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. Author manuscript; available in PMC: 2021 Dec 13.
Published in final edited form as: Home Health Care Manag Pract. 2016 Dec 12;29(2):70–80. doi: 10.1177/1084822316678195

Preparing for the Future of Post–Acute Care: A Metasynthesis of Qualitative Studies

Allison M Gustavson 1, Jacqueline Jones 2, Kelly J Morrow 2,3, Jennifer E Stevens-Lapsley 1,4
PMCID: PMC8668077  NIHMSID: NIHMS1759875  PMID: 34908822

Abstract

Despite poor outcomes for older adults following hospitalization, practice patterns of post–acute care clinicians and factors impacting quality of care are not well studied, which limits advancements in clinical care. Qualitative research on the factors that influence physician practice patterns with respect to older adults has been studied and may provide a framework for hypothesizing factors relevant to other post–acute care clinicians. Three themes emerged from this qualitative metasynthesis: (1) Current medical education and clinical guidelines are not aligned with the multifaceted care needed for older adults, (2) communication gaps impact quality of care, and (3) health policies constrain quality of care. Identifying potential factors that impact practice patterns in post-acute care providers may guide future research initiatives that shape health professional education and system policies.

Keywords: practice patterns, post–acute care, clinical decision making, sub–acute care, geriatrics, older adults

Introduction

The growing aging population1 and concurrent rise in post–acute care health care costs2 create an impetus for health care providers to collectively achieve the Triple Aim: improved population health, reduced per capita costs, and optimized patient care experience.3 However, although there has been a profound increase in spending on post–acute care services over the last decade, quality metrics such as rates of community discharge and rehospitalization have remain unchanged.4 This discrepancy between spending outcomes in post–acute care may be attributable to current clinical practices.

Thus, an in-depth knowledge of the factors that influence clinical practice patterns in post-acute care settings will help researchers, clinicians, and clinical educators target specific areas for advancement of clinical practice. To gather such information, qualitative research approaches can explore the factors and challenges to care of older adults that subsequently influence the quality and value of health care services delivered across a multitude of health care settings.5–8 The clinical practices of post-acute care providers are largely unknown, in terms of how current practices influence patients’ quality of life, functional outcomes, and health care utilization.9 As a result, the system, clinical, and personal factors specific to post–acute care have not been adequately studied.10,11 In contrast, physician practice patterns—with respect to care of older adults in primary care settings—have been qualitatively studied.12–20 A metasynthesis can explore physician practice patterns to determine whether the results represent an overlap of emerging themes across different physician specialties and primary care settings. The results may then be potentially transferable to post-acute care providers who care for older adults (i.e., multiple disciplines in skilled nursing facilities, home health, long-term acute care hospitals, and inpatient rehabilitation facilities). The purpose of this metasynthesis is to synthesize and interpret existing qualitative studies on factors impacting physician practice patterns and decision making in the care of older adults across multiple primary health care environments. Second, this metasynthesis extrapolates data provided in physician literature to create a hypothesized framework to begin to explore and understand the clinical practice patterns of post–acute care providers.9,21

Methods

Search Strategy and Methodological Critical Review

Investigators searched PubMed (MEDLINE) and Ovid databases, with filters for English-language articles and human subjects. The search terms identified qualitative studies regarding physician practice patterns with respect to the care of older adults in the United States (due to the large variation in health care policies and delivery worldwide). The search was not restricted to physician work in post–acute care as there was an absence of published literature in this area. Instead, the search included all health care settings where physicians treat older adults to increase the data collection and context variation, which in turn improves the strength of transferability of results to post–acute care providers. Investigators used the following search terms in PubMed: “aged” [MeSH] AND “qualitative research” [MeSH] AND “United States” [MeSH] AND “physician’s practice patterns” [MeSH]. Use of MeSH terms broadened the search to include as many relevant articles as possible. In Ovid, search terms included “aged, 80 and over” OR “health services for the aged,” “qualitative research,” “physician’s practice patterns,” and “United States.” Use of the explosion feature allowed the database to search for specified subject headings as well as more specific terms related to the subject headings. The final collection of articles did not contain duplicates from the combined searches (Figure 1). Three authors reviewed abstracts and titles to determine relevance. In addition, the identified articles showed potential for transferability across multiple health care settings and disciplines based on extensive description of physician practice patterns and the overlapping themes observed across settings and disciplines.22–25 Investigators hand-searched all included articles for references to additional, relevant studies. The McMaster University Tool was utilized to assess methodological quality, because of its comprehensive criteria, especially around procedural rigor.26 Using the tool as a first step in data immersion, each investigator rated 17 items as either present or absent for each identified study (Table 1).

