Perceived Costs of Care Influence Post-Acute Care Choices by Clinicians, Patients, and Caregivers

J Am Geriatr Soc. 2019 Apr;67(4):703-710. doi: 10.1111/jgs.15768. Epub 2019 Feb 1.


Background/objective: Older adults frequently receive post-acute care (PAC) after hospital discharge, but little is known about how perceived costs influence PAC choices. This research study sought to understand how clinicians, patients, and their caregivers evaluate the cost of skilled nursing facility (SNF) care in their decisions about whether to utilize SNFs after hospital discharge.

Design: Guided by principles of social constructivist theory, we conducted a qualitative interpretative study using semistructured interviews with clinicians, patients, and caregivers.

Setting: The study took place in three SNFs and three hospitals located in an urban area. Purposive sampling was used to maximize variability in SNFs, hospitals, units within hospitals, and staff.

Participants: A total of 104 participants made up the study: 25 hospital clinicians, 20 SNF clinicians, 20 hospital patients, 15 SNF patients, 14 hospital caregivers, and 10 SNF caregivers who were directly involved in patients' transition from acute hospitalization to SNFs.

Measurements: Central themes related to how perceived costs of care influence PAC choices.

Results: Clinicians, patients, and caregivers did not understand the nuances of SNF insurance coverage or out-of-pocket costs. They felt constrained by insurance coverage in their discharge disposition choices and faced delays in hospital discharge due to insurance authorization processes. Some clinicians reacted to these constraints by "documenting failure," sending patients home to "fail" so they could justify SNF to insurers. Others changed their recommendations to provide patients "some" postdischarge care, even if inadequate, because of cost constraints. Clinicians discussed conserving resources to take maximal advantage of insurance-covered SNF days. Overall, cost constraint resulted in patient safety concerns, clinician professional dilemma, and moral distress.

Conclusion: Improving patient and caregiver understanding about costs and constraints of PAC would improve decision making. There is a need for improved comprehension of cost and insurance coverage of SNF care for informed patient and provider decision making at the time of hospital discharge. J Am Geriatr Soc 67:703-710, 2019.

Keywords: constraints of insurance; cost of care; post-acute care.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Attitude of Health Personnel*
  • Attitude to Health*
  • Caregivers*
  • Decision Making*
  • Facilities and Services Utilization / economics*
  • Female
  • Health Care Costs*
  • Humans
  • Male
  • Middle Aged
  • Skilled Nursing Facilities / economics*
  • Subacute Care / economics*