SHM Converge Scientific Abstract ePoster Gallery-What Tools Are Needed to Improve Post-Acute Care Decisions?

Pdf Summary

The study examined how to improve decision-making for post-acute care (PAC), especially choices between skilled nursing facilities (SNFs) and home health (HH), from the perspective of national VA operational stakeholders.<br /><br />Researchers conducted 18 one-hour semi-structured interviews with leaders from VA offices including Community Care, Geriatrics and Extended Care, Rural Health, Nursing Services, Social Work, Health Equity, and Quality and Safety. The interviews were transcribed and thematically analyzed.<br /><br />Key findings showed that current PAC decision-making is often not standardized, inconsistently informed, and uses different language across teams. Stakeholders wanted a “perfect tool” that would:<br />- ensure patients and caregivers understand PAC options,<br />- support higher-quality assessments,<br />- help select the best provider,<br />- elicit patient and caregiver priorities,<br />- and improve expectation-setting.<br /><br />Several existing tools were identified and discussed:<br />- mandated assessments and documentation tools, such as the Case Mix Tool and PASRR,<br />- quality comparison tools, such as CMS Nursing Home Compare and VA CLC Compare,<br />- PAC dashboards, such as the VA Contract Nursing Home Dashboard,<br />- and online educational resources, such as the VA Geriatric Extended Care website.<br /><br />Overall, participants viewed mandated assessments as highly used, quality metrics as moderately to highly used, while dashboards and online educational resources were used less often. Across the proof-of-concept tools, a majority of interviewees liked the matching tool most, suggesting that tools that create a shared mental model and better align patient needs with available PAC options may be especially valuable.<br /><br />The study concludes that improved PAC decision support tools should be patient-centered, standardized, and designed to help both clinicians and patients/caregivers make higher-value discharge decisions.

Asset Subtitle

Jacqueline A. Benson

Meta Tag

Author List Jacqueline A. Benson, Kirstin M. Piazza, Leslie RM Hausmann, Marilyn M. Schapira, Robert E. Burke

Category Research

Concept Post-Acute Care Transition

Concept Decision Support Tool

Concept Shared Decision-Making

Concept Hospital-to-Post-Acute Care Transition

Concept Standardization

Distinguished Non-Finalist

Presenter Organization Center for Health Equity Research and Promotion

Presenting Author Jacqueline A. Benson

Track Transitions of Care

Keywords

post-acute care

skilled nursing facilities

home health

VA stakeholders

decision-making

patient-centered tools

caregiver priorities

quality assessment

discharge planning

matching tool

Post-Acute Care Transition

Decision Support Tool

Shared Decision-Making

Hospital-to-Post-Acute Care Transition

Standardization