Figure 1.

Figure 1.

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Article selection process.

Table 1.

Critical Review of Identified Studies.

Hinton et al17 Lewis et al19 Fried et al15 Hunt et al16 Kistler et al18 Adams et al13 Adams et al14 Boise et al12 Sloane et al20
Study purpose:
 Was the purpose and/or research question stated clearly?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
Literature:
 Was relevant background literature reviewed?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
Study design:
 Was a theoretical perspective identified?		 No No No No No Yes Yes No Yes
Sampling:
 Were the sampling methods appropriate?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Was sampling done until redundancy in the data was reached? No Yes No No No No Yes No No
Data collection:
 Was procedural rigor used?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
Descriptive clarity:
 Clear and complete description of the participants		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Role of researcher and relationship with participants No No No No No Yes Yes No No
Analytical rigor:
 Were data analyses inductive?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Were findings consistent with and reflective of data? Yes Yes Yes Yes Yes Yes Yes Yes Yes
Auditability:
 Was a decision trail developed?		 No No No No No No No No No
 Was the process of analyzing the data described adequately? Yes Yes Yes Yes Yes Yes Yes Yes Yes
Theoretical connections:
 Did a meaningful picture of the phenomenon under study emerge?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
Overall rigor
 Credibility:
  Do the descriptions and interpretations of the participants appear to capture the phenomenon?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Transferability:
  Can the findings be transferred to other situations?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Dependability:
  Was there consistency between the data and findings?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes
 Confirmability:
  Were strategies employed to minimize bias?		 No No No No No Yes Yes No No
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Metasynthesis

This metasynthesis sought to identify factors influencing physician practice patterns in the care of older adults across multiple primary care settings and physician specialties through examination of published qualitative studies. Results were then extrapolated to post–acute care clinicians because of the similarities in themes identified across different health care settings and physician specialties.23–25 The transferability of results allowed investigators to gain preliminary insight into the poor patient outcomes following hospitalization and to generate new hypotheses that can be used to develop a framework by which post–acute care practice patterns can be studied. New information is obtained through “interpretations of interpretations,” in which a larger meaning is abstracted from the data acquired through participant text of original studies.27 The processes of interpretive integration or reciprocal translation align with Noblit and Hare’s28 assertion that studies with similar content can be grouped together. Three members of the research team independently reviewed each study and then met as a group to discuss findings through an iterative process. Following group discussion, team members reread the articles to determine whether the themes discussed within the group accurately reflected the original data. This iterative and analytical team process resulted in multiple cycles of reexamination of the original articles followed by further discussions to derive higher levels of abstraction.29 The interactive process occurred over the span of several months to map an evidentiary matrix of original themes from the primary studies and new themes identified by investigators.

Results

Search Results and Study Characteristics

The search produced 14 abstracts across after removal of three duplicates. Nine studies were excluded due to unrelated content (n = 7), quantitative-only methodology (n = 1), or occurring outside of the United States (n = 1). Investigators hand-searched the remaining five articles for additional references and yielded four more articles (Figure 1). Congruent with existing standard guidelines for systematic reviews of qualitative studies,30,31 this metasynthesis draws from a yield (nine articles) to develop a novel interpretive synthesis that goes beyond the original studies. The number of articles is relatively small but collectively represents 492 participants across a wide variety of physician specialties and health care settings. Studies were published between 1999 and 2013, with sample sizes ranging from 20 to 165 participants (N = 492 total; Table 2). Seven studies used a qualitative descriptive design. Two studies utilized a mixed methods approach; only the qualitative data were evaluated for this metasynthesis.

