Racial disparities in in-hospital death and hospice use among nursing home residents at the end of life.

BACKGROUND: Significant racial disparities have been reported regarding nursing home residents' use of hospital and hospice care at the end of life (EOL). OBJECTIVE: To examine whether the observed racial disparities in EOL care are due to within-facility or across-facility variations. RESEARCH DESIGN AND SUBJECTS: Cross-sectional study of 49,048 long-term care residents (9.23% black and 90.77% white) in 555 New York State nursing homes who died during 2005-2007. The Minimum Data Set was linked with Medicare inpatient and hospice claims. MEASURES: In-hospital death determined by inpatient claims and hospice use determined by hospice claims. For each outcome, risk factors were added sequentially to examine their partial effects on the racial differences. Hierarchical models were fit to test whether racial disparities are due to within-facility or across-facility variations. RESULTS: 40.33% of blacks and 24.07% of whites died in hospitals; 11.55% of blacks and 17.39% of whites used hospice. These differences are partially due to disparate use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders. We find no racial disparities in in-hospital death [odds ratio (OR) of race=0.95; 95% confidence interval (CI), 0.87-1.04] or hospice use (OR of race=0.90, 95% CI, 0.79-1.02) within same facilities. Living in facilities with 10% more blacks increases the odds of in-hospital death by 22% (OR=1.22, 95% CI, 1.17-1.26) and decreases the odds of hospice use by 15% (OR=0.85, 95% CI, 0.78-0.94). CONCLUSIONS: Differential use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders lead to racial differences in in-hospital death and hospice use. The remaining disparities are primarily due to overall EOL care practices in predominately black facilities, not to differential hospitalization and hospice-referral patterns within facilities.

Nursing home environment and organizational performance: association with deficiency citations.

BACKGROUND: Work environment attributes--job design, teamwork, and work effectiveness--are thought to influence nursing home (NH) quality of care. However, few studies tested these relationships empirically. OBJECTIVE: We investigated the relationship between these work environment attributes and quality of care measured by facility-level regulatory deficiencies. METHODS: Data on work environment were derived from survey responses obtained (in 2006-2007) from 7418 direct care workers in 162 NHs in New York State. Data on facility deficiencies and characteristics came from the Online Survey, Certification and Reporting database. We fit multivariate linear and logistic regressions, with random effects and probability weights, to models with the following dependent variables: presence/absence of quality of life deficiencies, number of quality of care (QC) deficiencies, and presence/absence of high severity G-L deficiencies (causing actual harm/immediate jeopardy). Key independent variables included work effectiveness (a 5-point Likert scale score); percent staff in daily care teams and primary assignment. The work effectiveness measure has been demonstrated to be psychometrically reliable and valid. Other variables included staffing, size, facility case-mix, and ownership. RESULTS: In support of the proposed hypotheses, we found work effectiveness to be a statistically significant predictor of all 3 measures of deficiencies. Primary assignment of staff to residents was significantly associated with fewer QC and high severity deficiencies. Greater penetration of self-managed teams was associated with fewer QC deficiencies. DISCUSSION: Work environment attributes impact quality of care in NHs. These findings provide important insights for NH administrators and regulators in their efforts to improve quality of care for residents.

Have Hospice Costs Increased After Implementation of the Hospice Quality-Reporting Program?

CONTEXT: The Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014. OBJECTIVES: This study examined whether this requirement has increased hospice total costs, general costs, and visiting services costs. METHODS: We conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD, and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage index, care volume, case-mix, and hospice and market characteristics, stratified by hospice ownership type. RESULTS: Both for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 than 2012. Nonprofit hospices also reported higher general costs PPD in 2014 than 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for nonprofit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and nonprofit hospices showed lower costs PPD for all types associated with more patients and longer length of stay. CONCLUSION: Hospice costs increased after the Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits.

Nursing Facilities Can Reduce Avoidable Hospitalizations Without Increasing Mortality Risk For Residents.

Implementation of the Centers for Medicare and Medicaid Services' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents reflected recognition of the adverse impacts of excess hospitalizations on the cost of care and the well-being of long-stay residents. Prior studies of the initiative have found favorable effects on reducing hospitalizations and costs, but were these accompanied by unintended consequences for well-being? We tracked all-cause mortality rates in each year for the period 2014-16 among long-stay residents at nursing facilities in seven states that participated in the initiative, and we found no evidence of excess mortality. The initiative's effects on mortality rates were small-ranging from a reduction of 0.8 percentage points to an increase of 1.5 percentage points, relative to changes in mortality rates at comparison-group facilities-and none of the effects was significant. This suggests that efforts to reduce unnecessary hospitalizations among nursing facility residents can succeed without increasing mortality rates.

