Complex Care Clinical Model

Residents in skilled nursing facilities (SNF) have multiple chronic illnesses which lead to poor prognosis and shortened lifespan. Evidence demonstrates majority of these patients and their families lack insight into the severity of their illness. We know that advance care planning (ACP) is an integral part of every patients’ care in SNFs. We also know there is lack of effective quality ACP and goals of care conversations causing last-minute crisis decision-making. This results in inappropriate, potentially harmful, and unwanted treatments.