Table 2.

Description of Studies.

Authors Study purpose Country Study design Methods Participants Summary of findings
1. Hinton et al17 To study primary care physician’s perspectives on the practice constraints which impede appropriate care management of the patient with dementia, with a specific focus on behavioral and psychiatric disturbances. United States Not described (qualitative description) Open-ended, structured interviews were conducted by study authors; 30 to 60 minutes in duration. Data were coded by two investigators based on structural or practice barrier. 40 primary care physicians in Northern California Interviews revealed physician-perceived barriers to the care of the patient with dementia, which included time and reimbursement constraints, difficulty coordinating access to community resources, and lack of interdisciplinary approach to care of a complex patient population.
2. Lewis et al19 To understand the process and factors which influence physician’s decisions to prescribe screening for colon cancer in older adults. United States Not described (qualitative description) Individual interview and focus groups. The interview guide was based on a conceptual model, developed by the authors, for decision making with respect to colon cancer screening. The authors also used two clinical vignettes to focus the discussion. Themes were identified by two investigators and a codebook was created. 55 primary care physicians. The decision to recommend screening for colon cancer in the older adult was impacted by a physician’s clinical and individual factors. Physicians viewed the decision-making process as complex due to the need to calculate life expectancies to assess the potential benefit of screening.
3. Fried et al15 To understand how primary care clinicians decide on treatment regimens for older adults with multiple diseases. United States Not described (qualitative description) Focus groups were outlined with open-ended questions; 60 minutes in duration. Content analysis was used by two investigators independently to code the transcriptions. 40 primary care providers (physicians, nurse practitioners, physician assistants) Focus group content revealed primary care clinician’s concerns, debates, and uncertainties regarding how to approach treatment for older adults with multiple comorbidities.
4. Hunt et al16 To understand the substantial increase in diagnosis and pharmaceutical management of type 2 diabetes and hypertension. United States Not described (qualitative description) Two authors studied and observed 107 clinical consultations over 2 years. Open-ended, unstructured interviews were conducted with clinicians and patients; ~60 minutes in duration. Anthropology graduate assistants coded data. In-depth coding categories were generated on the basis of emerging thematic patterns; several research team members reviewed each case for consistency. 44 primary clinics in Michigan. Interviews with 58 clinicians and 70 patients Numerous factors promote the use of pharmaceuticals in the primary management of type 2 diabetes and hypertension. Patients perceived the reliance on recommended regimens of pharmaceuticals as challenging for financial reasons and overall well-being.
5. Kistler et al18 To understand the process of prescribing antibiotics in assisted living communities. United States Not described (mixed methods: qualitative description and survey data) Cross-sectional survey and semistructured interviews with open-ended questions. Two investigators independently performed content analysis. 30 residents who received antibiotics and their family, staff, and prescribing medical provider Providers often prescribed antibiotics based on limited information on the resident and communication with staff as well as family.
6. Adams et al13 To understand the barriers faced by clinicians when providing care to cognitively impaired older adults. United States Grounded theory In-depth interviews; average duration of 50 minutes. A multidisciplinary team applied a three-stage coding process, including axial coding, derived from grounded theory. 20 primary care physicians (10 internists and 10 family physicians) Primary care for cognitively impaired older adults is complex because current models of care do not encompass the social and emotional aspects necessary for this population.
7. Adams et al14 To understand physician perceptions of the difficulty in providing primary care for older adults. United States Grounded theory In-depth interviews; average duration of 50 minutes. A multidisciplinary team applied a three-stage coding process, including axial coding, derived from grounded theory. Follow-up interviews for member checking with five participants. 20 primary care physicians Three major domains emerged with respect to the difficulty of providing primary care to older adults: medical complexity and chronicity, personal and interpersonal challenges, and administrative burden. Practice environment, training, and personal values further shaped how care was provided and the perceived difficulty.
8. Boise et al12 To understand the barriers to the process by which physicians assess and diagnose dementia. United States Not described (qualitative description) Focus groups in three geographical areas (open ended and structured). Three-stage coding process of transcriptions was applied by an investigator and research assistant. 77 primary care physicians (35 internal medicine and 42 family practice) Barriers to the diagnosis of dementia by primary care physicians were identified and include the following: failure to recognize dementia, perceived lack of need to determine diagnosis, time constraints, and negative attitudes toward the importance of diagnosis.
9. Sloane et al20 To understand how physicians perceive the provision of medical care to residents of assisted living. United States Not described (mixed methods: qualitative description and questionnaire data) Telephone interviews (no duration specified) or mailed questionnaires asked questions regarding demographics, confidence in providing care to assisted living communities, and attitudes regarding care in assisted living. Five investigators met to identify themes and form a consensus. 165 physicians across 27 states. Physicians must provide primary care to assisted living facilities to be eligible. Physicians participated in either the interview or the questionnaire. System factors appeared to dictate physician’s confidences in providing care in assisted living. Qualitative analysis identified barriers to providing care in assisted living, compared with other settings.
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The sufficient similarities, in terms of the population assessed and the emergent themes, between relevant articles lend to the potential transferability of the novel results revealed in this metasynthesis to post–acute care providers.22–25,32,33

