Access to Nursing Home Hospice: Perspectives of Nursing Home and Hospice Administrators

Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings

BACKGROUND

The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life.

METHODS/DESIGN

This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention.

DISCUSSION

Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.

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

BACKGROUND/OBJECTIVE

Nursing homes (NHs) are an important setting for the provision of palliative and end-of-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.

Effect of Hospice Use on Costs of Care for Long-Stay Nursing Home Decedents

OBJECTIVES

To analyze the costs for long-stay (>90 days) nursing home (NH) decedents with and without hospice care.

DESIGN

Retrospective cohort study using a 1999-2009 data set of linked Medicare and Medicaid claims and minimum data set (MDS) assessments.

SETTING

Indiana NHs.

PARTICIPANTS

Long-stay NH decedents (N = 2,510).

MEASUREMENTS

Medicare costs were calculated for 2, 7, 14, 30, 90, and 180 days before death; Medicaid costs were calculated for dual-eligible beneficiaries. Total costs and costs for hospice, NH, and inpatient care are reported.

RESULTS

Of 2,510 long-stay NH decedents, 35% received hospice. Mean length of hospice was 103 days (median 34 days). Hospice users were more likely to have cancer (P < .001), a do-not-resuscitate order in place (P < .001), greater cognitive impairment (P < .001), and worse activity of daily living (ADL) function (P < .001) and less likely to have had a hospitalization in the year before death (P < .001). In propensity score analyses, hospice users had lower total Medicare costs for all time periods up to and including 90 days before death. For dually eligible beneficiaries, overall costs and Medicare costs were significantly lower for hospice users up to 30 days before death. Medicaid costs were not different between the groups except for the 2-day time period.

CONCLUSION

In this analysis of costs to Medicare and Medicaid for long-stay NH decedents, use of hospice did not increase costs in the last 6 months of life. Evidence supporting cost savings is sensitive to analyses that vary the time period before death.

The Intersection of Long-Term Care and End-of-Life Care

High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.

Barriers to hospice for children as perceived by hospice organizations in North Carolina

Despite improving organization of hospice for children with life-limiting illnesses, services may be underutilized. We asked representatives of all 76 existing North Carolina hospice organizations about barriers to serving children. Representatives of 61 agencies responded (80%). Hospices serving children differed from hospices not serving children on perception of barriers: 1) Lack of pediatric trained staff (8% vs 42%, p = 0.01); 2) lack of pediatrician consultation (23% vs 50%, p = 0.03); 3) lack of pediatric pharmacy (4% vs 32%, p = 0.006), and inconsistent plan of care between pediatrician and hospice (12% vs 47%, p = 0.01). Lack of pediatric referrals (78%) and families wanting to continue curative therapies while receiving hospice care (77%) were felt to be the most important barriers overall. Enhanced training of pediatric providers and a model of care which blends disease-specific treatment with hospice may improve access to hospice services for children.

Hospice care in the nursing home setting: a review of the literature

The U.S. Medicare hospice benefit has expanded considerably into the nursing home (NH) setting in recent years. This literature review focuses on the provision of NH hospice, exploring its growth and the impact of such care on NH residents, cost and efficiency implications for NHs and government, and policy challenges and important areas for future research. Although hospice utilization is relatively modest among NH residents, its increased availability holds great promise. As an alternative to traditional NH care, hospice has been shown to provide high-quality end-of-life care and offer benefits, such as reduced hospitalizations and improved pain management. The provision of NH hospice also has been shown to have positive effects on nonhospice residents, suggesting indirect benefits on NH clinical practices. Importantly, the expansion of hospice in NHs brings challenges, on both clinical and policy dimensions. Research has shown that NH-hospice collaborations require effective communication around residents' changing care needs and that a range of barriers can impede the integration of hospice and NH care. Moreover, the changing case mix of hospice patients, including increased hospice use by individuals with conditions such as dementia, presents challenges to Medicare's hospice payment and eligibility policies. To date, there has been little research comparing hospice costs, service intensity, and quality of care across settings, reflecting the fact that few comparative data have been available to researchers. The Centers for Medicare & Medicaid Services have taken steps toward collecting these data, and further research is needed to shed light on what refinements, if any, are necessary for the Medicare hospice program.

End-of-life care in U.S. nursing homes: nursing homes with special programs and trained staff for hospice or palliative/end-of-life care

BACKGROUND

The degree to which nursing homes have internal programs for hospice and palliative care is unknown. We used self-reported data from the 2004 National Nursing Home Survey (NNHS) to estimate the prevalence of special programs and (specially) trained staff (SPTS) for hospice or palliative/end-of-life care in U.S. nursing homes. Factors associated with the presence of SPTS for hospice or palliative/end-of-life care were identified.

METHODS

We merged 2004 NNHS data for 1174 nursing homes to county-level data from the 2004 Area Resource File and to Nursing Home 2004 Online Survey, Certification, and Reporting data. chi(2) tests and logistic regression models were applied.

