Study: Nursing homes increasingly pushing patients into rehab at end-of-life

October 03, 2018

A new study reveals a growing trend of potentially unnecessary - and harmful - high intensity rehabilitation services for residents of nursing homes. The study finds that this trend, which may be driven by a desire to maximize reimbursement rates, is on the rise for patients in the last 30 days of life, indicating that these services may be interfering with appropriate end-of-life care.

"This study raises several concerns and questions regarding the scope and intensity of therapy provided to nursing home residents prior to death," said Helena Temkin-Greener, Ph.D., M.S., with the University of Rochester Medical Center (URMC) Department of Public Health Sciences and lead author of the study, which appears in the Journal of the American Medical Directors Association. "If it is being driven by a failure to recognize that a resident is approaching end-of-life, then it calls for improving the skills of nursing home teams. If it is being driven by financial considerations then regulatory and policy interventions may be necessary."

Nursing home Medicare reimbursement rates are based on categories that place patients into resource utilization groups (RUGs) based on the complexity, intensity, and amount of staff time dedicated to their care. Patients who receive high levels of rehabilitation services fall into a category that makes these facilities eligible to collect the highest level of reimbursement for their care.

This phenomenon has been on the radar of federal regulators for some time. Recent reports from the Department of Health and Human Services Office of Inspector General (OIG) and the Center for Medicare and Medicaid Services (CMS) have suggested that the volume and intensity of rehabilitation services provided to residents in skilled nursing facilities may be more extensive than warranted and found that billing for these services was on the rise. The OIG has also indicated that this data suggests that some nursing homes may be exploiting the payment system for rehabilitation services in order to "optimize their revenues."

The authors of the current study analyzed data from 647 nursing home facilities in New York State to better understand the patterns and growth of rehabilitation services. Specifically, they focused on residents who had received very high to ultrahigh rehabilitation services - physical, occupational, and speech therapy - during the last 30 days of life. Very high intensity rehabilitation is defined as 520 minutes or greater per week and ultrahigh as 720 minutes or greater, or the equivalent of two hours of rehab per day.

They found that residents receiving ultrahigh rehabilitation had increased by 65 percent between 2012 and 2015 and that most of the rehabilitation therapy residents received was concentrated in the last seven days of life. They also found that there was a significantly higher use of these services in for-profit nursing home compared to not for profit homes.

While the study only included data from New York State, the authors contend that this phenomenon is likely more pronounced in other states, which have lower nursing home regulatory oversight. A 2013 CMS study showed that nursing homes in at least 17 other states billed for ultrahigh intensity rehabilitation services at higher rates than New York State.

The authors acknowledge that some level of rehabilitation may be necessary and appropriate for patients approaching the end-of-life, such as speech therapy, which can assist with difficulties in swallowing. However, they contend that many of the goals of these therapies can be attained at low or intermediate levels of intensity and that ultrahigh levels for patients nearing end-of-life are generally unnecessary and, in many instances, could be harmful and interfere with appropriate care.

"These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits," said Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study. "It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering. More worryingly, the focus on maximizing rehabilitation may represent an unnecessary barrier to the timely introduction of hospice and palliative care."
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Additional co-authors of the study include Tiffany Lee and Shubing Cai with URMC. The study was supported, in part, with a grant from the Patient Centered Outcomes Research Institute.

University of Rochester Medical Center

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