Children with intellectual disability and hospice utilization

A nurses' ethical commitment to people with intellectual and developmental disabilities

Aim: This article explores the issues of knowledge deficits of healthcare professionals in meeting the needs of people with IDD throughout the life span, and to identify factors that contribute to these deficits. Although statistics vary due to census results and the presence of a "hidden population," approximately 1%-3% of the global population identify as living with an intellectual or developmental disability. People with intellectual or developmental disability experience health inequities and confront multiple barriers in society, often related to the stigma of intellectual or developmental disability. Disparities in care and service are attributed to a lack of knowledge and understanding among healthcare providers about people with intellectual or developmental disability, despite their increased risk for chronic health problems. The near absence of educational programs in nursing both nationally and internationally contributes to this significant knowledge deficit. In addition, ethical considerations between paternalistic beneficence and idealized autonomy have resulted in a lack of clear direction in working with a population that is often ignored or exploited. Nurses who view people with intellectual or developmental disability as vulnerable without assessing or acknowledging their capabilities may err toward paternalism in an effort to "first do no harm." Likewise, nurses who fail to recognize the challenges and limitations faced by people with intellectual or developmental disability may not provide sufficient protections for a vulnerable person. People with intellectual or developmental disability are not binary, but rather complex individuals with a myriad of presentations. This article seeks to encourage a well-informed model of nursing care. Through an ethical lens, this article explores the nurse's ethical commitments in cases of victimization, access to care, decision making, and the provision of optimal end-of-life care for people with intellectual or developmental disability.

HPNA 2019-2022 Research Agenda: Development and Rationale

Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.

Children Enrolled in Hospice Care Under Commercial Insurance: A Comparison of Different Age Groups

Background:

Although most children at end of life have commercial insurance, little is known about their demographic and clinical characteristics, what care they are receiving, and how much it costs.

Objectives:

To describe commercially insured children who enrolled in hospice care during their last year of life and to examine differences across age-groups.

Methods:

A retrospective cohort study was conducted using 2005 to 2014 data from the MarketScan Commercial Claims and Encounters database from Truven Health Analytics. Variables were created for demographics, health, utilization, and spending. Analyses included χ2 and analysis of variance tests of differences.

Results:

Among the 17 062 children who utilized hospice, 49% had a preferred provider organization (PPO). Hospice length of stay averaged less than 5 days. Over 80% of children visited their primary care physician. Eight percent had hospital readmissions, and 38% had emergency department (ED) visits. Average expenditures were US$3686 per month or US$44 232 annually. The most common condition for children less than 1 year was cardiovascular (21.96%). Neuromuscular conditions were the most frequent (7.89%) in children aged 1 to 5 years, while malignancies (10.53% and 11.32%, respectively) were prevalent in ages 6 to 14 and 15 to 17. Children less than 1 year had the highest frequency of hospital readmissions (16.25%) with the lowest ED visits (28.67%) while incurring the highest expenses (US$11 211/month).

Conclusions:

The findings suggest that commercially insured children, who enroll in hospice, have flexible coverage with a PPO. Hospital readmissions and ED visits were relatively low for a population who was seriously ill. There were significant age-group differences.

Children With Intellectual Disability and Hospice Utilization: The Moderating Effect of Residential Care

BACKGROUND

Children with intellectual disability commonly lack access to pediatric hospice care services. Residential care may be a critical component in providing access to hospice care for children with intellectual disability.

OBJECTIVE/HYPOTHESIS

This research tested whether residential care intensifies the relationship between intellectual disability and hospice utilization (ie, hospice enrollment, hospice length of stay), while controlling for demographic characteristics.

METHODS

Multivariate regression analyses were conducted using 2008 to 2010 California Medicaid claims data.

RESULTS

The odds of children with intellectual disability in residential care enrolling in hospice care were 3 times higher than their counterparts in their last year of life, when controlling for demographics. Residential care promoted hospice enrollment among children with intellectual disability. The interaction between intellectual disability and residential care was not related to hospice length of stay. Residential care did not attenuate or intensify the relationship between intellectual disability and hospice length of stay.

CONCLUSIONS

The findings highlight the important role of residential care in facilitating hospice enrollment for children with intellectual disability. More research is needed to understand the capability of residential care staff to identify children with intellectual disability earlier in their end-of-life trajectory and initiate longer hospice length of stays.

Comparative Effectiveness of Usual Source of Care Approaches to Improve End-of-Life Outcomes for Children With Intellectual Disability

CONTEXT

Children with intellectual disability (ID) are at risk for adverse end-of-life outcomes including high emergency room utilization and hospital readmissions, along with low hospice enrollment.

OBJECTIVES

The objective of this study was to compare the effectiveness of usual source of care approaches to improve end-of-life outcomes for children with ID.

METHODS

We used longitudinal California Medicaid claims data. Children were included who were 21 years with fee-for-service Medicaid claims, died between January 1, 2007, and December 31, 2010, and had a moderate-to-profound ID diagnosis. End-of-life outcomes (i.e., hospice enrollment, emergency room utilization, hospital readmissions) were measured via claims data. Our treatments were usual source of care (USC) only vs. usual source of care plus targeted case management (USC plus TCM). Using instrumental variable analysis, we compared the effectiveness of treatments on end-of-life outcomes.

RESULTS

Ten percent of children with ID enrolled in hospice, 73% used the emergency room, and 20% had three or more hospital admissions in their last year of life. USC plus TCM relative to USC only had no effect on hospice enrollment; however, it significantly reduced the probability of emergency room utilization (B = -1.29, P < 0.05) and hospital readmissions (B = -1.71, P < 0.001).

CONCLUSIONS

Our findings demonstrated that USC plus TCM was more effective at improving end-of-life outcomes for children with ID. Further study of the extent of UCS and TCM involvement in reducing emergency room utilization and hospital readmissions at end of life is needed.