End-of-Life Care in Nursing Homes: From Care Processes to Quality

Abstract

Background/Objective: Nursing homes (NHs) are an important setting for the provision of palliative and endof-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. Design and Methods: We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. Results: Better communication with residents/family members was statistically significantly ( p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly ( p = 0.006) associated with lower use of hospice. Conclusions: Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.

End-of-Life Education and Discussions With Assisted Living Certified Nursing Assistants

“…Coordination of care and communication between health care workers can have a significant impact on EOL. Better communication between direct care providers (e.g., CNAs, nurses) has been found to be signifi cantly associated with an improved ability to deliver EOL care to residents and reduce hospitalizations prior to death (Temkin-Greener, Li, Li, Segelman, & Mukamel, 2016). In addition, a study of CNAs revealed that familiarity with residents promotes development of relationships, as well as CNAs' expertise in making care decisions on residents' behalf (Carpenter & Th ompson, 2008).…”

Areas of Control Desired by Patients and Families Referred to Hospice Care: Perspectives of Hospice Admissions Staff

“…For those who are referred to hospice care but are uncertain about it, concerns about loss of control may pose a substantial psychological barrier to accepting it, adding to other existing structural or cultural barriers to hospice care (Cagle et al, 2016; Selsky et al, 2012; Washington, Bickel-Swenson, & Stephens, 2008). Considering the continued research and practice efforts to alleviate the obstacles (Kirolos et al, 2014; Reese, 2011; Temkin-Greener, Li, Li, Segelman, & Mukamel, 2016; Townsend, March, & Kimball, 2017), concerns about losing control in certain areas in transitioning to hospice care should be given attention as a potential barrier to its use. If not appropriately addressed in a timely manner, preferably early in the referral process, such concerns may delay or discourage eligible patients’ enrolling in hospice care.…”

International comparison of spending and utilization at the end of life for hip fracture patients

“…One potential reason is that women are more likely to have a do‐not‐resuscitate order than men. 31 , 32 , 33 In addition, other work has found that end‐of‐life spending at least in the United States declines with age, indicating declining treatment intensity. 28 Thus, while there is some evidence in the area of cancer care, the evidence for frail elders with a hip fracture, while similarly important, is less established.…”