Nationwide Quality of Hospice Care: Findings From the Centers for Medicare & Medicaid Services Hospice Quality Reporting Program.

CONTEXT: With increasing use of the Medicare hospice benefit, policymakers recognize the need for quality measurement to assure that terminally ill patients receive high-quality care and have the information they need when selecting a hospice. Toward these goals, Centers for Medicare & Medicaid Services has been collecting standardized patient-level quality data via the Hospice Item Set (HIS) since July 1, 2014. OBJECTIVE: This article presents a first look at the national hospice HIS quality data. METHODS: We calculated seven quality measures using the HIS data. These measures are endorsed by the National Quality Forum and focus on important care processes hospice providers are required to perform at admission, including discussion of patient preferences regarding life-sustaining treatments, care for spiritual and existential concerns, and symptom management (pain, opioid-induced constipation, and dyspnea). RESULTS: Our sample included 1,218,786 hospice patients discharged from 3922 hospices from October 1, 2014 to September 30, 2015. More than 90% of patients received screenings and assessments captured by six of the seven quality measures. The only exception was pain assessment, for which the national mean score was 78.2%. A small number of hospices (156, 4.0%) had perfect scores for all seven quality measures. CONCLUSIONS: Most hospices conduct critical assessments and discuss treatment preferences with patients at admission, although few hospices have perfect scores.

Access to Care for Medicare-Medicaid Dually Eligible Beneficiaries: The Role of State Medicaid Payment Policies.

STUDY OBJECTIVES: Medicaid programs are not required to pay the full Medicare coinsurance and deductibles for Medicare-Medicaid dually eligible beneficiaries. We examined the association between the percentage of Medicare cost sharing paid by Medicaid and the likelihood that a dually eligible beneficiary used evaluation and management (E&M) services and safety net provider services. DATA SOURCES: Medicare and Medicaid Analytic eXtract enrollment and claims data for 2009. STUDY DESIGN: Multivariate analyses used fee-for-service dually eligible and Medicare-only beneficiaries in 20 states. A comparison group of Medicare-only beneficiaries controlled for state factors that might influence utilization. PRINCIPAL FINDINGS: Paying 100 percent of the Medicare cost sharing compared to 20 percent increased the likelihood (relative to Medicare-only) that a dually eligible beneficiary had any E&M visit by 6.4 percent. This difference in the percentage of cost sharing paid decreased the likelihood of using safety net providers, by 37.7 percent for federally qualified health centers and rural health centers, and by 19.8 percent for hospital outpatient departments. CONCLUSIONS: Reimbursing the full Medicare cost-sharing amount would improve access for dually eligible beneficiaries, although the magnitude of the effect will vary by state and type of service.

Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results.

Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

The effect of hospice on hospitalizations of nursing home residents.

OBJECTIVES: Hospice enrollment is known to reduce risk of hospitalizations for nursing home residents who use it. We examined whether residing in facilities with a higher hospice penetration: (1) reduces hospitalization risk for nonhospice residents; and (2) decreases hospice-enrolled residents' hospitalization risk relative to hospice-enrolled residents in facilities with a lower hospice penetration. METHODS: Medicare Beneficiary File, Inpatient and Hospice Claims, Minimum Data Set Version 2.0, Provider of Services File, and Area Resource File. Retrospective analysis of long-stay nursing home residents who died during 2005-2007. Overall, 505,851 nonhospice (67.66%) and 241,790 hospice-enrolled (32.34%) residents in 14,030 facilities nationwide were included. We fit models predicting the probability of hospitalization conditional on hospice penetration and resident and facility characteristics. We used instrumental variable method to address the potential endogeneity between hospice penetration and hospitalization. Distance between each nursing home and the closest hospice was the instrumental variable. RESULTS: In the last 30 days of life, 37.63% of nonhospice and 23.18% of hospice residents were hospitalized. Every 10% increase in hospice penetration leads to a reduction in hospitalization risk of 5.1% for nonhospice residents and 4.8% for hospice-enrolled residents. CONCLUSIONS: Higher facility-level hospice penetration reduces hospitalization risk for both nonhospice and hospice-enrolled residents. The findings shed light on nursing home end-of-life care delivery, collaboration among providers, and cost benefit analysis of hospice care.

Hospices' use of electronic medical records for quality assessment and performance improvement programs.