Metasynthesis

Three themes emerged from this qualitative meta-analysis (Table 3): (1) Clinical decision making and care strategies for older adults may not be best representated by current medical education and clinical guidelines; (2) gaps in communication between the older adult patient, family, and other providers have the potential to limit the accuracy of clinical decision making and the quality of care delivered; and (3) the quality of care delivered and the clinical decisions made regarding older adults are potentially compromised by current health care policies. Primary studies were linked to subthemes through reciprocal translation and identified by a number (indicated in Table 2). The following narrative exemplifies the findings from this metasynthesis by utilizing participant quotations from the primary studies.

Table 3.

Team Synthesis and Reciprocal Translation.

Derived analytic themes and subthemes In paper number (corresponding to Table 2) Primary study themes
1. Clinical decision making and care strategies for older adults may not be best represented by current medical education and clinical guidelines.
Current medical model is not adequate to encompass the needs of older adults 1, 4, 6, 7 Lack of interdisciplinary approach, which encompasses biomedical as well as psychosocial issues and overall well-being. The current medical model does not provide a framework to make difficult decisions regarding driving and independent living (i.e., psychosocial issues)
Clinical decisions are difficult when evaluating risk versus benefit of treatment due to considerations of life expectancies and quality of life 2, 4, 5 Clinical factors (e.g., patient age, functional status, number of comorbidities) and individual factors (e.g., physician screening behaviors or patient expectations) drive clinical decisions
Feelings of frustration and inadequacy by physicians 2, 6 Physicians frustration and sense of inadequacy regarding their skills and educational training on care for older adults
Chronicity and multiple conditions limit ability to adequately and appropriately apply clinical guidelines 2, 3, 4, 7, 9 Clinical guidelines are developed by trials that typically exclude older and more medically complex patients and, therefore, lend to uncertainty of the application of such guidelines to this vulnerable population
Perceptions of aging and older adults influence clinical decision making in terms of early diagnosis 2, 3, 8 Hesitancy to alarm the patient or family about early screening or diagnostic processes, as the condition may be potentially untreatable (e.g., colon cancer or Alzheimer’s disease)
Practice variation in clinical decision making for older adults 2, 3, 5, 8 The complexity of caring for older adults leads to inconsistent clinical decision-making patterns by physicians
2. Gaps in communication between the older adult patient, family, and other providers have the potential to limit the accuracy of clinical decision making and the quality of care delivered.
Cognitive impairments hinder the communication accuracy 1, 5, 6, 7 Loss of personhood and ability of the older patient with cognitive impairments to communicate needs and wants to the physician
Reliance on third-party communication (i.e., family) 1, 3, 5, 6, 7, 8, 9 Loss of autonomy for the patient with subsequent increased reliance on family members for histories and decisions
Specialists, other health care providers, and community providers are not well matched with the primary care system which leads to gaps in communication 1, 5, 9 Lack of coordinated care and access to specialists or community services
Conflict in communication related to treatment decisions 1, 2, 3, 4, 5, 6, 7, 8 Mismatch between provider-to-patient, patient-to-family, and provider-to-family goals and expectations for treatment or ambiguity
3. The quality of care delivered and the clinical decisions made regarding older adults are potentially compromised by current health care and system policies.
Increased time to manage older adult patients 1, 3, 7, 8, 9 Older adults are more complex and thus require increased time
Increased administrative burden 1, 6, 7, 8, 9 Interdisciplinary communication and referrals require increased persistence and paperwork
Lack of incentive in the health care system to support coordinated care 1, 3, 5, 6, 7, 8, 9 Current health care systems to not facilitate interdisciplinary care planning and communication due to productivity and reimbursement constraints
Reimbursement system constrains the quality of care provided 1, 3, 6, 7 Complexity is not considered in current reimbursement policies
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Theme 1: Clinical decision making and care strategies for older adults may not be best represented by current medical education and clinical guidelines.

