continuity of patient care, hospitalization, nursing homes, palliative care, post-acute care



  1. Carpenter, Joan G. PhD, CRNP, ACHPN
  2. Berry, Patricia H. PhD, RN, ACHPN, FPCN, FAAN
  3. Ersek, Mary PhD, RN, FPCN


Despite hospital palliative care consultations during which goals of care are discussed in the context of poor prognoses, older adults are admitted to nursing homes (NHs) for post-acute care where the focus is on rehabilitation. The purpose of this qualitative descriptive study was to describe factors that influence discontinuity between a palliative care consult and NH care and explore the potential consequences of this discontinuity. Twelve adults (mean age, 80 years) were enrolled from 1 community hospital and NH in the mid-Atlantic United States. Semistructured interviews and medical record reviews were used to elicit information about clinical course, care processes, and patient/family preferences at hospital discharge and up to 4 times after NH admission. Data were analyzed using inductive content analysis techniques. Analysis revealed 2 themes: inadequate communication, characterized by the lack of information about the palliative care consult after hospital discharge, and prognosis incongruence, evidenced by data demonstrating a discrepancy between hospital prognosis and NH care. Ongoing communication between settings to readdress goals of care, prognosis, and symptoms-the central tenets of palliative care-is lacking. Efforts to improve access to comprehensive palliative care delivery after hospitalization and during NH transitions are greatly needed.