Background
Conceptual model
Methods
Selection of study participants
Interviews
Coding
Analysis
Results
Sample characteristics
Characteristic | Frequency | Percentage |
---|---|---|
Gender | ||
Male | 26 | 52% |
Female | 24 | 48% |
Age | ||
< 65 | 10 | 20% |
65–74 | 13 | 26% |
75–84 | 18 | 36% |
≥85 | 9 | 18% |
Race | ||
White | 26 | 52% |
Black | 19 | 38% |
Other | 5 | 10% |
Education | ||
Some high school or less | 4 | 8% |
High school diploma | 18 | 36% |
Some college | 7 | 14% |
College degree | 12 | 24% |
Graduate degree | 9 | 18% |
MoCA score (n = 44) | ||
High (26–30) | 15 | 34% |
Intermediate (20–25) | 19 | 43% |
Low (Less than 20) | 10 | 23% |
Major recurrent themes
Theme | Sub-theme | Representative quotes |
---|---|---|
Poor awareness of the physician(s) in charge of their care at the skilled nursing facility | Inability to name or otherwise identify the physician(s) overseeing their care | “I’ve never really talked to him...I didn’t even know he was a doctor.” – Female, 70’s-80’s years old |
Expectation that external providers (i.e. their surgeons, hospitalist, or primary care provider) would be directing their post-acute care at the skilled nursing facility | “From what I’ve been told there’s a separate physician here. It’s not my surgeon, which I’m not crazy about. I mean, he gave me the surgery, he should be in here to check on meat least once or twice during the 10 days I’m here. But he hasn’t been. It’s been a different doctor who was only here one time.” - Female, 60’s-70’s year old | |
Confusion about the distinct roles of physicians, nurse practitioners, nurses, and nursing assistants on the care team | “It’s very hard to tell who’s a doctor. That person, I guess, he’s a doctor, it happens every once in a while, a guy comes in with a suit and tie on and he doesn’t really introduce himself. He just sits down and we start talking about things. I wish they would announce themselves - exactly who they are.” – Male, 60’s-70’s years old | |
Distress associated with the lack of understanding about the physician(s) coordinating their care | “I don’t know [if there is a separate doctor or nurse practitioner who coordinates my care in this facility]. I don’t know. I feel kind of stupid not knowing.” - Female, 70’s-80’s years old | |
Frequency and quality of communication with the physician did not meet participants’ expectations | Frequency of communication did not meet expectations | “I mean, if I need a question they always tell me to ask the nurse. And Dr. [last name], I only saw him once and I probably won’t see him again this week.” – Male, 50’s-60’s years old |
Quality of communication did not meet expectations: perceived to be rushed, superficial, insufficient to learn patient preferences for care | “I think that [physicians] can stay on top of stuff a little bit more. I know they have a lot of patients here and I know they’re really busy, but I just feel like I’m like their supervisor and I’m keeping on top of them and making sure they do their job. And I don’t think I should be doing that. I don’t want to have to be burdened with that mindset that I need to stay on top of these people in order for them to do what I need to have done.” – Female, 60’s-70’s years old | |
Caregivers expected more frequent and detailed communication with the physician | “I thought [the physician] should have had a little more [communication] with me when I asked him a question. I told him, ‘[My father] is an [80’s] year-old man. If you have a question, you need to call me.’”– Female, 30’s-40’s (caregiver) | |
Participants valued care that was perceived to be individualized to their needs by the physician(s) in the facility | Perception of physician(s) being dismissive of the patients’ symptoms | “I didn’t care for the doctor there because she acted like I didn’t know my own body and I didn’t know what I was talking about. And I know how much insulin I need, because I give it to myself, because I’ve been a diabetic for [many] years, which is a long time.” – Female, 70’s-80’s years old |
Appreciation of specialized care to meet individual needs | “And [the physician] is very understanding of my father and how he thinks. And thinking so much about my father and then specifically understanding of his needs, like the [diet] element, things like that. Some people really shake that off like it’s not important – he has to eat – but for a man who spent his life that way, it is important.” – Female, [declined to provide age] (caregiver) | |
Patients felt they were a burden due to their medical complexity or custodial needs | “You know one thing I think about this place – they knew that I was [medically complex and high needs] – why did they accept me? Don’t accept people because you need patients. You accept them because you wanna help them.” – Female, 70’s-80’s years old |
Poor awareness of physician(s) in charge of the Patient’s Care at the Facility
“From what I’ve been told there’s a separate physician here. It’s not my surgeon, which I’m not crazy about. I mean, he gave me the surgery, he should be in here to check on me at least once or twice during the 10 days I’m here. But he hasn’t been. It’s been a different doctor who was only here one time.”
Active involvement in their post-acute care (including in-person visits, frequent communication, medication management) by the attending physician in charge of their hospital stay was an expectation of patients admitted to the SNFs for post-acute care, and patients expressed disappointment when this expectation was not met.Participants were also frequently confused about the roles of different healthcare providers in the SNF. Other than the misconception that hospital attending physicians were in charge of their care at the SNF, participants did not have any expectations of physician care at the facility. Patients described the intake process at the facility that typically included interactions with different members of the clinical team, but reported confusion about individual clinicians’ roles. For example:- (Female, 60’s-70’s years old).
“I'm not sure who makes decisions about my medications at [this facility]. I know there is a plan, and they asked me different things, if I need this or that or the other, but I don't know who is actually–whether it's the nurse, whether it's a supervising physician. I assume it's a supervising physician, but I don't know.”- (Male, 70’s-80’s years old).
“I don’t know [if there is a separate doctor or nurse practitioner who coordinates my care in this facility]. I don’t know. I feel kind of stupid not knowing.”- (Female, 70’s-80’s years old).
Frequency and quality of communication
“I think the case managers and the hospital need to make sure the patients understand that…you're not gonna see a doctor every week.” - (Female, 60’s-70’s years old).
“I think that [physician] can stay on top of stuff a little bit more. I know they have a lot of patients here and I know they’re really busy, but I just feel like I’m like their supervisor and I’m keeping on top of them and making sure they do their job. And I don’t think I should be doing that. I don’t want to have to be burdened with that mindset that I need to stay on top of these people in order for them to do what I need to have done.” – (Female, 60’s-70’s years old)
Participants attributed other perceived deficiencies in their care at the facility to the infrequent and superficial communication with the SNF physician(s). Patients and caregivers experienced distress and felt neglected if they experienced communication with the physicians that did not meet their expectations. One patient felt that the SNF physician “doesn’t give a toot” about his/her patients."I thought [the physician] should have had a little more [communication] with me when I asked him a question. I told him, '[My father] is an [80’s] year-old man. If you have a question, you need to call me.'" – (Female, 30’s-40’s years old, caregiver)
Perceptions of individualized care from the physician(s) associated with more positive SNF experience
"I didn’t care for the doctor there because she acted like I didn’t know my own body and I didn’t know what I was talking about. And I know how much insulin I need, because I give it to myself, because I’ve been a diabetic for [many] years, which is a long time." – (Female, 70’s-80’s years old)
"And [the physician] is very understanding of my father and how he thinks. And thinking so much about my father and then specifically understanding of his needs, like the [diet] element, things like that. Some people really shake that off like it’s not important – he has to eat – but for a man who spent his life that way, it is important." – (Female, [declined to provide age] (caregiver)).
"You know one thing I think about this place – they knew that I was [medically complex and high needs] – why did they accept me? Don’t accept people because you need patients. You accept them because you wanna help them." – (Female, 70’s-80’s years old)