The current clinical guidelines do not specifically address the needs of older adults because they were developed from a younger, healthier cohort of adults, and subsequently, physicians expressed uncertainty about the risk versus benefit of applying these guidelines to older adults. As one physician stated, “In a good training program, you’re taught to make a diagnosis and treat the underlying cause. Well, sometimes you just can’t. Sometimes that’s hard [with elderly patients] …” (Paper 6, p. 235). Furthermore, the chronicity and multiplicity of conditions present in a large number of older adults are not accounted for in current clinical guidelines,16 which are often based on clinical trials that exclude older adults who are medically complex.34 “The whole thing with colon cancer screening is that you’re trying to find something before [the condition is untreatable] and make a difference 5-10 years down the road. If you don’t have 5, 10 years then what’s the point?” (Paper 2, p. 819). Physicians also voice concern regarding the quality of life resulting from clinical decisions made solely on the current guidelines for practice: “I mean, if someone is 80 and you recommend a colonoscopy [based on clinical guidelines] and then their bowel got perforated. What was I thinking, 80 years old, doing this colonoscopy?” (Paper 2, p. 819).

The clinical decision-making process of weighing risk versus benefit may be influenced by the physician’s perception of what the older patient needs, rather than what clinical guidelines state in terms of early detection and diagnosis for a younger adult:

I’ve walked out of the room lots of times going I think something’s going on here but not pushed it, because what am I going to do? … I think they have early dementia, but is it going to change anything? No. Can I do anything about it? No. So, why get everybody all excited when we’ll just keep a close eye on it. (Paper 8, p. 460)

In other instances, recommendations regarding screening and potential diagnosis are voiced to the patient, but the physician may strongly discourage the patient from taking further action before understanding the patient or family’s beliefs:

Bringing [the issue of colon cancer screening] up is the reasonable thing, but then you have to be very, very honest with them and you have to say look here’s a situation … what are you going to really do if they tell you there’s [something] there and we have to do something about it? Do you really want to know that? (Paper 2, p. 820)

The uncertainty in diagnosis and treatment guidelines impacts a physician’s feelings of frustration and inadequacy due to lack of skills and formal training in geriatric care during their medical education: “No matter what you do, they hurt. No matter what you do, they get agitated. And no drug exists to stop a [patient who is cognitively impaired] from falling. You know, yeah, that’s frustrating” (Paper 7, p. 838). Participants cited communication with older adults who have cognitive impairments as a vital skill, yet it is not formally taught in most medical education programs.13,14,35 For example, physicians are often unable to glean the information they need to appropriately assess and treat patients with cognitive impairments:

I’m doing more laboratory-x-ray medicine than clinical medicine sometimes because I don’t get as much feedback [from the patient]. I don’t know what’s going on in their mind. I don’t really particularly care for that part of my practice … I want them to be able to talk to me, tell me what’s going on. (Paper 6, p. 234)

