Goal Setting Practice Within a Patient-Centered Model of Postacute Care

Changes to Medicare payment policies have increased postacute care (PAC) intensity measures in nursing homes (NHs), while hospitals, in contrast, have generally decreased these measures; thus, hospitals are discharging patients to skilled nursing facilities (SNFs) “sicker and quicker” and in greater need of intensive care.¹ However, the quality of the medical care received within SNFs is frequently inadequate given the complexity of many SNF patients.²

Patient-centeredness is considered an essential component of high-quality health care.³ Indeed, the recently revised regulations for long-term care facilities, announced by the Centers for Medicare & Medicaid Services, emphasizes the use of resident-centered care planning to ensure that residents are informed, involved, and in control of their care.⁴ Individualized goal setting is considered one of the keys to resident-centeredness in terms of respect for patient preferences, values, and expressed needs.⁵ Research has also shown that the actual care goals of patients and caregivers are often different from those perceived by clinicians.^6,7 Yet, there is little previous research demonstrating what SNF patients perceive to be their goals and concerns. A better understanding of individualized goals may provide insight as to what matters to patients and help guide patient involvement during their post-acute SNF stay. 

Previous studies that involved some domains of patient-centered care in their interventions have shown improved outcomes. For example, one study published results of a 6-month pilot program to improve the discharge disposition (ie, acute care, long-term care, home, or death) of patients admitted to a single PAC SNF unit.⁸ Resident admission procedures were standardized with patient-centered domains, including goals-of-care discussion regarding code status, number of hospital admissions in the past 6 months, and whether repeat hospitalization is consistent with patient’s wishes. This study reported a 20% decrease in acute readmissions and a 6% increase in discharges to the community in the intervention group. In another study, researchers conducted a 1-year randomized control trial (N = 26) to promote post-acute patients’ engagement in rehabilitation and functional outcomes.⁹ The intervention featured a patient-directed, interactive rehabilitation process. At the end of intervention, authors found higher patient engagement in rehabilitation and better functional outcomes in the intervention group.

Although this and other research has been published supporting the use of person-centered interventions, a wider knowledge base surrounding patient goals and the goal setting process in SNFs is lacking. More insight into actual patient goals and the goal setting process is needed in order to guide future investigations and practical interventions.

Recently, our team conducted a pilot evaluation to test the feasibility of implementing an innovative, patient-centered model of care (the Patient-Oriented Interdisciplinary Subacute Care [POISe-Care] model) within a SNF in the central United States. The POISe-Care model features four components: interdisciplinary team care in the patient room, patient-centered flow of care processes, interactive communication, and standardized process and documentation tools. This care model encourages patients’ engagement in their care and invites patients to select their own goals of care using their own language and priorities with collaborative assistance from the care team. Additional details of the POISe-Care model can be found in Nazir et al.¹⁰

This manuscript discusses the portion of the pilot evaluation that focused on better understanding patient goals of their PAC. A content analysis of patient goals was completed, aiming: (1) to determine patients’ capabilities of setting their own goals freely, (2) to determine the clinical usefulness and practicality of patients’ statements, (3) to determine PAC patients’ care priorities from their own perspective, and (4) to discuss the feasibility and impact of goal setting practice in SNFs for PAC patients.

Evaluation of the POISe-Care program was funded by the Clinical and Translational Science Institute. The project was given Institutional Review Board approval by Purdue University and Indiana University School of Medicine. 

The study setting was an 89-bed urban SNF located in the Midwest United States. It was a for-profit SNF and had an average daily census of more than 20 post-acute patients.

The intervention period was 6 months and included all consenting admissions for a total of 40 postacute patients. Patient medical records were used to collect demographic data for this study, including age, gender, race, payment type, and primary diagnoses at admission. Complete list of diagnoses was not displayed in this study. It should be noted that 5 patients (out of 38 patients) had the secondary diagnosis: Dementia-related Behaviors. However, those residents interacted with the care team independently and expressed their goals and concerns. Residents with severe cognitive impairment as indicated by an initial cognitive screen—the Callahan 6-Item Cognitive Screen¹¹—were not included in the study. 

