Sample Characteristics
A total of 50 SNF patients and 6 caregivers participated in the study. Half (48%) of participants were female; 20% were younger than 65 years old, 26% were between 65 to 74 years of age, 36% were between 75 to 84 years of age, and 18% were over 85 years old at the time of the interview. Of the sample, 52% were white, 38% black, and 10% other race(s). Most patients (92%) completed high school or higher education. At the time of the interview, 34% of patients interviewed had no detectable cognitive impairment, 43% of patients had a mild degree of cognitive impairment, and 23% had moderate to severe cognitive impairment (Table 1).
Table 1. Study Sample Characteristics (N=50)*
Characteristic
|
Frequency
|
Percentage
|
Gender
|
Male
|
26
|
52%
|
|
Female
|
24
|
48%
|
Age
|
<65
|
10
|
20%
|
|
65-74
|
13
|
26%
|
|
75-84
|
18
|
36%
|
|
≥85
|
9
|
18%
|
Race
|
White
|
26
|
52%
|
|
Black
|
19
|
38%
|
|
Other
|
5
|
10%
|
Education
|
Some high school or less
|
4
|
8%
|
|
High school diploma
|
18
|
36%
|
|
Some college
|
7
|
14%
|
|
College degree
|
12
|
24%
|
|
Graduate degree
|
9
|
18%
|
MoCA score
|
High (26-30)
|
15
|
34%
|
|
Intermediate (20-25)
|
19
|
43%
|
|
Low (Less than 20)
|
10
|
23%
|
*Patients only. We did not collect demographic information or perform MoCA assessments of caregiver participants.
Major Recurrent Themes
Table 2 shows the three major recurrent themes and their sub-themes that describe the participants’ expectations and experiences of physician care in SNFs. Those major themes were: (1) participants had poor awareness of the physician(s) in charge of their care at the facility (awareness was defined as knowledge of identifying characteristics [e.g., name, appearance, contact information] or professional activities [medical services or expertise provided, or typical role in relation to other staff such as nurses, hospital physicians, external consultants]); (2) they were dissatisfied with the frequency and quality of communication with the physician(s); and (3) participants valued the perception of receiving individualized care from their physician(s). The themes and select sub-themes are described in detail below. All sub-themes and their representative quotes are presented in Table 2.
Table 2. Participant Perceptions of Their Experiences and Expectations of Physician(s) Care in Skilled Nursing Facilities
Theme
|
Sub-theme
|
Representative quotes
|
Poor awareness of the physician(s) in charge of their care at the skilled nursing facility
|
Inability to name or otherwise identify the physician(s) overseeing their care
|
"I've never really talked to him...I didn't even know he was a doctor." – Female, 70’s-80’s years old
|
Expectation that external providers (i.e. their surgeons, hospitalist, or primary care provider) would be directing their post-acute care at the skilled nursing facility
|
"From what I’ve been told there’s a separate physician here. It’s not my surgeon, which I’m not crazy about. I mean, he gave me the surgery, he should be in here to check on meat least once or twice during the 10 days I’m here. But he hasn’t been. It’s been a different doctor who was only here one time." - Female, 60’s-70’s year old
|
Confusion about the distinct roles of physicians, nurse practitioners, nurses, and nursing assistants on the care team
|
“It’s very hard to tell who’s a doctor. That person, I guess, he’s a doctor, it happens every once in a while, a guy comes in with a suit and tie on and he doesn’t really introduce himself. He just sits down and we start talking about things. I wish they would announce themselves - exactly who they are.” – Male, 60’s-70’s years old
|
Distress associated with the lack of understanding about the physician(s) coordinating their care
|
“I don’t know [if there is a separate doctor or nurse practitioner who coordinates my care in this facility]. I don’t know. I feel kind of stupid not knowing.” - Female, 70’s-80’s years old
|
Frequency and quality of communication with the physician did not meet participants’ expectations
|
Frequency of communication did not meet expectations
|
"I mean, if I need a question they always tell me to ask the nurse. And Dr. [last name], I only saw him once and I probably won't see him again this week." – Male, 50’s-60’s years old
|
Quality of communication did not meet expectations: perceived to be rushed, superficial, insufficient to learn patient preferences for care
|
“I think that [physicians] can stay on top of stuff a little bit more. I know they have a lot of patients here and I know they’re really busy, but I just feel like I’m like their supervisor and I’m keeping on top of them and making sure they do their job. And I don’t think I should be doing that. I don’t want to have to be burdened with that mindset that I need to stay on top of these people in order for them to do what I need to have done.” – Female, 60’s-70’s years old
|
Caregivers expected more frequent and detailed communication with the physician
|
"I thought [the physician] should have had a little more [communication] with me when I asked him a question. I told him, '[My father] is an [80’s] year-old man. If you have a question, you need to call me.'" – Female, 30’s-40’s (caregiver)