Once a treatment is recommended, physicians experience frustration with finding strategies to encourage patients to adhere to treatment regimens: “I get a lot of [treatment non-adherence] happening where I just try one thing and then they don’t end up doing it right and we end up taking two steps back instead of two steps forward” (Paper 6, p. 235). Overall, the lack of support from medical education and clinical guidelines for the treatment of older adults leads to uncertainty and frustration regarding the diagnosis and treatment of older adults. Uncertainty, in turn, precipitates inconsistency and variation in physician practice patterns, obscuring which treatment elements were successful and which may have caused unintended harm.12,15,18,19

Theme 2: Gaps in communication between the older adult patient, family, and other providers have the potential to limit the accuracy of clinical decision making and the quality of care delivered.

Gaps in communication between physicians and other providers, as well as between patients and family, may limit the quality of care delivered due to the lack of coordinated care or sufficient information to make an accurate clinical decision. One factor that may limit the effectiveness of communication is cognitive impairment among some older patients, because symptom and adherence reports from the patient are not considered accurate.12,13,17,18 Therefore, physicians may be forced to make decisions that fail to reflect the goals and needs of the patient. In addition, the loss of personhood in the patient profoundly hinders communication and impacts the provider-patient relationship: “You have to tell them the same thing every visit. And they don’t remember you. It eliminates some of the camaraderie, if you will, with the patient” (Paper 6, p. 236).

With older adults, involvement of family in the decision-making process increases as, oftentimes, physicians must rely on the patient’s family for histories and decisions regarding care:

[Patients who are cognitively impaired] won’t tell you that they’re having problems or they just don’t realize that they’re having problems functioning and you need a family member to tell you that they’re not eating or that they eat candy all day long. (Paper 6, p. 234)

In addition to communication gaps between physicians and the patient or family, the current primary care system fails to facilitate interdisciplinary coordination and communication, which in turn inhibits accurate clinical decision making:

[F]eedback is slow [from specialists] … [s]o you don’t get anything and then the patient comes back and … [the patients] don’t have any idea [what is wrong], and then [the patients are] kind of frustrated too. (Paper 1, p. 1490)

The larger the number of people involved in the care team (i.e., patient, family, and multiple disciplines), the more likely conflict regarding treatment recommendations may arise. Each member of the care team may have differing expectations and goals for the patient, which leads to inconsistent care that may not reflect an older patient’s best interest. The conflict between family and patient desires becomes most prevalent in situations where removing means of independence from the patient is at issue (i.e., driving, independent home living):

It’s usually a struggle between family wanting them to move to a more supervised level of care or out of their home and the … parents not wanting to do that, so it’s usually a negotiating process, usually a slow process. (Paper 7, p. 839)

At the end of life, clinical decisions may conflict with family or the patient’s best interest: “When they’re more demented, I feel less … I shouldn’t say less responsible … I feel less pressure to make them well, to have to perform, because ‘death is an acceptable outcome’” (Paper 6, p. 235).

I have a patient now out at [a local nursing home] who has recurrent aspiration pneumonia, he has Parkinson’s dementia, does not talk, does not communicate with the world around him, but his wife has nothing else in the world except her husband and she wants everything done to the fellow … I simply can’t do what they want me to do, I just don’t have it in my heart to do it. (Paper 6, p. 236)

Theme 3: The quality of care delivered and the clinical decisions made regarding older adults are potentially compromised by current health care and system policies.

Current health care and system policies constrain the quality of care delivered by physicians to older adults, by imposing efficiency requirements (i.e., productivity), creating greater administrative burden, and providing little incentive to improve coordinated communication and care. Productivity requirements for physicians typically dictate a quota of patients be seen per day, usually in 15-minute time slots designed for maximal efficiency rather than the highest level of patient care. 12–15,17,20 For older adults with multiple medical issues as well as psychosocial needs, short appointments are not adequate to provide quality and comprehensive care:

[Behavior problems aren’t] something that I have to deal with clinically. Usually, the family deals with [the behavior problems]. And that’s another problem in a 15-minute visit, is that in the same way that we don’t do an exhaustive mental exam on each visit, we often don’t talk adequately with the family in the 15 minutes. (Paper 1, p. 1489)

