Trends in Contracting and Common Ownership Between Hospice Agencies and Nursing Homes.

BACKGROUND: In recent years, policymakers have paid particular attention to the emergence of a robust for-profit hospice sector and increased hospice use by nursing home residents. Previous research has explored financial incentives for nursing home-hospice use, but there has been limited research on nursing home-hospice partnerships and none on the extent of nursing home-hospice common ownership. OBJECTIVE: To describe trends in nursing home-hospice contracting and common ownership and to identify potential tradeoffs in care provided by nursing homes and hospice agencies that share common ownership. RESEARCH DESIGN: Retrospective cohort study of nursing home-hospice patients between 2005 and 2015. RESULTS: Between 2005 and 2015, the number of hospice agencies and nursing homes with common ownership grew substantially, now representing almost 1-in-5 providers in each sector. Relative to individuals using hospice in nursing homes without common ownership, adjusted analyses found that individuals receiving hospice from a commonly owned agency had a greater likelihood of having stays of 90 days or more [odds ratio (OR)=1.06; 95% confidence interval (CI), 1.02-1.10], having a stay resulting in a live discharge (OR=1.06; 95% CI, 1.02-1.11), and having at least 1 registered nurse/licensed practical nurse visit during the last 3 days of life (OR=1.17; 95% CI, 1.05-1.29); these individuals also had a lower mean visit hours per day (-0.07; P=0.003). CONCLUSIONS: Common ownership between hospice agencies and nursing homes is an emerging trend that reflects a broader push toward consolidation in the health care sector. Our analyses highlight potential concerns relevant to Medicare payment policy and are a first step toward improving our understanding of these trends and their implications.

The Impact of Chain Standardization on Nursing Home Staffing.

BACKGROUND: Standardization in production is common in multientity chain organizations. Although chains are prominent in the nursing home sector, standardization in care has not been studied. One way nursing home chains may standardize is by controlling the level and mix of staffing in member homes. OBJECTIVES: To examine the extent to which standardization occurred in staffing, its relative presence across different types of chains, and whether facilities became more standardized following acquisition by a chain. RESEARCH DESIGN: We estimated predictors of the difference between facility and chain staffing using Generalized Estimating Equations with 2000-2010 data. SUBJECTS: This study included nursing homes nationally, excluding hospital-based homes and homes in Alaska, Hawaii, and the District of Columbia. MEASURES: Chain ownership was coded from text identifying chain names. Two nurse staffing measures were used: staff hours per resident day and staff mix. RESULTS: Very large for-profit chain nursing homes and large nonprofits had less variation in staff hours per resident day (P<0.001) but greater variation in staffing mix (P<0.001) compared with the chain average nationally. Large for-profit chains and medium nonprofit chains had greater dispersion on staff hours per resident day (P<0.001), while large nonprofit chains had greater dispersion in staffing mix (P<0.001). The difference between facility and chain staffing decreased over time. CONCLUSIONS: The largest chains (for-profit and nonprofit) had less staffing variation compared with national standards, suggesting they were best at implementing corporate practices. Following ownership changes, staffing converged towards chain averages over time, suggesting standardization takes time to implement.

Nursing Home Chain Affiliation and Its Impact on Specialty Service Designation for Alzheimer Disease.

