Raising The Standard: Palliative Care In Nursing Homes

Meier, Diane E.; Lim, Betty; Carlson, Melissa

doi:10.1377/hlthaff.2009.0912

Cited by 69 publications

(72 citation statements)

References 18 publications

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“…31,32 Our findings provide substantial support for these recommendations. The variations in hospice use between SNF and non-SNF residents raise a compelling concern regarding the quality of EoL care received by NH residents with advanced dementia; and, the low level of nonhospice palliative care and expertise in many U.S. NHs 31,32 heightens this concern. The substantially reduced risk of dying in a hospital for residents who access hospice subsequent to an EoL SNF admission provides support for the notion that dual access to SNF and hospice may reduce the rate of EoL hospitalizations.…”

Section: Discussionsupporting

confidence: 67%

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Miller

Lima

Looze

et al. 2012

Journal of Palliative Medicine

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Background: Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. Methods: This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n = 99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital. Results: Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short ( £ 7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025). Conclusions: Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.

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Section: Discussionsupporting

confidence: 67%

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Miller

Lima

Looze

et al. 2012

Journal of Palliative Medicine

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“…Advance care planning (see below) is increasingly recognized as an important issue with reports on how to introduce this appearing in several countries such as Belgium [151], the US [152], and the UK [153,154]. Australia is the first country with national guidelines on palliative treatment for residents in long-term care including those with dementia [155], although only seven of 181 pages could be dedicated to advanced dementia.…”

Section: Availability Of Guidelines For End Of Life Care In Patients mentioning

confidence: 99%

“…Others [152] defined it as: "Advance care planning allows individuals to make decisions about their care if they happen to become unable to speak for themselves. Advance care planning decisions are typically based on personal values, preferences and discus-sions with loved ones."…”

Section: Advance Care Planningmentioning

confidence: 99%

Dying with Dementia: What We Know after More than a Decade of Research

Steen

2010

JAD

225

177

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Abstract. Death with dementia is increasingly common. Although prognostication is difficult, it is an incurable life-limiting illness for which palliative care for the patient is often appropriate. Dementia patients are otherwise at risk of overtreatment with burdensome and possibly non-beneficial interventions and undertreatment of symptoms. Although recent studies indicate encouraging trends of improved palliative care, little evidence supports effectiveness of specific treatments. As of January 2010, at least 45 studies, almost all performed after 2000, have reported on treatment, comfort, symptom burden, and families' satisfaction with care. Over half (25; 56%) of these studies were in US settings, and most were small or retrospective. Few randomized trials and prospective observational studies have been performed so far, but several promising studies have been completed recently or are underway in various countries. Guidelines for care and treatment, still mostly consensus-based, support the benefits of advance care planning, continuity of care, and family and practitioner education. Assessment tools for pain, prognosis, and family evaluations of care have been developed and some have been shown to be effective in clinical practice. With increasing numbers of well-designed, large-scale studies, research in the next decade may result in better evidence-based guidelines and practice.

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“…27 As the debate over hospice use in nursing homes continues, many also advocate for an increase in palliative care services outside of the hospice benefit to meet the needs of patients with serious, chronic diseases such as dementia, but an uncertain illness trajectory. 23,28,29 The findings of this study provide data that will hopefully inform this debate.…”

Section: Discussionmentioning

confidence: 78%

Hospice Use Among Nursing Home and Non-Nursing Home Patients

et al. 2014

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BACKGROUND:For nursing home patients, hospice use and associated costs have grown dramatically. A better understanding of hospice in all care settings, especially how patients move across settings, is needed to inform debates about appropriateness of use and potential policy reform. OBJECTIVE: Our aim was to describe characteristics and utilization of hospice among nursing home and nonnursing home patients. DESIGN AND PARTICIPANTS: Medicare, Medicaid and Minimum Data Set data, 1999-2008, were merged for 3,771 hospice patients aged 65 years and above from a safety net health system. Patients were classified into four groups who received hospice: 1) only in nursing homes; 2) outside of nursing homes; 3) crossover patients utilizing hospice in both settings; and 4) "near-transition" patients who received hospice within 30 days of a nursing home stay. MAIN MEASURES: Differences in demographics, hospice diagnoses and length of stay, utilization and costs are presented with descriptive statistics. KEY RESULTS: Nursing home hospice patients were older, and more likely to be women and to have dementia (p<0.0001). Nearly one-third (32.3 %) of crossover patients had hospice stays > 6 months, compared with the other groups (16 % of nursing home hospice only, 10.7 % of nonnursing home hospice and 7.6 % of those with near transitions) (p<0.0001). Overall, 27.7 % of patients had a hospice stay <1 week, but there were marked differences between groups-48 % of near-transition patients vs. 7.4 % of crossover patients had these short hospice stays (p<0.0001). Crossover and near-transition hospice patients had higher costs to Medicare compared to other groups (p<0.05). CONCLUSIONS: Dichotomizing hospice users only into nursing home vs. non-nursing home patients is difficult, due to transitions across settings. Hospice patients with transitions accrue higher costs. The impact of changes to the hospice benefit on patients who live or move through nursing homes near the end of life should be carefully considered.

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Raising The Standard: Palliative Care In Nursing Homes

Cited by 69 publications

References 18 publications

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Dying with Dementia: What We Know after More than a Decade of Research

Hospice Use Among Nursing Home and Non-Nursing Home Patients

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