|
Participants valued care that was perceived to be individualized to their needs by the physician(s) in the facility
|
Perception of physician(s) being dismissive of the patients’ symptoms
|
"I didn’t care for the doctor there because she acted like I didn’t know my own body and I didn’t know what I was talking about. And I know how much insulin I need, because I give it to myself, because I’ve been a diabetic for [many] years, which is a long time." – Female, 70’s-80’s years old
|
Appreciation of specialized care to meet individual needs
|
"And [the physician] is very understanding of my father and how he thinks. And thinking so much about my father and then specifically understanding of his needs, like the [diet] element, things like that. Some people really shake that off like it’s not important – he has to eat – but for a man who spent his life that way, it is important." – Female, [declined to provide age] (caregiver)
|
Patients felt they were a burden due to their medical complexity or custodial needs
|
"You know one thing I think about this place – they knew that I was [medically complex and high needs] – why did they accept me? Don’t accept people because you need patients. You accept them because you wanna help them." – Female, 70’s-80’s years old
|
Poor Awareness of Physician(s) in Charge of the Patient’s Care at the Facility
Patients and their caregivers had poor knowledge of their physician(s) at the SNF. Nearly all patients interviewed were either unable to name or misidentified the physician in charge of their care at the facility. For example, a prevalent misconception among patients was that the attending physician who treated them during the hospital stay that preceded the SNF stay was directing their care and prescribing their medications. As a result, many patients expressed disappointment when they were unable to see their hospital attending physician (or clinician team) after admission to the SNF. For example, a patient discussed her disappointment that her operating surgeon did not have a continued role in her care at the SNF,
“From what I’ve been told there’s a separate physician here. It’s not my surgeon, which I’m not crazy about. I mean, he gave me the surgery, he should be in here to check on me at least once or twice during the 10 days I’m here. But he hasn’t been. It’s been a different doctor who was only here one time.”
- (Female, 60’s-70’s years old).
Active involvement in their post-acute care (including in-person visits, frequent communication, medication management) by the attending physician in charge of their hospital stay was an expectation of patients admitted to the SNFs for post-acute care, and patients expressed disappointment when this expectation was not met.
Participants were also frequently confused about the roles of different healthcare providers in the SNF. Other than the misconception that hospital attending physicians were in charge of their care at the SNF, participants did not have any expectations of physician care at the facility. Patients described the intake process at the facility that typically included interactions with different members of the clinical team, but reported confusion about individual clinicians’ roles. For example:
“I'm not sure who makes decisions about my medications at [this facility]. I know there is a plan, and they asked me different things, if I need this or that or the other, but I don't know who is actually–whether it's the nurse, whether it's a supervising physician. I assume it's a supervising physician, but I don't know."
- (Male, 70’s-80’s years old).
As a result of these misconceptions and confusion, participants reported difficulties accessing their physicians to change their medications, address new symptoms, or discuss the plan of care. Many patients described feeling disempowered to take an active role in their care. Patients were uncomfortable with their lack of knowledge of the physicians in charge of their care and stated that it made them uneasy. For example, one participant said,
“I don’t know [if there is a separate doctor or nurse practitioner who coordinates my care in this facility]. I don’t know. I feel kind of stupid not knowing.”
- (Female, 70’s-80’s years old).
Frequency and Quality of Communication
Participants reported dissatisfaction with the frequency and quality of communication with the physician(s) at the SNFs. Most patients saw the physician no more than once a week during their stay but expected more frequent communication with the physician(s). Likewise, the caregivers interviewed also reported that they felt the frequency of communication was inadequate, and they were dissatisfied with their access to the physician(s). One patient discussed frustrations with unclear expectations of the frequency of interaction with their SNF physicians, stating the following:
“I think the case managers and the hospital need to make sure the patients understand that…you're not gonna see a doctor every week.” - (Female, 60’s-70’s years old).
