Nursing Home-Hospice Collaboration and End-of-Life Hospitalizations Among Dying Nursing Home Residents

Trends in End-of-Life Hospitalizations of Nursing Home Residents between 2011 and 2020: Analyses of German Health Insurance Data

OBJECTIVES

To investigate trends in end-of-life hospitalizations among nursing home residents between 2011 and 2020.

DESIGN

A retrospective cohort study was conducted.

SETTING AND PARTICIPANTS

Using German claims data of the statutory health and long-term care insurance fund AOK Niedersachsen, all residents aged ≥65 years who were newly admitted to a nursing home between January 1, 2011, and December 31, 2020, and became deceased in the calendar year of admission were included.

METHODS

Proportions of deceased nursing home residents dying in hospital and being hospitalized in the last 7 and 30 days of life were analyzed and stratified by 2-year periods. Multiple logistic regressions were performed to examine changes over time, adjusting for covariates.

RESULTS

A total of 26,359 decedents were included (mean age, 84.0 years; 61.0% female). Proportions of nursing home residents dying in hospital decreased from 32.0% to 27.4% (odds ratio [OR], 0.88; 95% CI, 0.81-0.96), being hospitalized in the last 7 days decreased from 42.5% to 36.3% (OR, 0.84; 95% CI, 0.77-0.91), and being hospitalized in the last 30 days decreased from 61.6% to 56.7% (OR, 0.88; 95% CI, 0.82-0.96) between 2011-2012 and 2019-2020. Male sex, lower care dependency, and younger age (aged ≤94 years) were associated with an increased likelihood of end-of-life hospitalizations in all analyses. Of the 7923 terminal hospitalizations, mean length of hospital stay was 9.1 days and 33.4% lasted up to 3 days, with no changes over time.

CONCLUSION AND IMPLICATIONS

End-of-life hospitalizations of German nursing home residents have decreased over the years, but are still common. Because more policies have been introduced globally in recent years aimed at improving end-of-life care in nursing homes, longitudinal studies investigating trends with more recent data are needed.

A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project

This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.

Nursing Home Staff Perceptions of End-of-Life Care for Residents With Advanced Dementia: A Multisite Qualitative Study

Nursing homes (NHs) are an important site of death for residents with advanced dementia. Few studies have explored the experiences of NH staff about providing end-of-life care for residents with advanced dementia. This study aimed to describe NH staff perceptions on where end-of-life care should be delivered, the role of Medicare hospice care, and their experiences providing end-of-life care to residents with advanced dementia. Data from the Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life study were used to explore the study objectives. Semistructured interviews with 158 NH staff working in 13 NHs across the United States were analyzed. Most NH staff endorsed the NH as a better site of death for residents with advanced dementia compared with a hospital. They expressed mixed perceptions about hospice care. However, regardless of their role, the staff expressed experiencing difficult emotions while providing end-of-life care to residents with dementia because of the close attachments they had formed with them and bearing witness to their decline. The findings show that most NH staff have strong emotional attachments to their dying residents with dementia and prefer to care for them at the NH rather than transfer them to the hospital.

Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture

BACKGROUND AND OBJECTIVES

Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia.

RESEARCH DESIGN AND METHODS

Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death.

RESULTS

Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements.

DISCUSSION AND IMPLICATIONS

Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.

The Role of Regional and State Initiatives in Nursing Home Advance Care Planning Policies

OBJECTIVE

Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients' goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of "do not administer antibiotics" orders for NH residents at the EoL.

METHODS

We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on "do not administer antibiotics" orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation.

RESULTS

NHs in mature POLST states reported higher rates of "do not administer antibiotics" orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having "do not administer antibiotics" orders for seriously ill residents (β = 0.11, p = 0.006 and β = 0.12, p = 0.003, respectively).

DISCUSSION

NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have "do not administer antibiotics" orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.

Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study

AIMS

To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors.

DESIGN

A cross-sectional nationwide study.

METHODS

The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods.

RESULTS

In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001).