Specialty care units (SCUs) in nursing homes (NHs) grew in popularity during the 1990s to attract residents while national policies and treatment paradigms changed. Alzheimer disease has consistently been the dominant form of SCU. This study explored the extent to which chain affiliation, which is common among NHs, affected SCU bed designation. Using data from the Online Survey Certification and Reporting (OSCAR) from 1996 through 2010 with 207 431 NH-year observations, we described trends and compared chain-affiliated NHs with independent NHs. Designation of beds for Alzheimer disease SCUs grew from 1996 to 2003 and then declined. At the peak, 19.6% of all NHs had at least one Alzheimer disease SCU bed. In general, chain affiliation promoted Alzheimer disease SCU bed designation across time, chain size, and NH profit status. During the period of largest growth from 1996 to 2003, the likelihood of designation of Alzheimer disease SCU beds was 1.55 percentage points higher among for-profit NHs affiliated with large chains than independent for-profit NHs ( P < .001) and remained 1.28 percentage points higher from 2004 to 2010. However, chain-affiliated NHs generally had a lower percentage of residents with dementia than independent NHs. For example, although for-profit NHs affiliated with large chains had more Alzheimer disease SCU beds, they had nearly 3% fewer residents with dementia than independent NHs ( P < .001). We conclude that organizational decisions to designate beds for Alzheimer disease SCUs may be related to marketing strategies to attract residents since adoption of Alzheimer disease SCUs has fluctuated over time, but did not appear driven by demand.

Trends in Postacute Care Spending Growth During the Medicare Spending Slowdown.

Issue: Over the past decade, traditional Medicare's per-beneficiary spending grew at historically low levels. To understand this phenomenon, it is important to examine trends in postacute care, which experienced exceptionally high spending growth in prior decades. Goal: Describe per-beneficiary spending trends between 2007 and 2015 for postacute care services among traditional Medicare beneficiaries age 65 and older. Methods: Trend analysis of individual-level Medicare administrative data to generate per-beneficiary spending and utilization estimates for postacute care, including skilled nursing facilities, home health, and inpatient rehabilitation facilities. Key Findings and Conclusions: Per-beneficiary postacute care spending increased from $1,248 to $1,424 from 2007 to 2015. This modest increase reflects dramatic changes in annual spending and utilization growth rates, including a reversal from positive to negative spending growth rates for the skilled nursing facility and home health sectors. For example, the average annual spending growth rate for skilled nursing facility services declined from 7.4 percent over the 2008­11 period to ­2.8 percent over the 2012­15 period. Among beneficiaries with inpatient use, growth rates for postacute care spending and utilization slowed, but more moderately than observed among all beneficiaries. Reductions in hospital use, as well as reduced payment rates, contributed to declines in postacute spending.

Relationship between quality of care and negligence litigation in nursing homes.

BACKGROUND: It is unclear whether high-quality health care institutions are less likely to be sued for negligence than their low-performing counterparts. METHODS: We linked information on tort claims brought against 1465 nursing homes between 1998 and 2006 to 10 indicators of nursing home quality drawn from two U.S. national data sets: the Online Survey, Certification, and Reporting system and the Minimum Data Set Quality Measure/Indicator Report. We tested for associations between the incidence of claims and the quality measures at the facility calendar-quarter level, correcting for facility clustering and adjusting for case mix, ownership, occupancy, year, and state. Odds ratios were calculated for the effect of a change of 1 SD in each quality measure on the odds of one or more claims in each facility calendar-quarter. RESULTS: Nursing homes with more deficiencies (odds ratio, 1.09; 95% confidence interval [CI], 1.05 to 1.13) and those with more serious deficiencies (odds ratio, 1.04; 95% CI, 1.00 to 1.08) had higher odds of being sued; this was also true for nursing homes that had more residents with weight loss (odds ratio, 1.05; 95% CI, 1.01 to 1.10) and with pressure ulcers (odds ratio, 1.09; 95% CI, 1.05 to 1.14). The odds of being sued were lower in nursing homes with more nurse's aide-hours per resident-day (odds ratio, 0.95; 95% CI, 0.91 to 0.99). However, all these effects were relatively small. For example, nursing homes with the best deficiency records (10th percentile) had a 40% annual risk of being sued, as compared with a 47% risk among nursing homes with the worst deficiency records (90th percentile). CONCLUSIONS: The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

High-risk medication use by nursing home residents before and after hospitalization.

