Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life

Abstract

Background In the last 6 months of life many older adults will experience a hospitalization followed by a transfer to a skilled nursing facility (SNF) for additional care. We sought to examine patterns of SNF use in the last 6 months of life. Methods We used the Health and Retirement Study, a longitudinal survey of older adults, linked to Medicare claims (1994-2007). We determined the number of individuals age 65 and older at death who used the SNF benefit in the last 6 months of life. We report demographic, social, and clinical correlates of SNF use. We examined the relationship between place of death and hospice use for those living in nursing homes and community prior to the last 6 months of life. Results The mean age at death of the 5,163 subjects was 83 (54% female; 23% nursing home residents). We found 30.5% used the SNF benefit in the last 6 months of life, and 9.2% died enrolled on the SNF benefit. Use of the SNF benefit was greater among patients who were: 85 and older, had a high school education, did not have cancer, were nursing home residents, used home health services, and were expected to die (all p<0.01). Of community dwellers who used the SNF benefit 42.5% died in a nursing home, 10.7% died at home, 38.8% died in the hospital, and 8% died elsewhere. In contrast, of community dwellers that did not use the SNF benefit 5.3% died in a nursing home, 40.6% died at home, 44.3% died in the hospital, and 9.8% died elsewhere. Conclusion Nearly one-third of older adults receive care in a SNF in the last 6 months of life under the Medicare SNF benefit, and 1 out of 11 elders will die on the SNF benefit. Palliative care services should be incorporated into SNF-level care.

Leveraging the Health and Retirement Study To Advance Palliative Care Research

“…Furthermore, by linking to Medicare, the HRS can be used to examine hospital and hospice use by nursing home residents, and use of the SNF benefit by community-dwelling elders. Aragon et al, 23 for example, used the HRS combined with Medicare claims to find that 30% of older adults used the SNF benefit in the last 6 months of life, and 9% died while in SNF.…”

Geriatric Palliative Care in Long-Term Care Settings with a Focus on Nursing Homes

“…39,40 Despite these preferences, several large studies have documented that many NH residents are hospitalized in the final weeks of life 13,41,42 and receive burdensome treatments with little benefit; these treatments include tube feeding [43][44][45] and post-acute, rehabilitative care. 11,46,47 Some EOL hospitalizations are both appropriate and reflect residents' preferences. However, transitions between health care settings are fraught with problems, often causing residents and families unnecessary distress.…”

From Disability Rights to the Rights of the Dying (and Back Again)

“…However, because of the way the MHB is structured, providing them with such care requires removing them from hospice. The result generates an inherent tension between hospice and nursing home providers that can lead to the unnecessary discharge of dying patients from hospice (Aragon et al 2012;Institute of Medicine 2014, p. 297). Finally, the high rate of turnover in nursing home staff itself presents a barrier to care in general and the delivery of hospice in particular (Stevenson and Bramson 2009).…”

“…Finally, the high rate of turnover in nursing home staff itself presents a barrier to care in general and the delivery of hospice in particular (Stevenson and Bramson 2009). As a result, there are significant-and perhaps systemic-difficulties in coordinating hospice and nursing home care (Aragon et al 2012).…”