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Into the Great Unknown Our Patients Go

For over a decade, there has been increasing focus in healthcare on improving care transitions for patients moving from one setting to another. One of the most scrutinized transitions has been the transfer of patients from the acute inpatient setting to post-acute care in skilled nursing facilities (SNFs). This is a transition fraught with difficulties. Frequent hospital readmissions, potentially unnecessary emergency department visits, and a voltage drop of information across settings seem to be the rule and not the exception. It is not surprising, then, that in this issue of the Journal of the American Geriatrics Society two studies introduce evidence of even more dysfunction in the transition to post-acute care. Burke et al. explore how hospital clinicians select patients for skilled nursing facilities, while Gadbois et al. examine the patient and family perspective of selecting a skilled nursing facility for postacute care. Burke et al. note that hospital clinicians often have no knowledge of local SNFs or the outcomes of the patients they send there and conclude that SNFs have devolved into “safety nets” due to a rushed process “without a clear framework for making decisions” or even, disturbingly, a clear decision-maker. Gadbois et al. likewise describe a rushed and disorganized process in which patients receive no significant help from hospital discharge planners or physicians, leading them to select SNFs for reasons other than quality. The sense from both articles is that hospital clinicians and patients alike feel lost, unsupported, and overwhelmed during the discharge process. This harsh reality is all the more tragic given the emphasis in geriatrics on person-centered care and its associated components, including focusing on patient goals of care, streamlined care coordination, continual information sharing, and proper education and training of providers. How has this happened? Dr. Paul Batalden famously noted “every system is perfectly designed to get the results it gets.” In the case of transitions between the hospital and post-acute care settings, we have created a system that compartmentalizes inpatient providers, post-acute providers, and patients into their own separate silos. Traditional fee-for-service payment models have done nothing to encourage healthcare systems or providers to collaborate with each other across settings to ensure coordination across entire episodes of care. Physicians and discharge planners alike operate in fear of the well-intentioned Medicare Freedom of Choice Act and inadvertently make patients and families feel abandoned by studiously not assisting them in their choice of SNFs beyond providing names and addresses, while at the same time feeling pressured to get patients out of the hospital as quickly as possible. Moreover, the crucial process of discharging vulnerable patients from the hospital has no clear ownership and no clear organization—it seems to have slipped through the cracks of the healthcare system after being unsupported by education, planning, or resources. We are making some progress in the right direction. The last few years have seen a nascent shift from fee-forservice payments to performance and value-based reimbursement that incentivize care coordination. There are several policy initiatives supporting this shift, including the impact act, value-based purchasing (VBP), the formation of accountable care organizations (ACOs), and the bundled payment for care improvement (BPCI) initiative. The BPCI initiative links or “bundles” the payments for the services Medicare beneficiaries receive over an entire episode of care for certain conditions, encouraging multiple organizations such as hospitals and SNFs to better coordinate care across settings and to provide high-quality care every step of the way. Hospitals now face increasing financial penalties for high 30-day readmission rates. On the other side of the transition, public reporting of readmission rates on the Nursing Home Compare website is scheduled to begin on October 1, 2017, and CMS plans to apply reimbursement bonuses or penalties to SNFs starting a year later. In addition, a separate and somewhat different quality measure on rates of 30-day readmissions from SNFs is now included in the 5-star quality rating system. The 5-star rating system is relevant to value-based care because minimal quality requirements are increasingly being imposed to be a participant in some BPCI and ACO initiatives. All these initiatives, in particular the BPCI program, are promising in their potential to incentivize greater ownership across episodes of care. But, are they enough? Returning to the two articles, will they solve the problem of patients and families feeling isolated as they select a SNF? Will they change the fact that there is no clear ownership of the discharge process, which it is rushed and disorganized, or that inpatient providers are unfamiliar with their local SNFs and receive no feedback on their patients’ outcomes? We believe that more sweeping changes need to be made. First, changes in healthcare education for health professionals and patients are needed. From hospital admission to discharge, there are many healthcare professionals who interface with the patient and caregivers who may influence the decision-making process with regards to discharge to a SNF. Patients likely assume that healthcare This editorial comments on the article by Gadbois et al. and Burke et al.