OBJECTIVE: To understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care. DESIGN: Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory. SETTING: Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units. PARTICIPANTS: Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N = 25). MEASUREMENTS: Central themes related to clinician evaluation and discharge decision-making. RESULTS: Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker. CONCLUSION: Hospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.