RESULTS

Twenty-seven percent of U.S. nursing homes reported (internal) SPTS for hospice or palliative/end-of-life care. After controlling for covariates, we found nonprofit status, being in the southern region of the United States, having an administrator certified by the American College of Health Care Administrators, contracting with an outside hospice provider, and having other specialty programs to be associated with a greater likelihood of nursing homes having SPTS for hospice or palliative/end-of-life care. The largest effects were observed for nursing homes with programs for behavioral problems (adjusted odds ratio [AOR] 3.59; 95% confidence interval [CI] 2.40, 5.37) and for pain management (AOR 5.92; 95% CI 4.09, 8.57).

CONCLUSION

The presence of internal SPTS for hospice or palliative/end-of-life care is prevalent in U.S. nursing homes, and may be preceded by hospice contracting and/or the implementation of specialty programs that assist nursing homes in developing the expertise needed to establish their own palliative care programs.

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study

BACKGROUND

Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services.

AIM

To explore the influences on referrals within general and specialist community palliative care services.

DESIGN OF STUDY

Qualitative, multiple-case study.

SETTING

Three primary care trusts in the north-west of England.

METHOD

Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals.

RESULTS

Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes.

CONCLUSION

Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.

Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation

OBJECTIVES

The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death.

DESIGN

PROGRAM DESCRIPTION and evaluation using a retrospective chart review before and after implementation of the MAPP program.

PARTICIPANTS

NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72).

PROGRAM DESCRIPTION

The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation.

PROGRAM EVALUATION

Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death.

RESULTS

Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02).

CONCLUSION

An intervention designed to address the end-of-life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.

Death in the Nursing Home: Resident, Family, and Staff Perspectives

The actual experience of dying in the United States is far different from the expressed desires of most Americans. Although most Americans express a preference for dying at home, 73% of Americans die in medical institutions, with 23% dying in nursing homes (Teno, 2004). In this article, the author examines end-of-life care in the nursing home. A literature review identified more than 100 published articles relevant to end-of-life care in nursing homes. Of these, the author evaluated empirical research studies from the perspectives of residents, family members, and nursing home staff with findings specific to seriously ill nursing home residents. By identifying problematic issues and contributing factors, nurses can modify their practice to improve end-of-life care and substantially reduce suffering for nursing home residents and their families.

Palliative care services in Pennsylvania nursing homes

BACKGROUND

Palliative care is an interdisciplinary model that focuses on the comprehensive management of physical, psychological, social, and spiritual needs of individuals with lifelimiting illness. Although palliative care is increasingly common in acute care settings, regulatory, financial, and educational barriers often bar nursing home residents from access to palliative care services.

OBJECTIVE

The purpose of the Palliative Care Services in Pennsylvania Nursing Homes Survey was to describe existing palliative care services within nursing homes in Pennsylvania, and to classify these services by level of care delivery.

METHODS

Ninety-one nursing home administrators throughout the state of Pennsylvania participated in the mailed survey. Multiple logistic regression analysis was used to investigate the association between various organizational characteristics and provision of palliative care services.

RESULTS

Results reveal that urban facilities were more likely to provide palliative care services than rural facilities. Urban facilities cited the need for bereavement training most frequently, whereas rural clinical cited the need for training in pain management. Larger facility size was associated with an increased likelihood of pain management practices, even after adjusting for regional differences.

CONCLUSIONS

These pilot findings are consistent with and extend previous findings suggesting that palliative care practice in nursing homes is strongly influenced by nonclinical factors and invites further investigation.

Hospice Attitudes among Assisted Living and Nursing Home Administrators, and the Long-Term Care Hospice Attitudes Scale

OBJECTIVES

To examine the attitudes of residential care/assisted living (RC/AL) and nursing home (NH) administrators toward hospice and to assess facility and administrator characteristics related to those attitudes.

DESIGN

Two exploratory factor analyses of the Hospice Attitudes Questionnaire using principal factors with a promax (oblique) rotation were conducted. One was in a sample of 390 RC/AL and NH administrators from four states (Florida, Maryland, North Carolina, and New Jersey) and the other included NHs from this and a second sample (n = 244). Association between facility and administrator characteristics and administrator attitudes towards hospice were examined among the 146 RC/AL administrators.

RESULTS

Exploratory factor analysis in the full sample resulted in the 12-item Long-Term Care Hospice Attitudes Scale (LTC-HAS) with four component subscales: (1) emotional and spiritual support (three items, alpha = 0.83); (2) quality of care (four items, alpha = 0.78); (3) rapidity of death (three items, alpha = 0.66) and (4) end-of-life care coordination (two items, alpha = 0.73). The overall alpha for the 12-item scale was 0.81. When exploratory factor analysis was conducted on the NH data only, a three-item subscale related to financing and billing (alpha = 0.66) also emerged. Four facility and three administrator characteristics that were significantly related to hospice attitudes included state, facility type, facility age, affiliation with another level of care; and age, race, and nurse training.

CONCLUSION

Findings from this paper provide insight about RC/AL facility and NH administrators' attitudes towards Hospice using scale data, an area with limited research. They indicate positive attitudes toward Hospice care coordination, and that Hospice should supplement, as opposed to replace, the care provided by facilities. Findings also suggest areas where targeted outreach and further study may be recommended.