Advance care planning in the skilled nursing facility: what do we need for success?

Despite the established benefits of advance care planning (ACP) in the geriatric population, documentation of ACP counseling in the skilled nursing facility (SNF) setting remains poor. The primary aim of this study was to identify key barriers to ACP completion among SNF providers. A secondary aim was to identify ACP practice-based differences between SNF physicians and midlevel providers.

As part of a divisional quality improvement project, 43 SNF providers from the area's 9 facilities were asked to complete an optional 14-item electronic survey. The survey was designed to explore and contrast SNF physicians' and midlevel providers' experiences with ACP counseling and documentation.

We obtained a 91% completion rate. Systems-based factors, such as lack of a centralized document location, inconsistent documentation habits, dispersion of responsibility, lack of time, and under-recognition of team members' efforts, were cited as key barriers to ACP documentation. Perceived patient characteristics contributing to a low completion rate included cognitive impairment and lack of family involvement. Key differences between the 2 provider groups included the location of their ACP documentation (electronic medical record vs paper chart), frequency of documentation, and recognition of who is documenting the ACP.

The survey demonstrated that systems-based barriers contribute to poor ACP documentation in the SNF setting. Key differences in attitudes about the impact of ACP on loved ones were identified between provider groups. Strategies aimed at mitigating practice-level barriers, such as standardizing a location for ACP documentation and formalizing workflow, are needed for increased ACP completion rates in SNFs.