Empowering Health Care Consumers

Project Title

Promoting Patient-Centered Discharge Planning for Post-Acute Care Settings

Grant Amount


Priority Area

Empowering Health Care Consumers

Date Awarded

October 2, 2017








Post-acute care, including inpatient rehabilitation facilities, nursing homes, home health agencies, and long-term care hospitals, is a critical and growing component of the health care system.

Although there have been recent reforms to smooth the transition of patients discharged from hospitals to post-acute facilities and improve continuity of care, the system is not functioning as well as it should. Current hospital discharge protocols often overlook patient preferences and limitations, and the rush to discharge can lead to poor choices with significant consequences. Helping patients and their families choose the right setting at the right time could improve outcomes and lower costs. In 2017, NYHealth awarded the United Hospital Fund of New York (UHF) a grant to improve the ability of patients and family caregivers to make informed decisions about post-acute care settings.

Under this grant, UHF examined patient and family caregiver experiences, including opportunities for better communication and information-sharing about post-acute care options. UHF also studied how hospital staff involve patients and families and share information to support their post-acute care choices. Discussion groups were held with patients and family caregivers, hospital discharge teams, nursing home staff, and other key stakeholders to determine what type of information is most helpful and how to improve the discharge planning process for patients. UHF also convened stakeholders to examine innovations, processes, and models happening in other states and assess their potential for implementation in New York State. Based on its findings, UHF produced and shared a report with specific recommendations and an action plan for improving current practices to create greater transparency and support for patients and caregivers in post-acute care decision-making.

Read the reports:

Difficult Decisions About Post-Acute Care and Why They Matter

The Illusion of Choice: Why Decisions About Post-Acute Care Are Difficult for Patients and Family Caregivers

Health Care Provider Perspectives on Discharge Planning: From Hospital to Skilled Nursing Facility

Pathways to Progress on Difficult Decisions in Post-Acute Care