In McKnight’s Long-Term Care News this month, there was a report on a study examining factors that contribute to transfers of frail residents from skilled nursing facilities to emergency departments.
Using focus groups of residents and family caregivers, researchers found four main contributors to the transfers: “(1) doubts about the quality of skilled care facility nurses’ assessments; (2) perceptions that physicians were absent from the nursing home; (3) misunderstanding the relative capabilities of skilled care settings and emergency departments; and (4) beliefs that responses to medical needs were inadequate.” In addition, the lead author found that some of the transfers were due to a lack of acceptance on the part of family members that their relative was near the end of life.
The study authors stated that telehealth could address some of these factors. While that may be the case, my experience suggests that there are additional ways in which facilities can address family concerns and reduce potential hospital transfers. These center on educating residents and families, and on setting reasonable expectations.
One of the most frequent discussions I have with residents and families is regarding their impression that they “never see the doctor.” As I point out in my book, “The Savvy Resident’s Guide,” the nurses notify the doctor if there are any problems. I tell residents that because the doctor visits mainly when something is wrong: “If you’re not seeing the doctor, it’s a good thing.” This shift in perception can make a huge impact, whether it’s conducted via a one-to-one conversation, a book or some other communication method.
One of the contributors to mistrust is that the families of short-term residents tend to be in crisis and to have dealt with a multitude of healthcare providers prior to admission. They are often being pulled in many directions and don’t know whom to rely upon for good care of their relative.
In a previous column, “7 powerful ways to deliver family-centered care,” I noted that if we considered that we’re admitting families rather than residents, we’d put additional focus on family members. People turning to healthcare professionals in the middle of a personal catastrophe will be more likely to trust those who recognize their moment of crisis and treat them accordingly. Sometimes even small things like being offered a cup of tea while filling out paperwork can create a feeling of safekeeping for them and their loved one. See the above-mentioned article for ideas on family-centered care.
It’s important to educate residents and families about a number of issues related to the value of skilled nursing over hospital emergency departments. While those in the industry are aware that nursing homes are able to provide more medically complex care than they used to, families may not have been in skilled nursing since a parent or grandparent was there decades ago; they need to have their perceptions updated.
An educational program or pamphlet along the lines of, “It’s not your grandmother’s nursing home,” might address this, along with the dangers of emergency departments for frail elders and the benefits of having staff members who know the resident.
Families of long-term residents, who have established relationships with staff members, might be more trusting of care than newly admitted resident, yet they could still view the hospital as a way to rescue from death someone who is very ill. From what I’ve observed over the years, facilities could be having deeper, more consistent end-of-life conversations with families much sooner than they do.
One of the good parts of working in a team is that the physician, who may not feel comfortable with such discussions, can delegate the task. This is an area where the consulting psychologist, working along with team members such as the nurse and social worker, can be extremely helpful, especially when a resident is referred for services sooner rather than later. Doing so allows time for relationship development and therefore confidence that the psychologist or other team member is offering advice that’s best for the resident and their family, rather than driven by the financial priorities of the facility.
Interestingly, research1, 2, 3 indicates that not only do nursing staff want to be involved in end-of-life decisions, and that advance planning improves care, but it also indicates that providing “futile care” increases staff burnout. By enhancing end-of-life care, facilities can improve care quality for residents, minimize the family trauma of losing a loved one, improve staff retention and reduce the likelihood of unnecessary transfers to hospital emergency departments.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.