At the core of the model was the biweekly care plan meetings that were held in patient rooms based on their schedules. The team used a templated approach to inquire from patients, in their own words, their primary health concerns. Specifically, the POISe-Care meeting template included the following fields: patients’ three most important goals, patients’ three most important concerns, and the attending personnel at the meeting. Medical staff provided feedback and answered questions as needed but allowed the patient to freely state their goals and concerns without staff additions. Medical staff then documented patients’ responses in the POISe-Care meeting templates, again, careful to document the patients’ own words. As led by the medical staff, the care team planned the focus of care for the following 2 weeks according to patients’ goals and concerns.

Data Analysis

Demographic data was collected and was accessible to the research team in REDCap,¹² an online data management system. Patients’ goals and concerns, as well as the linked demographic characteristics (gender, race, main diagnosis), were imported into Nvivo 11 (QSR International; Melbourne, Australia) for thematic textual analysis. 

Due to the multiple biweekly meetings, some patients had multiple POISe-Care templates. This study did not count frequency to indicate common themes because patients commonly had consistent goals over time. Instead, for patients with multiple meetings, same goals or concerns over time were only coded once. For example, one patient’s goals in two POISe-Care meetings were: (1) “lift weights; have strength in legs; bed and wheelchair; hand railing for steps leading to house”; and (2) “lift weights; have strength in legs; bed and wheelchair; diabetes education; glucose meter.” Six references (nonduplicate count of patient’s goals) were captured from these two goals: (1) “lift weights”; (2) “have strength in legs”; (3) “bed and wheelchair”; (4) “hand railing for steps leading to house”; (5) “diabetes education”; and (6) “glucose meter.” These references were then labeled and sorted into three parent nodes, or themes: (1) “strength”; (2) “equipment”; and (3) “medical needs.” Two authors independently coded patients’ goals and top concerns and then, after discussion, reached a consensus on coding. Data were then re-coded using the agreed-upon consensus coding scheme. Themes were then further analyzed and compared across patient demographic characteristics.

For the current analysis of patient goals, 38 of the 40 potential patient participant charts were reviewed (the POISe-Care meeting templates in two charts were unavailable): 28 females and 10 males; 16 non-Hispanic white Americans, 20 African Americans, one Hispanic American, and one patient with no race/ethnicity reported. Patients ranged in age from age 42 to 100 years old. Approximately 60% of patients were between ages 65 and 84, followed by 21% of between ages 40 and 64, and 18% between ages 85 and 100 (Table 1). A total of 129 valid POISe-Care meeting templates were reviewed, reflecting multiple biweekly goal setting meetings per patient. 

The main reasons for SNF admission were classified into two groups: nonorthopedic diagnoses (sepsis, respiratory, renal, cardiac, and gastrointestinal diseases) and orthopedic diseases (amputations, hip replacement/other orthopedic surgery, fracture, arthritis, and fall). Multiple comorbidities were recorded. More than 70% of the non-Hispanic white patients were admitted for orthopedic diseases, while over 70% of the African American patients were admitted to address other health concerns. Reimbursement types for patients included Medicare (92%, n = 35), Medicaid (42%, n = 16), and/or private insurance (3%, n = 1).

Patient goal setting meetings were held biweekly, and the mean number of POISe-Care meetings per patient was 3.4 (range 1-7). More than three-fourths of patients (76%, n = 29) had more than one meeting during their stay. Among those having multiple meetings, about two-thirds of patients (67%, n = 18) had some slight changes, mainly add-ins, to their top three goals over time. 

In the total 129 meetings, 99% of the patients provided up to three top goals during the stay in the SNF with only two documented as “none” and “not available.” The 13 themes that emerged from patients’ goals were to improve function (ie, Activities of Daily Living, Instrumental Activities of Daily Living), mobility, balance, strength, and general condition; to meet the needs regards to services, medical treatment, equipment, insurance application; to discharge to home; other; and none. Table 2 displays the 13 themes and patients’ statements.

As displayed in Table 3, most common goals were related to themes of mobility (17%), general health condition (12%), medical treatment (11%), and discharge to home (11%). Top three themes of goals among non-Hispanic White patients were mobility (24%), general condition (13%), and discharge to home (13%), while the top three themes among African American patients were services (20%), strength (14%), and medical needs (12%). 

