Strong Presence of Hospice in Nursing Homes Reduces Risk of End-of-Life Hospitalization for All Residents

Residents in nursing homes with higher rates of hospice penetration have a reduced risk of being hospitalized in the last 30 days of life, whether or not they themselves are enrolled in hospice, according to a report published in the Journal of the American Medical Directors Association.

“More exposure to the provision of palliative care may improve nursing home staff competencies in providing such care to all residents,” write the authors. “In addition to the end-of-life-appropriate care provided by hospice staff, hospice-enrolled residents may also benefit from nursing home staff’s improved end-of-life care competencies.”

Investigators analyzed data on 747,641 nursing home residents (non-hospice, 67.7%; hospice-enrolled, 32.3%) in 14,030 facilities nationwide who died in 2005 to 2007. Mean age in both groups was 87 years. Databases used included the Medicare Beneficiary file linked to the Minimum Data Set for resident-level characteristics, the Provider of Services file for facility characteristics and locations and the Area Resource file for county-level characteristics.

Higher facility hospice penetration (the proportion of residents in a nursing home receiving hospice care in the last month of life) was examined regarding its effect on:

• Rates of end-of-life hospitalization of non-hospice residents in high-penetration facilities compared with non-hospice residents in facilities with low or no hospice presence (the “spill-over effect”)
• Rates of hospitalization of hospice patients in high-penetration facilities compared with hospice patients in low-penetration facilities (the “expertise effect”)

Key Findings

• Overall in the last 30 days of life, 37.6% of non-hospice and 23.2% of hospice enrolled residents were hospitalized.
• Mean hospice penetration in facilities nationwide was 28.3%.
• For every 10% increase in hospice penetration of a facility, there was a 5.1% reduction in the risk of hospitalization for non-hospice residents.

Each 10% increase in hospice penetration yielded a 4.8% risk reduction for hospice-enrolled residents. “[I]n addition to hospice’s effect on reducing enrollees’ risk of hospitalization, higher facility-level hospice penetration has a spillover effect on non-hospice residents and an expertise effect on hospice residents,” write the authors. “The spill-over and expertise effects of hospice found in the present study suggest that nursing home staff’s exposure to palliative care provided by hospice staff may influence the way in which nursing home staff care for end-of-life residents.”

The authors note that the quality of end-of-life care in nursing homes is a growing concern, as these facilities have increasingly become the last site of care for older Americans. Although hospice has been shown to reduce the risk of hospitalization for hospice-enrolled patients, nursing home residents are frequently transferred to hospitals near life’s end.

Transfers to hospitals near the end of life:

• Disrupt care plans
• May result in adverse clinical outcomes
• Frequently run counter to patients’ end-of-life care wishes
• Are often potentially avoidable

“More collaboration between nursing home and hospice staff may bring about more effective and efficient communication between the two parties, which may result in more successful attempts in preventing potentially avoidable end-of-life hospitalizations for both hospice and non-hospice residents,” comment the authors.

“In addition, more collaboration with hospice may allow nursing home staff to recognize residents’ terminal status and the need to provide palliative care in a more timely fashion, which may result in earlier hospice enrollment and therefore lower risk of hospitalization in the last thirty days of life.”

Facility characteristics associated with a higher risk of hospitalization for nonhospice residents only, and not for those receiving hospice care, included closer proximity of a nursing facility to a hospital and location of the nursing home in a county with more hospital beds.

The authors recommend further investigation of resident preferences for hospice care, and future research focusing on the relationship between hospice penetration and the timing of hospice enrollment, as well as on the relationship between the timing of hospice enrollment and the risk of end-of-life hospitalization.

Source: “The Effect of Hospice on Hospitalizations of Nursing Home Residents,” Journal of the American Medical Directors Association; October 7, 2014; Zheng NT, Mukamel DB, Friedman B, Caprio TV, Temkin-Greener H; Aging, Disability and Long-Term Care, Division of Health Services and Social Policy Research, RTI International, Waltham, MA; Department of Medicine, Health Policy Research Institute, University of California, Irvine; Department of Public Health Sciences; Division of Geriatrics and Aging, Department of Medicine; and Center for Ethics, Humanities and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY.