Placing patient preferences at the center of care plans for older adults transitioning from the hospital to a skilled nursing facility

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PROJECT SUMMARY / ABSTRACT This is an application for a K01 Award for Dr. James Harrison, an Assistant Professor at the University of California San Francisco. Dr. Harrison’s career goal is to become an independent researcher in aging who uses patient engagement and implementation science to improve the outcomes of older adults transitioning from the hospital to skilled nursing facilities (SNFs). Dr. Harrison’s aspiration is for health systems to place older adults at the center of innovation discovery and care redesign. This K01 Award will help make this aspiration a reality by providing him with the training and research experience needed to develop and implement care transition interventions that are patient-centered and sustained in real-world settings. To facilitate successful completion of these activities, Dr. Harrison has assembled a strong mentorship team. His primary mentor is Dr. Margaret Fang, a clinical outcomes researcher who focuses on medications for vulnerable older adults. His co-mentors are Dr Rebecca Sudore, an expert in developing and testing tools to facilitate health communication for diverse older adults; Dr. Audrey Lyndon, an expert in qualitative research methods focusing on communication and teamwork; Dr Andrew Auerbach, an expert implementation scientist. Older adults comprise 75% of all hospital discharges to SNFs each year. Transition care planning remains persistently medicalized, failing to be guided by patients’ own preferences for their recovery, and does not incorporate elements that support preferences related to independence, returning home and function, or factors that allow participation in family or community activities that provide a foundation for personal purpose. An intervention to support patient and provider communication around patient preferences that can guide SNF transition planning is needed. In Aim 1, Dr. Harrison will conduct a qualitative grounded theory study to explore how patients and caregivers anticipate and are prepared for a SNF discharge. This study will also examine care team behaviors and processes that impact on how preferences are incorporated into transition plans. Aim 2 will involve co-developing a SNF preparation tool (SNF-PT) and associated implementation strategy with stakeholders using human centered design techniques. The objective of the SNF-PT will be to facilitate communication and implementation of patient preferences into SNF transition plans. In Aim 3, the SNF-PT will be piloted focusing on implementation outcomes and preliminary impacts on patient outcomes. This data will inform future R01 type-applications evaluating the SNF-PT. Through a focused program of mentored training and coursework, Dr. Harrison will gain skills in 1) Core principles of geriatrics, 2) The theory and application of advanced qualitative research methods (e.g. grounded theory), 3) User-centered design techniques to intervention development for older adults, and 4) Research leadership development. This K01 Award will provide Dr. Harrison with the expertise and data to launch his career as an independent investigator in aging focused on the hospital to SNF care transition.