Male patients’ top three goals were most related to mobility (21%), strength (13%), and general condition (13%). Female patients’ top three goals were related to services (14%), mobility (11%), strength (8%), medical needs (8%), and discharge to home (8%). 

Patients with orthopedic diagnoses most commonly focused upon mobility (22%), services (16%), and discharge to home (16%). Patients with non-orthopedic diagnoses most commonly set goals relevant to services (18%), strength (14%), and medical needs (14%). 

Seventy-eight percent of the patients documented key concerns when asked during their POISe-Care meetings. Those key concerns showed a vast range of specific health conditions and health needs. Concern categories were arranged in alphabetical order, as displayed in Table 4. Some of the concerns were overlapping with the goals such as: discharge to home, balance, strength and mobility improvement, and service needs.

Attendance of staff members in each meeting were recorded for 104 POISe-Care meetings; 25 forms were missing the staff attendance list. Meetings were attended by the physician (60%), collaborating nurse practitioner (NP) (40%), therapists (93%), nurses (90%), social workers (85%), and the dietician (59%). Caregivers or family members were present 20% of the time. Nursing aides were rarely present in POISe-Care meetings (3%) but were encouraged to provide feedback about the care of the resident before and after the meetings about any key challenges or successes.

Discussion

In this study, the objective was to determine patients’ capabilities of setting their own goals freely; to determine the clinical usefulness and practicality of those statements; to determine the priorities of post-acute patient perspectives; and to discuss the feasibility of goal setting practice and its possible impact among post-acute patients. The majority of post-acute patients in this patient-centered model of SNF care were able to set their own goals and freely express their primary concerns with the encouragement from the care team. The findings in this study demonstrated that goals of care conversation in postacute patients is feasible, and patients were able to provide realistic and meaningful goals to guide care. Continued analysis of data from the POISe-Care evaluation will inform our knowledge of the effectiveness of patient-centered care planning in the SNF setting. 

The findings showed differences in goals between genders and races. African American residents were more frequently admitted with complex medical needs. In contrast, non-Hispanic white American residents were mainly admitted for rehabilitation of orthopedic conditions. Differences in goals between racial categories of residents paralleled this difference in primary diagnoses. For example, non-Hispanic white Americans mainly admitted for rehabilitation aimed to improve mobility and achieve early discharge to home. Men were more eager to improve general health condition, mobility, and strength so as to become more independent, while women more frequently expressed a need of help at home (home services). 

Patients’ goals were relatively consistent over time, with slight changes or add-ins, while the patient concerns were more dynamic. Patients consistently aimed for challenging but potentially achievable goals regarding their healing and early discharge to community, and their goals were clinically relevant and specific enough for use in guiding the care planning meetings/process. Successful transition of care and care coordination upon discharge to community was another common goal, including health insurance application, home services, durable equipment, living arrangement, primary care services, among others. This demonstrated the importance of the interdisciplinary care team and the interdependence of social support with medical care needs and recovery. 

As mentioned above, patient concerns were more varied. Patient concerns were primarily related to receiving rehabilitation and medical treatment, promoting recovery and discharge, and comfort during their stay. Patients were also concerned about different aspects of their health, mainly including better understanding the healing process, pain management, chronic comorbidity management, and acute signs and symptoms. Some patients mentioned their concerns regarding the nursing, dining, and general services in the facility. 

Goal setting practice in this study is similar to a recent study implementing goal of care conversation in veterans’ NHs nationally.¹³ Another study implemented a goal setting practice by focusing on four goal areas among residents in a NH: oral health, stress reduction, physical activity, and healthy diet.¹⁴ But the key feature of our study’s goals of care conversation is that patients’ thoughts were not limited by the facility’s predetermined goal areas. Additionally, those two studies mainly focused on long-term care residents^13,14 whereas our study of goal setting practice was uniquely targeting post-acute patients. Postacute patients had their own medical conditions with a large diversity of orthopedic or non-orthopedic diseases. They had high aims on medical treatment and rehabilitation and less attention to lifestyle preferences, which can be noted from the goal themes found in this study.

In addition, the goal setting practice in this study featured the integration of asking and documenting patients’ primary concerns, not just goals. Patients’ goal statements are usually indicative of their terminal goals, while patients’ concerns mainly serve as short-term goals. For example, a female patient’s goals were “be able to go home” and “walking with cane.” This patient was also concerned about her “left shoulder” and “sore on the back” that would prevent her from walking with a cane and going back home. The combination of patients’ goals and concerns facilitates effective care planning by the interdisciplinary care team. 

