Difficult Decisions About Post-Acute Care


Finding the right post-acute care is a complex task for patients and family caregivers, making accessible information that can help them choose a provider that best meets their needs and preferences essential. 

Supported by a grant from the New York State Health Foundation

Following a hospitalization for an illness or injury, one in five patients need additional health care services for their recovery. These post-acute care services can be provided in a nursing home or rehabilitation facility, through outpatient therapy, or at home. Yet despite the growing role of these services in New York’s health care system, the process of discharging patients to a facility that best meets their needs and provides high-quality care has not received sufficient attention.

Health care professionals face tight time constraints when attempting to develop and execute safe discharge plans that place patients in the right setting at the right time. Too often, insufficient time is devoted to identifying the preferences and priorities of patients who need post-acute care, and helping patients and families understand their care options and available quality metrics to make informed decisions. It is a process that, especially when rushed or poorly executed, can be a source of great stress for patients and family caregivers. It can also have serious implications for patients: transfer to a facility that does not meet all the patient’s needs can result in longer stays, declines in physical or psychological function, and readmission, and increases the likelihood that patients will become nursing home residents.

Supported by a grant from the New York State Health Foundation, UHF’s Quality Institute is examining patient and family caregiver preferences and experiences related to decision making on post-acute care options, hospital discharge planning processes and policies that can foster or limit informed decision making by patients and families, how insurance coverage and other factors such as bed availability restrict choice, and innovative tools, models, and strategies that can better support patient and family caregiver decisions about needed care.

The project aims to address several key questions:

  • What are patient and family caregiver information needs, preferences, and experiences related to post-acute care decisions?
  • How do hospitals’ discharge planning processes account for patient and family caregiver goals, needs, and preferences?  What role do health plans and prior authorization requirements play?
  • How do discharge planning teams communicate information to patients and family caregivers and assist them with decisions about post-acute care settings and providers?
  • What are the gaps in information needs and assistance, as well as barriers that can hinder patient and family caregiver choice?
  • How do changes in health care delivery, financing, and regulations, nationally and in New York State, influence the transition from hospital to post-acute care and the care choices available to patients and families?
  • Are there innovative tools, models, and best practices that could help improve the discharge planning process and foster informed and timely decisions by patients and family caregivers?

Patients and family caregivers should be able to choose post-acute care providers based on their own priorities and circumstances and informed by provider performance on relevant quality measures. Their information needs, preferences, and participation in the decision-making process should help shape the discharge planning process to the extent possible.

“Difficult Decisions about Post-Acute Care” will be completed in 2018. The scope of work will include convening stakeholders to better understand the issues and a report that identifies promising best practices, innovative tools, and policy levers that can help New Yorkers make more informed choices about post-acute care.


Contact: Lynn RogutPooja Kothari