't know where to go. So, they sprung it on us that we're running out of time. (family member, Midwest)
Patients Received a Large List of SNFs	They give you a list. Names and addresses. And you look it up. It's up to you to go on the internet and look it up. (patient, Midwest) Oh, my—they gave my daughter a whole sheet with facilities that we could choose from. And we looked at the addresses. (patient, Midwest) They gave us a two page list. It was all the SNFs in town. (patient, Northwest) Well there were like a hundred of them [SNFs]. It's all the facilities in the area. (patient, Midwest)
Patients Received a Few SNF Options	There was two choices. One [place] and this one. (patient, Midwest) Oh they named a couple of different places, but I can't remember which ones they named, but when they mentioned this one I told them this one right here because it's closer to home. (patient, Northeast) Well, they didn't give me a big list because they had to find out if there was availability. So they named about three and [present SNF] was one of them and I said that's where I wanted to go. (patient, Northwest) They said, “Do you wanna stay in [the hospital] system?” And I was happy with [the hospital] system - they had done my surgery. I was treated very well there and the care was very good. So I said, “Uh, sure, I'll stay in [the system].” And there's really only two [system] facilities. (patient, Northeast)
Role of Discharge Planners	They don't try to slant your opinion. They're very informative and very nice, and help expedite it. But I don't think they would've helped me decide. (patient, Midwest) I don't think that it's their job to base how good they are here or anything. That would be promoting where they're sending me. (patient, Northeast) They were very forthcoming as far as the extent that I asked any questions. But I didn't know that many questions to ask….I've never been somewhere, so I didn't know how the whole thing worked. So I just let them handle it. (patient, South)
Role of Physicians	I didn't ask them for help. I think they wanted to stick to the medical side of things. (patient, Northwest) The physicians, they're out there. They, ya know, you might see 'em once or twice at the most. They're in and they're out and they're gone, and so they're not really involved. (patient, Northeast) No, she doesn't do that. She's just a surgeon. (patient, Northeast)

Table 3. Quotes Describing Important Factors in Patients' Decisions.

Sub-Theme	Example Respondent Quotations
Location	They gave me a sheet with about 50 on there, but I looked for ones that were in my area so I wouldn't have to drive so far and this is the closest one that had an opening. (patient, Midwest) Location, location number one and their qualifications, but I was hoping they had good qualifications, you know, but right now it was really location because my niece really doesn't drive too far. (patient, Northeast) And I picked this place mainly, it was my first time bein' here, mainly because of the location. It's only five minutes from my house and it would be easier for my husband. (patient, Northeast)
Prior Experience	There is a comfort, in knowing certain elements versus fear with the unknown, ya know. So that's why I came here. (patient, Midwest) So you gotta think what ya don't know, you're a little bit afraid of! (patient, Midwest) Um, but I got to tell you, I even thought about [choosing another facility], but I kept coming back to the devil you know is better than the devil you don't know. (patient, Northeast) I thought, why wouldn't I go to a facility that I know rather than some facilities where's there's some questions about them…I just felt a little loyalty to coming here. (patient, Northeast)
Family/Friend Experience	It seems that word of mouth is the best way. Probably to know somebody who was cared for at the place, because the brochures don't tell you anything. These people try to fill their places up, and there's a lot of hype in there. (patient, Northwest) My son had been here before too. My husband, so it just, because, it's kind of a family thing. You call that a family thing. You know, this is where they've been and this is where they've been satisfied, so that to me is reason enough. (patient, Midwest) I like word of mouth of people who've already been there because the doctor, they're not lying in the bed, they haven't been where you've been. (patient, Midwest)
Quality	Well, the quality of the care. I want, because I've seen other places, and you want to be able to walk into a place and feel comfortable right away, that the workers and people are taking care of the people and are treating them with respect. (patient, Midwest) Well, the first, the very first thing is cleanliness, that you know, and that the people have to be knowledgeable too. That's very important, you know. (patient, Midwest) Okay, I think the ambience, clean, quiet, well-organized and trained staff, and that's one important area. Another important area are the amenities like food, showers. I think another area, big area, is that of mutual respect between the staff and the patients and nursing staff's patience with the patients is important. (patient, Northwest)

Table 4. Quotes Describing Other Aspects of the Transition Process.