[If you see 15 elderly people,] it takes time. You feel like you’ve done a big day’s work. You can see 15 young people with sore throats and be done in an hour. (Paper 7, p. 839)

In addition, system and health care policies place greater administrative burden on physicians who care for older adults through increased paperwork for referrals.12–14,17,20 The large administrative burden deters physicians from engaging in care coordination, including providing the patient access to community resources and specialty referrals:

Another thing that makes [geriatric care] complex and is a disincentive is that … factors [involving] psychosocial issues [have] … integral importance in the care of frail individuals, young or old … [Therefore] one often needs an interdisciplinary team. One needs access to a social worker [or] the nurses who are properly trained in geriatric issues. (Paper 1, p. 1490)

I think we’re all drowning, I do. It’s, you know, we are all truly trying to keep our heads above water … These [older adults with dementia] do take a lot of time and energy and when you’re doing all the other stuff that we’re doing with all the other patients that, to be honest, sometimes it’s like, you know, you just don’t want these people in your practice cause a 15-minute visit turns into much more than that. (Paper 1, p. 1489)

Physicians caring for residents in assisted living spoke of “‘more phone calls,’ ‘lots of faxes,’ and ‘more paperwork and hassle’” (Paper 9, p. 5).

Finally, current reimbursement policies do not take into account the complexity of the older adult patient, and, therefore, services rendered to older adults may be underpaid. As a result, physicians may be constrained in their ability to provide quality care to older adults while earning an appropriate amount of money for their skills and time17: “When you deal with a patient who has dementia, maybe depression, as well as hypertension and diabetes, it’s a lot more complicated than the intact 50-year old [who has hypertension and diabetes] but the reimbursement is the same” (Paper 1, p. 1489).

You owe it to your employer to be as productive as you can but you also owe it to your patient to be as helpful as you can and sometimes the two masters can’t be served at the same time. (Paper 7, p. 841)

… It takes longer time to take care of [elderly patients]. You superimpose upon this slow reacting patient, a worried … family member who has a number of questions … It adds more time to the office visit and the way Medicare is paying us for office visits. From an economic standpoint, it just does not make sense to take care of older people. (Paper 7, p. 841)

Discussion

To date, no qualitative research has explored the practice patterns of post–acute care providers, despite the discrepancy between increased spending and the continuation of poor outcomes in these settings. Understanding factors impacting clinical decision making and care for older adults is critical to advancing clinical practices in post–acute care and achieving the Triple Aim. The current metasynthesis is the first step in developing a clinical practice framework to address the difficulties post-acute care providers face when managing older adults following hospitalization, by identifying themes in physician practices in primary care settings that cater to older adults. Themes and subthemes threaded throughout the identified articles were similar and included viewpoints from physicians who practice in different health care settings and with different specialties. Thus, the application of results to post–acute care providers appears reasonable given the transferability of the data (i.e., across settings and specialties) and the shared population: older adults who require health care services.22–25,32,33 Solutions include providing more adequate training in geriatrics for health care professionals; developing process improvements to minimize communication gaps and threats to patient safety;and advocating for changes in current health care policies to provide quality care at minimal cost.

The results from this metasynthesis identify geriatric care as a key area for emphasis and change in current health professional curricula. The growing proportion of older adults in the United States is projected to double between 2010 and 2030 to one out of every five persons,40 which suggests a larger volume of patients seen across all health care settings will be older adults. The current pool of geriatric specialists is experiencing a shortage compared with demand for services;36,37 thus, other providers will be required to assist with care for older adults. For many disciplines, deficiencies in geriatric clinical education include lack of time in curricula, paucity of geriatric-trained educators, and low student demand due to poor clinical experiences in geriatric settings.35 Quantitative studies have shown current rehabilitation and medical education may not ensure adequate training in geriatric care in terms of the skills necessary to evaluate, treat, and make clinical decisions regarding older adults.38–40 Thus, similar to physician practice in primary care settings, uncertainty in post–acute care exists regarding the best evidence-based practices, which perpetuates practice variation and inconsistencies in outcomes across post-acute care settings.41 Adequate geriatrics training in educational curricula may prompt clinical research efforts to understand the effectiveness behind treatment strategies and, consequently, limit the amount of uncertainty or variation observed in post–acute care.