CONCLUSIONS

Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment.

IMPACT

What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.

End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics

OBJECTIVES

Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics.

DESIGN

Cross-sectional.

OUTCOMES

Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition.

SETTING AND PARTICIPANTS

Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge.

METHODS

National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions.

RESULTS

As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD.

CONCLUSIONS AND IMPLICATIONS

Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015

OBJECTIVES

We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays.

STUDY DESIGN

Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.

MAIN OUTCOME MEASURES

We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates.

RESULTS

A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses.

CONCLUSIONS

End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.

Hospitalizations of nursing home residents at the end of life: A systematic review

BACKGROUND

End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable.

AIM

We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents.

DESIGN

Systematic review (PROSPERO registration number CRD42017072276).

DATA SOURCES

A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions.

RESULTS

A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings.

CONCLUSION

There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.

Predictors of reliably high-value end-of-life care

PURPOSE OF REVIEW

Care near the end of life is expensive and frequently not aligned with the expressed preferences of decedents, creating an opportunity to improve value, or increase quality while lowering cost. This review examines publications from 2017 and 2018 on interventions and policies associated with high-value end-of-life care. Innovations in video and web-based advance care planning are promising to improve preference-congruent care at low cost.

RECENT FINDINGS

The patterns of care within hospice and in particular increased investment in patient care in hospice are shown to improve value. A meta-analysis demonstrated the role of inpatient palliative care consultations in decreasing hospitalization costs, as did several studies on inpatient palliative care units. Internationally, a range of home-based palliative care programs, implemented at the population level, demonstrated cost savings and reduced intensive care near the end of life. Finally, public policies that funded medical and long-term care and address broader inequalities were demonstrated to decrease low-value care near the end of life.

SUMMARY

This review demonstrates the efficacy of a range of approaches to improve value of care at the end of life, both within the health system and across public policy sectors.

Institutional Special Needs Plans and Hospice Enrollment in Nursing Homes: A National Analysis

BACKGROUND

Institutional Special Needs Plans (I-SNPs) in nursing homes could impact hospice use by residents with advanced illness. Little is known about their relationship.

OBJECTIVE

To determine whether I-SNP availability has been associated with changes in hospice utilization.

DESIGN

Federal data from 2011 and 2013 were extracted from the Minimum Data Set (MDS) and other sources. Multilevel models evaluated I-SNP-, resident-, and facility-related variables as predictors of hospice utilization.

SETTING

All US nursing homes in 2011 (N = 15 750) and 2013 (N = 15 732).

PARTICIPANTS

Nursing home residents enrolled in Medicare or in both Medicare and Medicaid.

MEASUREMENTS

Nursing home and resident data were obtained from Centers for Medicare and Medicaid Services sources: the MDS 3.0, Master Summary Beneficiary File, and Special Needs Plan Comprehensive Report.

RESULTS

The mean number of residents per nursing home was 210.9 (SD = 167.1) in 2011 and 217.2 (SD = 171.5) in 2013. The prevalence of I-SNP contracts in nursing homes increased between 2011 and 2013, from 55.2% (N = 8691) to 61.1% (N = 9605), respectively (P < .001). In multivariate analyses, greater hospice enrollment in nursing homes was associated with having at least one I-SNP enrollee per month; year (2013 higher than 2011); smaller facility size; urban (vs rural) setting; location in the Northeast (vs Midwest); lower average resident mental status; higher average resident mobility; younger residents, on average; and facilities with higher proportions of residents with specific diagnoses (cancer, cirrhosis, and dementia). After adjusting for resident and nursing home characteristics, the association between monthly I-SNP presence and hospice enrollment was found only in nursing homes with 50 or greater beds and there was a positive relationship with increasing size.

CONCLUSIONS

Growth of I-SNPs has been associated with changes in hospice utilization, and the relationship varies by facility size. Studies are needed to clarify the nature of this association and determine whether care may be improved through coordination of these programs. J Am Geriatr Soc 67:2537-2544, 2019.