Sub-Theme	Example Respondent Quotations
Help from Family/Friends	Well, my daughter took care of a lot of those things for me. I think they were very helpful to her because my daughter will ask a lot of questions and she can be pretty feisty and aggressive at getting the information that she wants. (patient, Northwest) And my son, is like my guardian angel I guess you'd say. And so he decided that he was going to check into places with a person that was there at the hospital. And this was one of the places that had one opening. And so he kind of checked into a lil' bit and decided that it would be a good place. (patient, Northwest) No, they [family] chose it for me and I was glad. (patient, Northeast)
Willingness to Travel Further	I would go anywhere if I thought they could help cure me or help facilitate my rehab. (patient, Midwest) Oh, yes! I want to go to the best of the best. (patient, South) I would do anything that would be better for me and better for my family. My daughters, they drive, they can either drive here or they can drive there. (patient, Midwest) If it would meet my needs better than the facility that I'm in, yes, I would. (patient, Northeast)
Feelings About the Process	It would have been nice to, I like to know everything ahead of time. But it's impossible. And I don't know what they could've told me that—there's some things you just have to go through to understand them….I tell you, you feel like you're on your own in most of these situations, I mean, I've never been faced with it before. Never thought about it, because she [the patient] was healthy as a horse. And then when I was put into the situation of making the decisions, and then for somebody to come up and say, well, ‘It could be tomorrow, you gotta go.’ Where do we go, you know? Oh, I got on meds at that time, to be able to handle all this. (family member, South) Well, other than not really being prepared it was, it was kind of a rush thing and a new experience, I don't know how you can really prepare you know to go from hospital to a nursing facility. (patient, Northeast) I think it was probably a month ago, I was having a meltdown. I thought, are they gonna put her out in the back? You know, I thought we were out of Medicare. I had no idea! So I just told my son, I said, I can't handle it. You're gonna have to go up and talk to somebody…I didn't know who to talk to, you know? Do you talk to Medicare? Do you talk to the social work people? And I wasn't getting anywhere. So he came up and settled me down, got me back in. You know, I think everybody needs to go through this process to know what us caregivers are going through, because it's crazy. Crazy. (family member, Midwest)

Overall SNF Decision-Making

Respondents discussed the overall SNF decision-making process. They reported that they felt rushed, and despite different reasons for hospitalization and different hospital lengths of stay, most respondents reported that they were required by hospital discharge planners to make decisions regarding SNF placement the day before or the day of their hospital discharge. In order to make this SNF decision, patients and/or family members were provided with facility options by the hospital discharge planners. Many respondents reported receiving a list of every facility in their geographic area (several pages of facilities). This list generally just included the names and addresses of each facility, often in alphabetical order. A few respondents reported receiving a list of just a few SNF options, often limited by location. The provision of this list was generally the extent of discharge planner involvement. Respondents reported that discharge planners were minimally involved in SNF decision-making, and they reported feeling that discharge planners were not allowed to make recommendations, which they viewed as demonstrating bias towards certain SNFs. Respondents reported that physicians were not involved in nursing facility selection. Respondents generally did not seek help in SNF decision-making from physicians, and did not view SNF selection as part of the physician role.

Important Factors in Patients' Decisions

Respondents reported a number of factors that were important during the decision-making process, including location, prior experience, the experience of family and friends, and quality. Many respondents mentioned location as a primary consideration in their SNF decision. This was not surprising given that the address was often the only information about the SNF that patients were given. Additionally, location was often given as the most important deciding factor by those who did not have prior experience and those less able to advocate for themselves. Another common factor associated with patients' decisions was previous experience: patients were likely to go back to SNFs they had already used, even if previous stays had been less than satisfactory. Patients also reported choosing SNFs that family and friends had previously stayed at. Respondents were likely to trust the judgment and experience of the people they knew. Lastly, some respondents reported that quality was the most important factor in their decisions. Respondents tended to define quality by cleanliness, the amount and availability of the staff, and the friendliness of the staff.

