Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities

Background: Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied. Objectives: To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization. Design, setting, and participants: Retrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016. Measurements: Validity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission. Results: Of 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation ("No CPR"), 58% selected "Full Treatment," 17% chose "Selective Treatment," and 23% chose "Comfort-Focused Treatment." Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing "No CPR." Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose "Comfort-Focused Treatment" and were hospitalized for more than symptom management. Conclusion: Seventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. (C) 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.