Best practices for advanced care planning in skilled nursing facility settings

Today’s health care reform continues to drive toward greater patient-centered care. Health plans are seeing this more and more as we continue to provide increasing amounts of information through a myriad of touch points. We want our members to have access to the information they need to feel more informed, and more confident, when making decisions that will improve their health and well-being.

But how does patient-centered care translate to complex organizations like skilled nursing facilities (SNF)?

Patient care in the SNF setting is typically characterized as reactive, costly and confusing for all involved — the patient, the family and caregivers. Health care providers in these settings are responsible for caring for large populations, with many patients presenting multiple co-morbidities. Often, there simply isn’t time for meaningful discussions on patient-centered care, or advance care planning.

Another barrier is the limited on-site availability to assess and manage acute changes in condition. As a result, patients are often transferred to more costly emergency care settings, where the medical staff is unfamiliar with medically complex patients who have multiple advanced illnesses.

Add to this patients and families are often not well informed as to the status and prognoses of multiple chronic and acute illnesses to even know what advanced care planning would entail.

A new approach based on best practices

Overcoming these challenges starts with having consistent providers in the SNF environment all day, every day. These providers should manage small caseloads, ideally no more than 80 patients, to allow the time necessary to have meaningful, advanced care planning discussions with patients and families. This allows for a care plan that’s developed in conjunction with the patient and family, focused on addressing their concerns.

This care plan is then communicated with all members of the health care team — nursing assistants, aides, nurses, pharmacists, physicians, therapists and others responsible for caring for that patient. This step is critical to ensure the seamless alignment of care at every level, and moves care from a “production” approach to one focused on outcomes.

Measuring success

Advanced care planning is successful when the responsible provider anticipates the conditions the patient will develop, and adapts as they progress. This means focusing on:

  • Improved quality of life
  • Reduction of disease and symptom burden
  • Informed decision-making
  • Care focused on meeting appropriate goals

Advanced care planning in the SNF environment is a discussion that must continue if we are to ensure that patients and their families feel confident in the care provided. For more insights, please visit  CarePlus: Practical, proven care for high-risk, high-cost members.

–Robert D. MacArthur, Jr. MD, MS, National Medical Director, Complex Population Management, Optum

About the author

Dr. Robert MacArthur currently serves as the National Medical Director for OptumCare’s Complex Population Management.  Dr. MacArthur previously served as Regional Chief Medical Officer for United Health Group’s Medicare programs for vulnerable seniors, and as a market Medical Director for Optum of North Carolina.  Prior to his position with United Health Group, Dr. MacArthur practiced Internal Medicine and Geriatrics in Greensboro, North Carolina.

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