Hospice care in nursing homes can reduce end-of-life hospital stays

July 23, 2001

A new study shows that elderly nursing home residents who receive hospice care through Medicare are less likely to be hospitalized in their last days of life than peers who do not receive such care or reside in facilities where it is not present.

The presence of hospice care can improve the quality of life for dying nursing home residents and their families by keeping patients in comfort in one place, with one staff, and without the aggressive and often costly acute-care interventions associated with end-of-life hospital stays, said lead author Susan Miller, of the Brown Medical School.

Moreover, when elderly nursing home residents stay in one place in the last days of life, the cost of care is lower for the federal government, as Medicare covers end-of-life hospitalizations, Miller said.

The goal of hospice is to manage symptoms, reduce unneeded and unwanted medical intervention, and attend to the psychosocial needs of patients and families. The study appears in the July issue of the American Journal of Medicine.

Miller and colleagues compared 9,202 nursing home residents in five states who enrolled in hospice between 1992 and 1996 and who died before 1998 to 27,500 residents who did not receive hospice care or were in facilities where it was not available.

The researchers found that 24 percent of hospice and 44 percent of non-hospice residents were hospitalized in the last 30 days of life. However, for residents enrolled in hospice for the entire last 30 days of life, rather than just a portion of that time, only one percent were hospitalized.

Also considered were the 226,469 nursing home residents who died in the United States during the same time period and who did not receive hospice care. Those in facilities with no hospice presence had a 47 percent hospitalization rate, while rates were 41 percent in facilities with low hospice use and 39 percent with moderate hospice use.

Wrote the authors, "Possibly through diffusion of palliative philosophy and practices, non-hospice residents who died in nursing homes having a hospice presence had lower rates of end-of-life hospitalizations."

Miller recommends that potential nursing home residents and their families ask about the presence or availability of hospice care when evaluating facilities for admittance. Given that hospice care is contracted through a nursing home, "patients and families also have the option of choosing which hospice they want to use for their care," she said.

Currently about 51 percent of nursing homes nationwide offer patients hospice care contracted through Medicare. Nursing homes are the site of death for one in four older Americans. Hospitalization of nursing home residents is common.

Previous studies associated home-based hospice with reduced hospitalizations. This study was designed to determine whether that benefit generalized to nursing homes, Miller said.

The data were collected as part of the Health Care Financing Administration's Multistate Nursing Home Case-Mix and Quality Demonstration Project. Nursing home staff in all Medicare and Medicaid facilities in Kansas, Maine, Mississippi, New York and South Dakota evaluated patients using an assessment which includes a 350-item minimum data set.

In addition, the researchers used Medicare data forms to identify hospice enrollment and acute care hospitalizations.
Primary funding for the study came from the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

Miller is an assistant professor in the Center for Gerontology and Health Care Research.

Co-authors are investigator Pedro Gozalo, Center for Gerontology and Health Care Research, and Vince Mor, professor and chairman, Department of Community Health.

Brown University

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