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Break the Hospital-SNF-Hospital Cycle at the End of Life

Analysis  |  By Christopher Cheney  
   February 21, 2019

For clinicians, effective communication with patients, families, and colleagues is crucial to achieve optimal care in the final months of life.

For a significant number of Medicare beneficiaries, the final months of life degenerate into alternating back and forth between acute care hospitals and postacute care facilities, a recent journal article shows.

In 2013, about 23% of hospitalized Medicare beneficiaries were discharged to a postacute setting, with 87% of those patients sent to a skilled nursing facility (SNF). From 2006 to 2011, one in eight of Medicare beneficiaries who died were transferred back and forth from hospitals to SNFs in the last year of life.

"In treating discharge to a postacute care facility as a routine event, we are missing an opportunity to improve care for seriously ill older adults," the authors of the New England Journal of Medicine article wrote.

Improving communication between clinicians and patients

To help break the hospital-to-SNF care cycle, clinicians should hold discharge discussions for patients that mirror typical goals of care conversations, the lead author of the journal article told HealthLeaders last week.

"When discussing discharge, clinicians should get a sense of the patient's and family's understanding of the patient's condition, fill in the gaps where needed including discussion of prognosis for functional recovery, however uncertain it may be, then identify the patient's and family's goals given the new clinical situation," said Lynn Flint, MD, an associate professor in the Division of Geriatrics, School of Medicine, University of California, San Francisco.

Reconciling the prognosis with the patient's and family's goals is essential, she said.

"If the goal is to get as close to prior functioning as possible, a short stay in a nursing home for rehab could make sense. However, if the prognosis is uncertain and time might be limited, certain patients and families might value time at home over maximal functional recovery, and a home discharge with added supports could be explored."

Resources are available to help clinicians hold these conversations, Flint said.

"All inpatient clinicians and postacute clinical staff could benefit from additional training in serious illness communication. A great option is the VitalTalk 'Mastering Tough Conversations' course. The VitalTalk website has some frameworks for breaking bad news and eliciting goals of care that can be a useful introduction or refresher for those who are unable to take a formal course."

There are several essential elements to training clinicians about serious-illness communication, Flint said.

"The key pieces to learn and practice are the basics: active listening, responding to emotion, breaking bad news, and inquiring about what matters most. This sounds straightforward, but these things are really difficult in the moment and every situation is unique."

Improving communication between clinicians

Discharge discussions between acute care clinicians and patients should be shared with clinicians at postacute facilities, Flint and her coauthors wrote. "The details of these discussions could be documented in the medical record and communicated explicitly to clinicians at the postacute care facility, enabling them to continue the conversation more effectively."

Boosting communication between clinicians in the acute and postacute settings requires additional time and effort, they wrote.

"We recognize that these types of conversations are more complicated and time consuming than typical discharge communications. But hospitalists, discharge-planning nurses, and social workers can be trained in communication about serious illness. Advance care planning codes, introduced in 2016, can be used to bill for the extra time spent."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


In the final months of life, about one in eight of Medicare beneficiaries alternate back and forth between hospitals and postacute care settings.

To maximize quality of life, discharge to a postacute care facility should be viewed as an opportunity to improve care.

Essential elements of serious illness communication include active listening, responding to emotion, and breaking bad news.

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