As a palliative care nurse practitioner in a large academic medical center, I’m dismayed when some of my frailest patients get discharged to “rehab”. It seems unlikely they will be able to effectively participate there, so what happens is those who can’t end up becoming long-term care or nursing home patients through the rehab back door.
I can understand patients and families wanting to pursue rehab. It sounds so promising: a chance to gain enough strength to resume their previous lives. But, as I’ve blogged before (http://palliativejournal.stanford.edu/?p=45109), that hope is unrealistic for many. And the transition to long-term care/nursing home status can be abrupt. Rehab facilities are required to make a regular determinations of a patient’s performance and so, from one day to the next, patients can “fail” rehab. Reviewing the literature, it looks like 20-30% of rehabilitation patients do so and become long-term care residents. (This is actually a very difficult area to search because there are so many different post-acute options and the patient population is heterogeneous.) In my experience most would refuse to be discharged from the hospital to a nursing home but go willingly to rehab.
Part of the problem, again, is that we don’t talk about this possibility in the hospital or when we send patients to rehab. Instead, that falls on our colleagues working in long-term care. I recently met with a wonderfully progressive team at the Genesis Spa Creek facility outside of Annapolis, Maryland http://www.genesishcc.com/SpaCreek . They shared the difficulty they have as the ones who finally have to break the bad news to patients and families that they are not able to go home and that a nursing facility is their only option. Many patients had begged their families never to send them to a nursing home, yet that is where they are.
So, my apologies to my long-term care colleagues and to the patients and families who sign onto rehab but end up in nursing homes. Post-acute care is a hot topic in healthcare reform and hopefully someone will come up with better options and transitions for us all.
The fine line between son-in-law and doctor-in-law: by Nicky Quinlan, JPM Fellow-in-Training Columnist
The World Health Organization has recently released a report entitled Palliative Care for Older People: Better Practices (2011). It provides an interesting review of palliative care services throughout Europe (including a description of integrated palliative care in four Eastern European countries), and it includes sections on dementia, palliative care in the nursing home, and family caregivers. Of special interest is the description of England’s End of Life Care strategy, which includes advance care planning and coordination of care across settings.