Supported by a grant from the New York State Health Foundation

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. 

Following a hospitalization for major surgery or serious illness or injury, one in five patients needs additional health care services for recovery. These post-acute care services can be provided in a nursing home or rehabilitation facility, through outpatient therapy, at home, or in the community. Yet despite the growing role of these services in New York’s health care system amid pressures to shift care to lower intensity settings, the process of helping patients and families make informed decisions about which care setting best meets their needs and provides high-quality care has not received sufficient attention.

Why This Is Important

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 hospital readmission, and it increases the likelihood that patients will become nursing home residents.

Our Work

Supported by a grant from the New York State Health Foundation, UHF’s Quality Institute and Families and Health Care Project conducted a yearlong, multi-faceted inquiry into post-acute care. A series of four Difficult Decisions reports present findings from interviews with patients and their families, health care providers, researchers, policymakers, and other stakeholders, as well as UHF’s own research. The final report of the series, Pathways to Progress on Difficult Decisions in Post-Acute Care, lays out a range of promising strategies and steps for tackling systemic barriers to more informed decision-making and for better supporting some 300,000 hospitalized New Yorkers and their families each year who need to make such decisions.  

The Bottom Line

Patients and family caregivers should receive the support they need from their hospital care team to understand the full range of care options and quality differences among providers based on their performance on relevant quality measures. Their information needs, priorities, preferences, preparedness, and involvement in decision-making should help shape the discharge planning process as much as possible.


Difficult Decisions #1: Difficult Decisions About Post-Acute Care and Why They Matter (view pdf)

Difficult Decisions #2: The Illusion of Choice: Why Decisions About Post-Acute Care Are Difficult for Patients and Family Caregivers (view pdf)

Difficult Decisions #3: Health Care Provider Perspectives on Discharge Planning: From Hospital to Skilled Nursing Facility (view pdf)

Difficult Decisions #4: Pathways to Progress on Difficult Decisions in Post-Acute Care (view pdf)