BACKGROUND: Two prominent challenges in nursing home care are ensuring appropriate medication use and achieving high-quality care as residents transition from the hospital to the nursing home. Research about prescribing practices at this important clinical juncture is limited. OBJECTIVE: To analyze the use of high-risk medications by nursing home residents before and after being hospitalized. We define high-risk medications using the Beers criteria for potentially inappropriate medication use. RESEARCH DESIGN, SUBJECTS, MEASURES: Using a dataset with Medicare claims for inpatient and skilled nursing facility stays and pharmacy claims for all medications dispensed in the nursing home setting, we examine high-risk medication use for hospitalized nursing home residents before and after being hospitalized. Our study population includes 52,559 dual-eligible nursing home residents aged 65 and older who are hospitalized and then readmitted to the same nursing home in 2008. Our primary outcome of interest is the use of high-risk medications in the 30 days before hospitalization and the 30 days following readmission to the same nursing home. RESULTS: Around 1 in 5 (21%) hospitalized nursing home residents used at least 1 high-risk medication the day before hospitalization. Among individuals with high-risk medication use at hospitalization, the proportion using these medications dropped to 45% after nursing home readmission but increased thereafter, to 59% by the end of the 30-day period. CONCLUSION: We found moderate levels of high-risk medication use by hospitalized nursing home residents before and after their hospital stays, constituting an important clinical and policy challenge.

New CMS Nursing Home Ownership Data: Major Gaps And Discrepancies.

Nursing home ownership has become increasingly complicated, partly because of the growth of facilities owned by institutional investors such as private equity (PE) firms and real estate investment trusts (REITs). Although the ownership transparency and accountability of nursing homes have historically been poor, the Biden administration's nursing home reform plans released in 2022 included a series of data releases on ownership. However, our evaluation of the newly released data identified several gaps: One-third of PE and fewer than one-fifth of REIT investments identified in the proprietary Irving Levin Associates and S&P Capital IQ investment data were present in Centers for Medicare and Medicaid Services (CMS) publicly available ownership data. Similarly, we obtained different results when searching for the ten top common owners of nursing homes using CMS data and facility survey reports of chain ownership. Finally, ownership percentages were missing in the CMS data for 82.40 percent of owners in the top ten chains and 55.21 percent of owners across all US facilities. Although the new data represent an important step forward, we highlight additional steps to ensure that the data are timely, accurate, and responsive. Transparent ownership data are fundamental to understanding the adequacy of public payments to provide patient care, enable policy makers to make timely decisions, and evaluate nursing home quality.

Does litigation increase or decrease health care quality?: a national study of negligence claims against nursing homes.

BACKGROUND: The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic. OBJECTIVE: To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes. RESEARCH DESIGN, SUBJECTS, MEASURES: We linked information on 6471 negligence claims brought against 1514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from 2 US national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homes' litigation experience in the preceding 12-18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥ 1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects. RESULTS: Nearly all combinations of the 3 litigation exposure measures and 9 quality measures--27 models in all--showed an inverse relationship between litigation costs and quality. However, only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates. CONCLUSIONS: Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly.

Service use at the end-of-life in Medicare advantage versus traditional Medicare.

BACKGROUND: Relative to traditional fee-for-service Medicare, managed care plans caring for Medicare beneficiaries may be better positioned to promote recommended services and discourage burdensome procedures with little clinical value at the end of life. OBJECTIVE: To compare end-of-life service use for enrollees in Medicare Advantage health maintenance organizations (MA-HMO) relative to similar individuals enrolled in traditional Medicare (TM). RESEARCH DESIGN, SUBJECTS, MEASURES: For a national cohort of Medicare decedents continuously enrolled in MA-HMOs or TM in their year of death, 2003-2009, we obtained hospice enrollment information and individual-level Healthcare Effectiveness Data and Information Set utilization measures for MA-HMO decedents for up to 1 year before death. We developed comparable claims-based measures for TM decedents matched on age, sex, race, and location. RESULTS: Hospice use in the year preceding death was higher among MA than TM decedents in 2003 (38% vs. 29%), but the gap narrowed over the study period (46% vs. 40% in 2009). Relative to TM, MA decedents had significantly lower rates of inpatient admissions (5%-14% lower), inpatient days (18%-29% lower), and emergency department visits (42%-54% lower). MA decedents initially had lower rates of ambulatory surgery and procedures that converged with TM rates by 2009 and had modestly lower rates of physician visits initially that surpassed TM rates by 2007. CONCLUSIONS: Relative to comparable TM decedents in the same local areas, MA-HMO decedents more frequently enrolled in hospice and used fewer inpatient and emergency department services, demonstrating that MA plans provide less end-of-life care in hospital settings.