Participants also reported that the quality of communication did not meet their expectations. They perceived physicians’ interactions with them as rushed, superficial, and insufficient to learn the patient as an individual and understand their preferences for care. Participants also perceived that physicians do not communicate adequately with external physicians in other facilities (e.g., hospital, primary care physicians), leading to disorganized and delayed care delivery. For example, participants assumed that inadequate communication with the discharging hospital’s physicians resulted in a lack of staff preparedness for intake upon their arrival to the SNF. Patients also perceive inadequate communication between the physicians and other SNF staff. They observed a lack of physicians responsible for care coordination and supervision of the care delivered to them by direct care staff, a role typically attributed to the physician in the hospital and clinic. One patient reported that he had to coordinate his own care, while another felt that she needed to act as the “supervisor” to SNF staff in order to receive care that she felt was adequate:
“I think that [physician] can stay on top of stuff a little bit more. I know they have a lot of patients here and I know they’re really busy, but I just feel like I’m like their supervisor and I’m keeping on top of them and making sure they do their job. And I don’t think I should be doing that. I don’t want to have to be burdened with that mindset that I need to stay on top of these people in order for them to do what I need to have done.” – (Female, 60’s-70’s years old)
Participants who experienced physician communication that did not meet their expectations felt that their physician(s) in the SNF did not know them or their preferences for care. Some caregivers expected more frequent and detailed communication with the physicians(s) in the facility especially because their loved one was in the facility for a short-term stay and the facility staff did not know the patient. For example, one caregiver said:
"I thought [the physician] should have had a little more [communication] with me when I asked him a question. I told him, '[My father] is an [80’s] year-old man. If you have a question, you need to call me.'" – (Female, 30’s-40’s years old, caregiver)
Participants attributed other perceived deficiencies in their care at the facility to the infrequent and superficial communication with the SNF physician(s). Patients and caregivers experienced distress and felt neglected if they experienced communication with the physicians that did not meet their expectations. One patient felt that the SNF physician “doesn’t give a toot” about his/her patients.
Perceptions of Individualized Care from the Physician(s) Associated with More Positive SNF Experience
Patients valued several aspects of the care they received from the physician(s) in the SNFs. One major recurrent theme was that participants who perceived that their care was individualized to their needs had more positive opinion of their physician(s). In contrast, patients who perceived that their physician(s) did not take time or make effort to understand their individual needs were likely to have a negative opinion of the physician’s care. For example, some patients perceived that their physician did not take their concerns seriously:
"I didn’t care for the doctor there because she acted like I didn’t know my own body and I didn’t know what I was talking about. And I know how much insulin I need, because I give it to myself, because I’ve been a diabetic for [many] years, which is a long time." – (Female, 70’s-80’s years old)
Patients also frequently expressed this sub-theme about pain management. When patients discussed their pain management, it was often to express concerns that the SNF physician(s) were dismissive of their symptoms, with one patient expressing that her experience made her feel like “some kind of drug addict”. In contrast, many participants described positive experiences with individualized care, including one patient’s caregiver who appreciated their physician’s awareness of special dietary needs:
"And [the physician] is very understanding of my father and how he thinks. And thinking so much about my father and then specifically understanding of his needs, like the [diet] element, things like that. Some people really shake that off like it’s not important – he has to eat – but for a man who spent his life that way, it is important." – (Female, [declined to provide age] (caregiver)).
Many patients stated that their overall experience with their physician in the facility was positive, even when they had discussed specific, negative aspects of their care. Overall, patients were satisfied with physician care, often stating that their physician(s) were “nice” and that the care was “good". Many patients felt that they required very complex and intensive care due to their medical needs and physical limitations. On one hand, patients expressed appreciation when those needs were recognized and met. On the other hand, some patients reported feeling like they were a burden to the facility:
"You know one thing I think about this place – they knew that I was [medically complex and high needs] – why did they accept me? Don’t accept people because you need patients. You accept them because you wanna help them." – (Female, 70’s-80’s years old)
Stratified Analyses
Participant perceptions of the physician(s) care in SNF were generally consistent for patient with vs. without cognitive impairment. Patients who were less cognitively impaired based on their MoCA score during the interview expressed confusion and poor knowledge of their physician who was directing their care in the facility, as did patients who were more impaired (based on their MoCA score). One notable distinction was that patients who were less cognitively impaired expressed concern about the lack of knowledge of the physician(s) at the facility, whereas more cognitively impaired patients were less concerned about their lack of awareness of the physician(s) at the facility.
Participants who were more cognitively impaired were more likely to confuse the different roles of physicians, nurse practitioners, nurses, and other SNF personnel when discussing their care teams. In contrast, participants who were not detected to have cognitive impairment based on MoCA performance were generally able to accurately describe the differences in the scope of practice of physicians vs. other staff. However, similar to cognitively impairment patients, many cognitively intact patients were unable to identify their physician(s) at the facility by name. Patients without cognitive impairment were more likely to be aware of this gap in their knowledge about their care team and to express concern about that.
Patients in SNFs with physicians who focused their practice in SNFs (i.e., SNFists) were more likely to report positive experiences with physician care as well as with their overall experience at the facility compared to the patients in SNFs where physicians did not focus their practice exclusively on SNF-based care. However, we did not detect differences in the major themes across participant perceptions between facilities with high vs. low degree of physician ‘specialization’ in SNF practice.