CONTEXT: Electronic medical records (EMRs) are increasingly viewed as essential tools for quality assurance and improvement in many care settings, but little is known about the use of EMRs by hospices in their quality assessment and performance improvement (QAPI) programs. OBJECTIVES: To examine the data sources hospices use to create quality indicators (QIs) used in their QAPI programs and to examine the domains of EMR-based QIs. METHODS: We used self-reported QIs (description, numerator, and denominator) from 911 hospices nationwide that participated in the Centers for Medicare & Medicaid Services nationwide hospice voluntary reporting period. The data reflected QIs that hospices used for their internal QAPI programs between October 1 and December 31, 2011. We used the primary data sources for QIs reported by hospices and analyzed EMR-based QIs in terms of the quality domains and themes addressed. RESULTS: EMRs were the most frequent data source for the QIs reported, followed by family survey and paper medical record. Physical symptom management was the largest quality domain--included in 51.5% of the reported EMR-based QIs--followed by patient safety and structure and process of care. CONCLUSION: Most participating hospices use EMRs for retrieving items needed for QI calculations. EMR-based QIs address various quality domains and themes. Our findings present opportunities for potential future reporting of EMR-based quality data.

Quality of end-of-life care of long-term nursing home residents with and without dementia.

OBJECTIVES: To describe the longitudinal patterns and the within- and between-facility differences in hospice use and in-hospital deaths between long-term nursing home (NH) residents with and without dementia. DESIGN: Retrospective analyses of secondary data sets from 2003 to 2007. SETTING: NHs in the United States. PARTICIPANTS: A total of 1,261,726 decedents in 16,347 NHs were included in 2003 to 2007 trend analysis and 236,619 decedents in 15,098 NHs in 2007 were included in the within- and between-facility analyses. MEASUREMENTS: Hospice use in the last 100 days of life and in-hospital deaths were outcome measures. Dementia was defined as having a diagnosis of Alzheimer's disease or other dementia based on Minimum Data Set (MDS) health assessments. RESULTS: Overall hospice use increased from 25.6% in 2003 to 35.7% in 2007. During this time, hospice use for decedents with dementia increased from 25.1% to 36.5%, compared with an increase from 26.5% to 34.4% for decedents without dementia. The rate of in-hospital deaths remained virtually unchanged. Within the same facility, decedents with dementia were significantly more likely to use hospice (odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.04-1.11) and less likely to die in a hospital (OR = 0.76, 95% CI = 0.74-0.78). Decedents in NHs with higher dementia prevalence, regardless of individual dementia status, were more likely to use hospice (OR = 1.67, 95% CI = 1.22-2.27). CONCLUSION: NHs appear to provide less-aggressive end-of-life care to decedents with dementia than to those without. Although significantly more residents with dementia now receive hospice care at the end of life, the quality evaluation and monitoring of hospice programs have not been systematically conducted, and additional research in this area is warranted.

Site of death among nursing home residents in the United States: changing patterns, 2003-2007.

CONTEXT: The proportion of US deaths occurring in nursing homes (NHs) has been increasing in the past 2 decades and is expected to reach 40% by 2020. Despite being recognized as an important setting in the provision of end-of-life (EOL) care, little is known about the quality of care provided to dying NH residents. There has been some, but largely anecdotal evidence suggesting that many US NHs transfer dying residents to hospitals, in part to avoid incurring the cost of providing intensive on-site care, and in part because they lack resources to appropriately serve the dying residents. We assessed longitudinal trends and geographic variations in place of death among NH residents, and examined the association between residents' characteristics, treatment preferences, and the probability of dying in hospitals. METHODS: We used the Minimum Data Set (NH assessment records), Medicare denominator (eligibility) file, and Medicare inpatient and hospice claims to identify decedent NH residents. In CY2003-2007, there were 2,992,261 Medicare-eligible NH decedents from 16,872 US Medicare- and/or Medicaid-certified NHs. Our outcome of interest was death in NH or in a hospital. The analytical strategy included descriptive analyses and multiple logistic regression models, with facility fixed effects, to examine risk-adjusted temporal trends in place of death. FINDINGS: Slightly more than 20% of decedent NH residents died in hospitals each year. Controlling for individual-level risk factors and for facility fixed effects, the likelihood of residents dying in hospitals has increased significantly each year between 2003 through 2007. CONCLUSIONS: This study fills a significant gap in the current literature on EOL care in US nursing homes by identifying frequent facility-to-hospital transfers and an increasing trend of in-hospital deaths. These findings suggest a need to rethink how best to provide care to EOL nursing home residents.

Hospice utilization in nursing homes: association with facility end-of-life care practices.