Goal setting practice requires more time for the interaction between patients and the care team as compared with usual care. As mentioned earlier in the Methods, patients in this study were cognitively competent enough to be involved in goal setting practice. However, patients’ cognitive status is a factor that could slow down the communicating process of goal setting within other contexts. Also, it should be noted that patients who have little medical knowledge or have never thought about their goals during their stay in the SNF may find it difficult to decide their goals and could hinder goal setting practice. 

Goal setting practice is a microsystem innovation that is unavoidably influenced by the macrosystem and the environmental context (Figure 1). The microsystem of goal setting practice involves key stakeholders: the patient, family/caregiver, and the care team. The care team includes a physician or NP, nurse, therapist, social worker, and food service manager. Two major dimensions comprise the essentials of goal setting practice: the interpersonal dimension (ie, communication and collaboration) and the clinical dimension (ie, decision making and care coordination). Efficient communication and a trusting relationship between patients and the care team is essential, and a key assumption of this model is that determining patients’ goals and concerns is beyond the ability of medical staff members alone. Instead, clinicians act as “coordinators,” comprehensively addressing patients’ conditions and goals, and the corresponding actions of the entire care team. Optimal goal setting practice aims to ensure shared clinical decision making is both evidence-based and coupled with patients’ goals, preferences, or needs. The elements in the SNF macrosystem include the facility’s buy-in of patient-centered practice and allocation of resources, such as time to work individually with patients, staff satisfaction with the model, and billing of clinician time—all of which pose potential barriers to the implementation of person-centered models of care. 

Appropriate reimbursement of care according to time spent with the patient is essential to keep the practice alive. The primary reimbursement source among post-acute patients in the United States is Medicare, a federally supported insurance that covers SNF care for up to 100 days, given certain clinical criteria are met.¹⁵ In our study, physicians were engaged in daily care meetings. However, wider dissemination of bedside goal setting may rely on access to advanced practice nurses to serve as team leaders. NPs are recognized as autonomous providers by Medicare and are reimbursed directly but at 85% of the physician rate, according to the legislation passed in August 1997.¹⁶ NPs are not authorized by Medicare to order oxygen, home blood glucose monitors, and a number of other durable medical equipment items without a physician’s signature.¹⁷ Similarly, NPs are not authorized to admit a patient to a SNF or order home health care services. Fortunately, NPs can order physical therapy and occupational therapy for Medicare patients under their care. Further research is warranted to better understand how restricted authorization and lower reimbursement rate affect the full engagement of NPs in SNF goal setting practice. 

Additionally, although the findings from this study did not explicate the ethical considerations of resident-centered practice change, the role switching raises two ethical considerations: patient decision-making capacity and the right to refuse treatment. Historically, the medical professional has been the director of patient care; in goal setting practice, the role switching between the medical professional and the patient is culturally unconventional. Evaluating patients’ capacity to determine their medical trajectory and the level of assistance patients need from the care team are issues that would benefit from expanded study in regards to implementation of patient-centered goal setting. 

Goal setting practice in our study was evaluated as feasible among post-acute patients in the intervention SNF. The analysis of individualized goals and concerns demonstrated care priorities from patients’ perspectives, potentially empowering clinicians to better assist patients to meet their care goals. Patient goals and concerns surrounded issues of comfort, community discharge, and disease management—concepts that, if addressed, could significantly improve the quality of PAC.

Authors: 
Yun Cai, MSN, AGNP¹; Kathleen Abrahamson, PhD, RN¹; Arif Nazir, MD, CMD² ; Nancy Edwards, PhD, AGNP¹; Elizabeth Richards, PhD, RN¹

Affiliation:
¹ Purdue University School of Nursing West Lafayette, IN
² Signature HealthCare Louisville, KY

Disclosures:
The authors report no relevant financial relationships.

Address correspondence to:
Kathleen Abrahamson, PhD, RN
502 N. University Street
West Lafayette, IN 47907
Phone: (765) 494-4019
Fax: (765) 494-4019
Email: kaabraha@purdue.edu