A Process for Making Life-Care Planning a Routine of Care for Patients Admitted to Skilled Nursing Facilities

Patient-centered care for those admitted to a skilled nursing facility is incomplete without a practitioner-patient life-care planning (LCP) conversation to facilitate informed decisions for the plan of care and a named surrogate decision maker. A medical records review of six target areas was used to identify patients who may benefit from an updated LCP conversation. Kaiser Permanente skilled nursing facility teams in the Marin-Sonoma area admitted 429 patients between November 2020 and April 2021. On admission, each patient's medical record was reviewed for clinical and social indicators to identify patients with LCP needs. In the first month, 45% of patients had their LCP decisions documented prior to discharge, which increased to 74% by the end of the pilot process. By standardizing a process to include LCP as a component of patient-centered care planning, as a department we established practitioner-patient LCP as a routine of care for patients at skilled nursing facilities and their families.