What Matters Most to Older Adults in Skilled Nursing Facilities

Introduction:

As part of an Age-Friendly Health System, the geriatric 5Ms framework focuses on 5 areas that impact quality care for older adults: Medication, Mentation, Mobility, what Matters most, and Multi-complexity.^1–3 In itself, What Matters Most is an important concept for providers to better understand older adult goals.^4,5 This patient-centric topic has been examined in a number of populations and locales, including the emergency department and acute care settings.^6–8 However, to our knowledge, there is a lack of information on what matters most to older adults in the post-acute or skilled nursing facility setting. Post-acute care refers to care provided to patients recently discharged from the hospital, and can take place in settings such as skilled nursing facilities, nursing homes, and rehabilitation centers.⁹ Skilled nursing facility care has experienced a number of regulatory changes and guidelines which may or may not reflect what matters most to patients.¹⁰ We sought to characterize what matters most to older adult patients in the post-acute setting.

Methods:

Older adults who were discharged from an urban skilled nursing facility were contacted by phone 1–2 weeks after discharge to complete qualitative surveys between January-June 2022. Subjects were asked “What did you value most?” and provided open ended responses. The responses were transcribed and de-identified. Open-ended responses were coded by three coders using constant comparative analysis with triangulation of themes.

Results:

Over the six-month period, 110 people were discharged from the skilled nursing facility and were attempted to be contacted by phone. 32 people completed telephone surveys, with 16 female, 9 male, and 8 no response. There were 14 family caregiver respondents and 21 older adult patient respondents (range 70–94 yrs., mean age 80.2 yrs.). Responses were separated into 48 statements and grouped into three overarching categories: Staff, Facility-based, and Personal. (Table 1) Each overarching category revealed several themes which consisted of:

Table 1:

What Matters Most Themes and Example Quotes

Theme	Example Quote (patient or caregiver)
Personal
Restored Health/Independence	Most important to me is that I get healthy and back to my independent state That I get taken care of and I get out fast is most important to me. They should put more facilities in the city.
Safety	The most important to me is his safety.” Safety metrics, Medicare metrics, reputation, and follow up by staff are all important to me.
Staff
Kindness and Caring.	It is most important that people treat you with kindness. If you are sick, you don’t need rude people. Most of them were very kind.
Competence/Professional	It’s attentive, professional, and analytical thinking and follow through. It’s that she receives excellent care both medically and personally.
Communication/Timeliness	Most important to me is that we are informed about the care, and those who provide the care do so with care and are professional. It’s also …hearing her and understanding what she’s trying to communicate.
Respect	It’s getting proper treatment and being treated with respect.
Facility
Cleanliness and Quality food	There’s also cleanliness and my diet. Diet affects the care. It was good.

Personal.

The patient-centered return to independence and remaining safe frequently mattered and was a goal of patients and their caregivers.

Restored Health and Independence.

Most important to me is that I get healthy and back to my independent state; That I get taken care of and I get out fast is most important to me.

(patient)

Safety.

“The most important to me is his safety.”

(caregiver)

Staff.

Attributes of staff in the post-acute setting were highly valued and mattered to patients:

Kindness/Caring.

It is most important that people treat you with kindness. If you are sick, you don’t need rude people. Most of them were very kind.

(patient)

Competence/Professional

Most important to me is that …those who provide the care do so with care and are professional.

(patient)

Communication/Timeliness

Most important to me is that we are informed about the care.

It’s also …hearing her and understanding what she’s trying to communicate.

(caregiver)

Respect.

It’s getting proper treatment and being treated with respect.

(patient)

Facility.

Specific to the facility, subjects reflected that what mattered to them was:

Cleanliness and Quality food

There’s also cleanliness and my diet. Diet affects the care. It was good.

(patient)

Discussion

In the post-acute setting, staff competence and professionalism were the most prevalent themes that mattered most to older adult patients and their caregivers. Restored health and independence followed closely, which is not surprising as this is the focus of most people discharged specifically for post-hospitalization rehabilitation. Staffing of skilled nursing facilities are key to what matters most to older adults, as they are the gateway for older adults to return home in restored health. With the staff turnover that has been occurring in the post-acute care setting, training and maintaining competent staff has been challenging. More efforts are needed to stimulate interest in long term nursing careers in the post-acute setting. A limitation of this research was that it was single site and depending on location, patients of other skilled nursing facilities may have differing ideas of what matters most. This research was also conducted only with patients discharged from short-term a skilled nursing facility. Residents of long-term care facilities may have different values as restorative health may not be a goal or possibility. In conclusion, older adults in the post-acute setting value staff competence and professionalism, as a means of regaining their health and independence. The road to restoring health in the post-acute setting centers on staff that are competence and professional.