OBJECTIVES: Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay. DESIGN: The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey). SETTING AND PARTICIPANTS: In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study. MEASUREMENTS: We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims. RESULTS: The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death. CONCLUSION: Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.

Rural-urban differences in end-of-life nursing home care: facility and environmental factors.

PURPOSE OF THE STUDY: This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents. DATA AND METHODS: We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location. RESULTS: We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas. IMPLICATIONS: This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.

Nursing home work environment and the risk of pressure ulcers and incontinence.

OBJECTIVE: To examine the association between nursing home (NH) work environment attributes such as teams, consistent assignment and staff cohesion, and the risk of pressure ulcers and incontinence. DATA SOURCES/SETTING: Minimum dataset for 46,044 residents in 162 facilities in New York State, for June 2006-July 2007, and survey responses from 7,418 workers in the same facilities. STUDY DESIGN: For each individual and facility, primary and secondary data were linked. Random effects logistic models were used to develop/validate outcome measures. Generalized estimating equation models with robust standard errors and probability weights were employed to examine the association between outcomes and work environment attributes. Key independent variables were staff cohesion, percent staff in daily care teams, and percent staff with consistent assignment. Other facility factors were also included. PRINCIPAL FINDINGS: Residents in facilities with worse staff cohesion had significantly greater odds of pressure ulcers and incontinence, compared with residents in facilities with better cohesion scores. Residents in facilities with greater penetration of self-managed teams had lower risk of pressure ulcers, but not of incontinence. Prevalence of consistent assignment was not significantly associated with the outcome measures. CONCLUSIONS: NH environments and management practices influence residents' health outcomes. These findings provide important lessons for administrators and regulators interested in promoting NH quality improvement.

End-of-life quality-of-care measures for nursing homes: place of death and hospice.

OBJECTIVE: The Centers for Medicare and Medicaid Services (CMS) publishes a web-based quality report card for nursing homes. The quality measures (QMs) do not assess quality of end-of-life (EOL) care, which affects a large proportion of residents. This study developed prototype EOL QMs that can be calculated from data sources available for all nursing homes nationally. METHODS: The study included approximately 1.5 million decedents residing in 16,000 nursing homes during 2003-2007, nationally. Minimum Data Set (MDS) data were linked to Medicare enrollment files, hospital claims, and hospice claims. Random effect logistic models were estimated to develop risk-adjustment models predicting two outcome measures (place of death [POD] and hospice enrollment), which were then used to construct two EOL QMs. The distributional properties of the QMs were investigated. RESULTS: The QMs exhibited moderate stability over time. They were more stable in identifying quality outliers among the larger nursing homes and in identifying poor-quality outliers than high-quality outliers. CONCLUSIONS: This study offers two QMs specialized to EOL care in nursing homes that can be calculated from data that are readily available and could be incorporated in the Nursing Home Compare (NHC) report card. Further work to validate the QMs is required.

End-of-life care in nursing homes: the importance of CNA staff communication.

OBJECTIVE: Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes. DESIGN: Secondary data analysis of 2 NH surveys conducted in 2006-2007. SETTING: One hundred seven nursing homes in New York State. PARTICIPANTS: Participants were 2636 CNAs and 107 directors of nursing (DON). MEASUREMENTS: The measures of EOL care processes-EOL assessment and care delivery (5-point Likert scale scores)-were obtained from survey responses provided by 107 DONs. The measure of CNA communication was derived from survey responses obtained from 2636 CNAs. Other independent variables included staff education, hospice use intensity, staffing ratio, staff-resident ethnic overlap index, facility religious affiliation, and ownership. METHODS: The reliability and validity of the measures of EOL care processes and CNA communication were tested in the current study sample. Multivariate linear regression models with probability weights were used. The analysis was conducted at the facility level. RESULTS: We found better CNA communication to be significantly associated with better EOL assessment (P = .043) and care delivery (P = .098). Two potentially modifiable factors-staff education and hospice use intensity-were associated with NHs' performance in EOL care processes. Facilities with greater ethnic overlap between staff and residents demonstrated better EOL assessment (P = .051) and care delivery scores (P = .029). CONCLUSION: Better CNA communication was associated with better performance in EOL care processes. Our findings provide specific insights for NH leaders striving to improve EOL care processes and ultimately the quality of care for dying residents.

Measuring end-of-life care processes in nursing homes.

PURPOSE: The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them. DESIGN AND METHODS: A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated. RESULTS: Four EOL process domains were identified-assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures. IMPLICATIONS: This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.