This metasynthesis found that communication gaps are pervasive across clinical settings and physician specialties, which can lead to inaccurate clinical decisions and potentially higher rates of adverse events such as hospitalizations.42–46 As changes in the older adult patient’s health, mental, and functional capacity occur with age, these changes subsequently impact the amount and type of care delivered across many settings including post–acute care.47 This may explain an older adult’s increased reliance on family support, the inclusion of multiple health care providers to manage aging conditions, and the increased number of conflicts between provider and patient treatment decisions. Care-coordination and interdisciplinary approaches are critical to improving outcomes in older adults across many health care settings, given the presence of high health care utilization and poor patient outcomes.48–51 Including the older adult patient and family in health care decision making has been shown to improve patient experience as well as outcomes when combined with efficient interdisciplinary coordination and communication.52–57

The results of this metasynthesis highlight the health policy and system constraints to the delivery of quality care to older adults by physicians, which are also applicable to post–acute care providers. Specifically, part of the barrier to advancing post-acute care practice is the lack of incentive for high-quality practices in current reimbursement policies, leaving providers to prioritize reimbursement-driven over evidence-based practices.52 The reimbursement-driven model suggests a significant gap between knowledge and implementation of alternative, evidence-based interventions to revolutionize post–acute care practices. The results of this metasynthesis are the first step toward prompting pertinent, clinically-driven research questions regarding the future of post–acute care for older adults.

The current metasynthesis has several strengths. First, the investigators were a multidisciplinary team consisting of nurses, physical therapists, and clinical researchers, which prompted an interdisciplinary interpretation of the data. Second, the results of this metasynthesis can be applicable more broadly to other non-physician, post-acute care providers who care for older adults after hospitalization. The transferability of results allows hypotheses to be generated that direct future research initiatives specific to this setting.22–25,32,33 The publication’s focus on post–acute care was chosen due to the continuation of poor short- and long-term outcomes for patients following hospitalization. However, utilizing data obtained from only physicians in non-post-acute care settings is a potential limitation. This limitation may be outweighed by the lack of qualitative research on post-acute care provider practice patterns and clinical decision making with respect to older adult care following hospitalization.

A few additional limitations of the current metasynthesis should be mentioned. A potential limitation was that the identified articles included physicians who practiced in the United States, which limits the generalizability to health care worldwide. However, narrowing the focus was necessary to control for variation in health care system, cultures, and beliefs. Finally, the search results yielded a relatively small number of articles. However, the large number of participants (N = 492) across articles increased the depth and breadth of the novel interpretive synthesis presented in this metasynthesis. The information gleaned from the small number of original articles was sufficient to increase our understanding of the care provided to older adults across different settings as well as varied provider and patient populations.

Conclusions

This qualitative metasynthesis is the first step toward exploring practice issues and potential solutions specific to post-acute care settings. The results obtained and hypotheses generated from this metasynthesis are timely given the nationwide demand for health care reform in post–acute care.4 For instance, a tremendous need exists to improve health care education to include the health care professional training necessary to adapt to dynamic changes in health care designed to manage the growing aging population. In addition, current health care and system policies must change to allow for reimbursement and productivity standards to capture the intricacy inherent to the management of older adults and provide incentives for coordinated care. Advancing geriatric clinical practice across all health care settings, including post–acute care, through interdisciplinary care coordination and patient-centered care will improve patient and population outcomes, while potentially reduce unnecessary health care costs per the Triple Aim.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded in part by the Promotion of Doctoral Studies I from the Foundation for Physical Therapy; the Fellowship for Geriatric Research from the Academy of Geriatric Physical Therapy; Integrative Physiology of Aging Training Grant T32AG000279 from the National Institutes of Health, National Institute on Aging; and the Rehabilitation Research & Development Small Projects in Rehabilitation Research I21 RX002193 from the U.S. Department of Veterans Affairs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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