Transitions to long-term care, assisted living, and other supportive living options are often made in difficult conditions, under the financial and time pressure that follows acute care and other crises. A recent article (Kane 2011) in the Journal of the American Medical Association’s “Care of the Aging Patient” series reviews transitional and long-term care options for older adult patients who are transitioning from acute care, and argues that physicians should familiarize themselves with such options and, when possible, be involved in the transition.
The article provides a review of the last two decades of research on transitional (post-acute) care, long-term care, rehabilitation and other assisted living options. The author contextualizes this for the reader through a case study example. It is stressed that there is a lack of generalizable research on long-term care quality. For example, the only consistent predictors of nursing home quality seem to be that registered nurse staffing is a strong correlate of high-quality care, and that for-profit nursing homes are, on average, of lower quality. Because it is difficult to make long-term care decisions based purely on the existing research, the author suggests that, to the extent that the wishes of the patient are not undermined, the family and doctor assess the various options.
In other words, we should be conscious that choosing post-hospital care is an important step in the rest of the patient’s life, and not just make the decision in the context of a hospital discharge plan. Staff involved with the patient’s transition out of the hospital may have the best of intentions, but are limited by their institution’s goal of discharging patients quickly. Patients are typically directed to institutions based on the availability of beds, rather than the best possible fit for that patient. Further, the article notes that, based on a study of hospital discharge experts, “their recommendations tracked their disciplines and professional experiences” (Kane, 287), further suggesting the lack of a systematic methodology for post-acute living recommendations.
These reasons, and others provided in the article, lead the author to suggest that physicians advocate for their patients following acute care by encouraging patients and their families to be given the time and information to make the decision that best supports the patient. The article identifies some ways that our current system impedes this, and reminds us that whoever is responsible for transitioning individuals into long term care should be working as a voice for the patient. This article is of use to physicians who work with older adults, as well as to older adults and their families who do not yet have a firm plan for post-acute transitions and other decisions concerning long-term care.
Kane, RL, (2011). “Finding the Right Level of Posthospital Care.” JAMA 305(3):284-293.
