Neither clinicians nor cancer patients’ or their families clearly typically understand who will lead their care if they’re transitioned to a skilled nursing facility, a concern that presents health systems and nursing homes themselves with an opportunity to do much more in oncology.
That’s the belief of a medical oncologist, a palliative care physician, and an emergency medicine doctor who last week published a series of recommendations in JCO Oncology Practice meant to help improve cancer care before and during a SNF stay.
Their letter follows a June study that found acute and post-acute care clinicians defer serious illness conversations to the oncologist even when patients “are on a steep trajectory of decline, experiencing multiple care transitions, and may have limited contact with their oncologist.”
Four areas of concern identified in that study make it clear that future research and systemic changes could address as “urgent, unmet clinical need in oncology,” Daniel E. Lage, MD; Craig D. Blinderman, MD; and Corita R. Grudzen, MD, wrote in “Rehabbed to Death in Oncology.”
Chief among them is that clinicians see a SNF discharge as linked to worsening prognosis, and family “distress” around that can make it hard to advocate for better patient care in the nursing home. Providers also said they were concerned about barriers to proper communication with outpatient teams, including the primary oncologist and palliative care, and a lack of clarity about which clinician should lead serious illness conversations, especially when patients aren’t making gains in rehab.
“As the clinicians in this study noted, the SNF-bound population is challenging precisely because it is sometimes unclear whether functional and clinical improvement is possible or whether the patient is near the end of life,” Lage, Blinderman and Grudzen wrote. “At other times, it is clear there is little chance of improvement, but the patient and family are not ready to accept this fact.”
They said health systems could help make the experience better by starting conversations about expectations before SNF-discharge, including more palliative care clinicians in the SNF setting, and more quickly identifying discharged patients failing to make functional progress.
They called SNF providers’ deference to patient-oncologist relationship an unsettling finding, arguing that oncologists cannot easily be directly involved in care of patients outside of their primary facility. They encouraged a larger role for nurse practitioners, as well as SNF, health system and payer support for telehealth to align care objectives.
“For patients cycling between hospital and PAC facilities, there may never be that perfect, outpatient appointment to have a serious illness conversation with the primary oncologist for logistical or clinical reasons, but that cannot be a barrier to those conversations advancing,” they wrote.
The team also noted that nursing home staff must be empowered “to identify failure to progress functionally — transferring, toileting, walking — and communicate that lack of progress to the patient and oncologist in the context of their cancer being a serious, advanced disease.”
They recommended training in serious illness conversations for physical therapy and nursing staff in SNF settings. Artificial intelligence and machine learning could also help to identify these patient subgroups and design targeted interventions to avoid rehospitalization.
