Study finds hospice use does not increase long stay nursing home decedents' care costs

May 05, 2016

INDIANAPOLIS -- Use of hospice services does not increase care costs in the last six months of life for long-stay nursing homes residents according to an analysis conducted by researchers from the Indiana University Center for Aging Research and the Regenstrief Institute.

Avoidance of costly hospitalization and subsequent post-acute care in the nursing home appears to offset hospice services costs, even when hospice services are provided over a prolonged period of time according to the study of 2,510 long stay nursing home decedents, a third of whom received hospice services. Age, race or gender had no effect on the findings.

"Impact of Hospice Use on Costs of Care for Long Stay Nursing Home Decedents" is published online ahead of print in the Journal of the American Geriatrics Association.

"The government, through Medicare and Medicaid, spends a lot of money on this vulnerable population, but is it getting appropriate value?," queries Indiana University Center for Aging Research and Regenstrief Institute investigator Kathleen Unroe, M.D., MHA, who led the study. "High quality end-of-life care for those living in nursing homes is the goal.

"An active debate about length of stay, reimbursement and other aspects of Medicare and Medicaid payment reform is underway. Our study provides data relevant to the evolving policy landscape surrounding hospice care." Dr. Unroe is an assistant professor of medicine at the IU School of Medicine.

Hospice is a service, not a place. Hospice care can and does take place in nursing homes with specially trained hospice workers coming to the facility to provide palliative care to terminal residents who have elected, or whose families have elected, hospice care which focuses on end-of-life comfort rather than cure.

"Hospice care is not always a perfect fit in nursing homes -- it can be difficult to determine when a person with advanced dementia, for example, has truly reached the end of life," said Dr. Unroe. "But despite concerns that Medicare's hospice benefit is not being used appropriately in nursing homes, we didn't find evidence of cost shifting between Medicare and Medicaid."

The study found few significant differences in clinical or demographic characteristics between long stay nursing home decedents who did and did not receive hospice services near the end of life. The exception was residents with a cancer diagnosis, who were more likely to receive hospice than those with other diagnoses, also true of hospice use by those not in nursing homes. Advanced dementia also was associated with increased hospice use.

The long stay nursing home residents whose records were reviewed for this study were disproportionately poor, non-white and characterized by high health care costs -- individuals often not included in healthcare utilization studies.
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In addition to Dr. Unroe, co-authors of the study are Greg Sachs, M.D., of the IU Center for Aging Research, Regenstrief Institute and IU School of Medicine; M.E. Dennis, B.A., of the IU Center for Aging Research and Regenstrief Institute; Susan Hickman, Ph.D., of the IU School of Nursing; Timothy Stump, M.A., of the Regenstrief Institute; Wanzhu Tu, Ph.D., and Christopher Callahan, M.D., of the IU Center for Aging Research, the Regenstrief Institute and IU School of Medicine. Dr. Sachs is division director of the IU School of Medicine's Division of General Medicine and Geriatrics. Dr. Callahan is founding director of the IU Center for Aging Research.

In 2014 the authors published a study in the Journal of General Internal Medicine comparing the characteristics of hospice patients in nursing homes with hospice patients living in the community.

Both studies were funded by National Palliative Care Research Center Grant 4183655 and National Institute on Aging Grants R01 AG031222 and K24 AG024078.

Indiana University

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