Can you get a palliative care (PC) consult in a Skilled Nursing Facility (SNF)?

Palliative Care Consultations in Skilled Nursing Facilities

Yes, palliative care consultations are available in Skilled Nursing Facilities (SNFs), though access varies by facility and is not universally available in all SNFs. 1, 2

Availability and Implementation of Palliative Care in SNFs

• Only about 37% of post-acute care facilities report having palliative care services available on-site 3
• Between 2.5% and 30% of SNF residents receive either hospice care or designated palliative care services 1
• Many SNFs have developed specialized "palliative" or "hospice" units, often in collaboration with hospice agencies 1

Models of Palliative Care Delivery in SNFs

1. External Consultation Model:

   • Palliative care specialists from hospitals or community organizations provide consultative services to SNF residents
   • Studies show approximately 4% of all NH residents receive palliative care consults 4
   • Two-thirds of palliative care consult recipients have short SNF stays 4

2. Embedded Social Worker Model:

   • Specialized palliative care social workers can be integrated into SNF settings
   • The ALIGN (Assessing & Listening to Individual Goals and Needs) intervention has shown feasibility and acceptability 5, 6
   • This model has demonstrated significant improvement in advance directive documentation (91% vs 39.6%) 6

3. Primary Palliative Care in Post-Acute Care (PPC-PAC):

   • Evidence-based approach designed to help align treatment plans with goals of care
   • 80% of participants expressed satisfaction with this model 7
   • 90% of clinicians implemented the PPC-PAC intervention as intended 7

Patient Populations Benefiting from Palliative Care in SNFs

• Not limited to end-of-life care: 50% of short-stay and 57% of long-stay residents receiving palliative care consults were still alive six months after initial consultation 4
• Medicare SNF benefit recipients: 81% of short-stay and 27% of long-stay palliative care consult recipients were on Medicare SNF benefit at time of initial consult 4
• Heart failure patients: Palliative care is particularly beneficial for SNF residents with heart failure, addressing symptoms like breathlessness, pain, fatigue, and weakness throughout the course of illness 1, 2

Barriers to Palliative Care in SNFs

1. Medicare reimbursement restrictions:

   • Medicare regulations prohibit simultaneous enrollment in the Medicare hospice benefit while receiving Medicare payment for the SNF stay 1
   • Patients must be in a non-Medicare-reimbursed bed (usually private pay) to receive the hospice benefit in a SNF 1

2. System-level barriers:

   • Limited access to palliative care specialists
   • Issues with cost and prognosis communication
   • Lack of understanding of palliative care's role 3

3. Attitudinal barriers:

   • Staff or family misconceptions about palliative care
   • Concerns that palliative care may take away hope 3

Implementing Palliative Care in SNFs

1. Advance care planning discussions:

   • Should occur at admission to the SNF and whenever there is a change in health status 2
   • Should include preferences for device deactivation (for patients with implantable cardiac devices) 2

2. Symptom management:

   • Regular assessment of pain, anxiety, depressive symptoms, fatigue, and dyspnea 1
   • Opioids have been found safe and effective for dyspnea management in advanced heart failure 1
   • Paroxetine is effective for depression management in heart failure patients 1

3. Medication management:

   • Heart failure medications should be continued until limited by decreased oral intake, inability to swallow, or hypotension 2
   • All treatments should be reevaluated in light of goals of care 1

Practical Considerations for Clinicians

• When considering a palliative care consult in a SNF, verify availability at the specific facility
• Understand that palliative care can benefit patients throughout their illness trajectory, not just at end-of-life
• Consider both the patient's Medicare status and the facility's arrangements with palliative care providers
• Recognize that palliative care in SNFs can reduce hospitalizations and improve symptom management and patient satisfaction 3