Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n=270 202), 2005 (n=291 819), or 2009 (n=286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Comparing 2000, 2005, and 2009 shows a decrease in deaths in acute care hospitals and increases in intensive care unit (ICU) use in the last 30 days, hospice use at the time of death, and health care transitions at the end of the life (test of trend P < .001 for each). 200020052009No. of decedents270 202291 819286 282Deaths in acute care hospitals, % (95% CI)32.6 (32.4–32.8)26.9 (26.7–27.1)24.6 (24.5–24.8)ICU use in last month of life, % (95% CI)24.3 (24.1–24.5)26.3 (26.1–26.5)29.2 (29.0–29.3)Hospice use at time of death, % (95% CI)21.6 (21.4–21.7)32.3 (32.1–32.5)42.2 (42.0–42.4)Health care transitions in last 90 d of life per decedent, mean (median) (IQR)2.1 (1.0) (0–3.0)2.8 (2.0) (1.0–4.0)3.1 (2.0) (1.0–5.0)Health care transitions in last 3 days of life, % (95% CI)10.3 (10.1–10.4)12.4 (12.3–12.5)14.2 (14.0–14.3) In 2009, 28.4% (95% CI, 27.9%–28.5%) of hospice use at the time of death was for 3 days or less. Of these late hospice referrals, 40.3% (95% CI, 39.7%–40.8%) were preceded by hospitalization with an ICU stay. Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

Health reform promotes the delivery of patient-centered care. Occupational therapy's rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapy's perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapy's research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

OBJECTIVES To examine the relationship between nursing home (NH) organizational characteristics and falls in newly admitted NH residents. DESIGN Observational cross-sectional study from January 1, 2006, to December 31, 2006. SETTING NHs in the United States in 2006. PARTICIPANTS Individuals (n = 230,730) admitted to a NH in 2006 without a prior NH stay and with a follow-up Minimum Data Set (MDS) assessment completed 30 days or more after admission. MEASUREMENTS The relationship between experiencing a fall noted on the MDS assessment and NH characteristics (e.g., staffing, profit and chain status, religious affiliation, hospital-based facility status, number of beds, presence of a special care unit, funding) was examined, adjusting for NH resident characteristics. RESULTS Twenty-one percent of this cohort (n = 47,750) had experienced at least one fall in the NH at the time of the MDS assessment, which was completed for newly admitted NH residents who had at least a 30-day stay. NHs with higher certified nursing assistant (CNA) staffing had lower rates of falls (adjusted odds ratio = 0.97, 95% confidence interval = 0.95–0.99). CONCLUSION For newly admitted NH residents, NHs with higher CNA staffing had a lower fall rate. In an effort to maximize fall prevention efforts, further research is needed to understand the relationship between CNA staffing and falls in this NH population.

Objective The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010. Design We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities. Setting All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims. Measurements We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff. Results In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities. Conclusion There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.