Other Aspects of the Transition

In addition to discussing SNF decision-making, respondents talked about other aspects of the transition. Some respondents reported relying on decision-making support from their family and friends (for example, having family members make calls to facilities or go on tours); indeed, respondents without involved family seemed to have more difficult and stressful experiences. Another aspect that respondents reported on was their overall satisfaction: most respondents reported being satisfied with their placement, but many stated that they would have been willing to travel further to a higher quality facility or one recommended by their doctor. Lastly, although respondents were generally satisfied with their placement, many described having been unprepared and somewhat unassisted during decision-making, stating that they did not know where or how to get help.

Discussion

Taken together, our interviews provide a detailed picture of the hospital discharge/SNF selection process. The dominant aspects of patients' experiences include that patients were given little time during which to choose a SNF, were given little direction in choosing, and were usually just given lists of SNF names and addresses and no quality information whatsoever. This resulted in patients choosing SNFs that were close to their homes even though most reported being willing to travel further away from home for better quality.

These findings confirm previous research. Although location was an important factor in patient choice, which is consistent with the literature,^2,3,5-8 respondents were willing to travel further for better quality of care. Additionally, as was found in previous research,^2,3,16 SNF stays were largely unplanned and decisions were made quickly and at a crisis point. Unlike previous research,^2-4 this study found that patients were frequently the SNF decision-makers, as opposed to family members or physicians: in 66 of the 98 interviews the patient served as the SNF decision-maker. This inconsistency with prior research may be the result of the difference in respondents: previous literature tended to disproportionately include family member respondents,^5,12,13 as opposed to our research which included primarily patient respondents.

A critical finding was that although respondents would have appreciated help from discharge planners, hospital staff were minimally involved with SNF selection. Although previous research found that hospital staff were very involved in the SNF decision,⁴ research has yet to thoroughly investigate the patient perception of this involvement. The present study sought to do so, and found that patients (and their families) felt that hospital staff were minimally involved and that they would have appreciated more help. This is consistent with existing literature which has found that home health case managers do not provide quality information or make recommendations, but instead provide only lists of agency names and contact information²⁷. It is also consistent with research that has highlighted the importance of providing information to patients, because consumer understanding of post-acute services is associated with decision-making.^9,28 In the present study, patients reported feeling that medical staff were not allowed to offer guidance or recommendations, despite the fact that because most nursing home admissions come from the hospital, hospital discharge planners are key stakeholders in the placement process. This lack of guidance may be the result of misinterpretation or over-interpretation of “patient choice” statutes that are embedded in Social Security and Medicare Conditions of Participation, which require that providers ensure patients' rights to freely choose their Medicare providers. This focus on providing “choice” at the expense of providing complete information may be doing a disservice to both patients and to healthcare systems that are increasingly responsible for PAC outcomes.

Such findings are timely, considering that CMS recently proposed changes to the discharge planning process that include requiring hospitals to help patients select PAC providers by using and sharing quality data and measures.²⁹ The present research demonstrates how critically valuable any additional data and assistance may be to patients and their family members, who are currently just receiving lists of facilities. This policy change may have serious implications for discharge planning within hospitals, and serious impacts on patients and their family members. Hospitals should consider empirical research, including the findings of the present study, which highlights the patient perspective and the areas for improvement in the overall process. In the meantime, hospitals have the responsibility to consider how discharge planners can engage patients in decision-making that incorporates quality of care while still adhering to “patient choice” requirements.

Limitations

Although these findings present a detailed picture of the SNF selection process, it is important to note that because the sample included 98 respondents in five cities across the country, these findings may not be representative of the experiences of others in these cities or in other areas. Because interviews were conducted in patients' rooms, which were semi-private spaces that staff often moved in and out of, it is possible that patients spoke less openly to avoid potentially offending staff. However, interviews were often conducted with doors closed and paused, according to respondent preference, when staff were in the room, and no respondents expressed privacy-related concerns.

Conclusion

Transitions are largely rushed and chaotic, and patients are ill-supported by healthcare systems in making informed decisions. Patients report selecting facilities for reasons other than quality, and describe the process as “crazy” and something they were not prepared for. In summary, SNF placement is a stressful transition, occurring at a time when patients are physically vulnerable, and often without significant help or guidance from experienced professionals like hospital discharge planners or physicians. Most patients select a facility based on its location, perhaps because they are not provided with quality information or advice.