A Process for Making Life-Care Planning a Routine of Care for Patients Admitted to Skilled Nursing Facilities.

Patient-centered care for those admitted to a skilled nursing facility is incomplete without a practitioner-patient life-care planning (LCP) conversation to facilitate informed decisions for the plan of care and a named surrogate decision maker. A medical records review of six target areas was used to identify patients who may benefit from an updated LCP conversation. Kaiser Permanente skilled nursing facility teams in the Marin-Sonoma area admitted 429 patients between November 2020 and April 2021.