Medicare Part D plan generosity and medication use among dual-eligible nursing home residents.

BACKGROUND: In 2006, dual-eligible nursing home residents were randomly assigned to a Medicare Part D prescription drug plan (PDP). Subsequently, residents not enrolled in qualified plans at the start of the next year were rerandomized. PDPs vary in generosity through differences in medication coverage and utilization management. Therefore, residents' assigned plans may be relatively more or less generous for their particular drugs. The impact of generosity on residents' medication use and health outcomes is unknown. METHODS: Using data from 2005 to 2008, we estimated logistic regression models of the impact of coverage and utilization management on the risk for medication changes and gaps in use, hospitalizations, and death among elderly nursing home residents using 1 of 6 selected drug classes, adjusting for patient characteristics. RESULTS: Few current medication users faced noncoverage of their drug (0.4% to 8.7%) or prior authorization or step therapy requirements if the drug was covered (1.1% to 37.4%). After adjusting for individual-level covariates, residents with noncovered drugs were more likely than residents with covered drugs to change medications in most classes studied (eg, for 2006 angiotensin receptor blocker users, the adjusted average probability of medication change was 0.35 when uncovered vs. 0.11 when covered). Those subjected to prior authorization or step therapy were more likely to change in a subset of classes. There were no statistically significant differences in the rates of hospitalization or death after correcting for multiple comparisons. CONCLUSIONS: The Part D benefit's special protections for nursing home residents may have ameliorated the health impact of coverage limits on this frail elderly population.

Nursing home ownership trends and their impacts on quality of care: a study using detailed ownership data from Texas.

The role of ownership in the provision of nursing home care has long been a challenging issue for policy makers and researchers. Although much of the focus historically has been on differences between for-profit and not-for-profit facilities, this simple distinction has become less useful in recent years as companies have employed more complicated ownership and management structures. Using detailed ownership data from the state of Texas, we describe the evolution of nursing home corporate structures from 2000 to 2007, analyze the effect of these structures on quality of care and staffing in nursing homes, and discuss the policy implications of these changes.

Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries.

Importance: Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes. Objective: To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees. Design, Setting, and Participants: This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design. Exposures: Enrollment in MA and dual eligibility for Medicare and Medicaid. Main Outcomes and Measures: Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services. Results: Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility. Conclusions and relevance: In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.

Traditional Medicare Episode-Related Spending on Postacute Care for Dual-Eligible and Medicare-Only Beneficiaries, 2009-2017.

Dual-eligible beneficiaries with Medicare and Medicaid coverage generally have greater utilization and spending levels than Medicare-only beneficiaries on postacute services, raising questions about how strategies to curb postacute spending will affect dual-eligible beneficiaries. We compared trends in postacute spending and use related to inpatient episodes at a population and episode level for dual-eligible and Medicare-only beneficiaries over the years 2009-2017. Although dual-eligible beneficiaries had consistently higher inpatient and postacute service use and spending than Medicare-only populations, both populations experienced similar declines in inpatient and postacute measures over time. Conditional on having an inpatient stay, most types of postacute service use increased regardless of dual-eligible status. These consistent patterns in episode-related postacute spending for Medicare-only and dual-eligible beneficiaries-decreased episode-related spending and use on a per beneficiary basis and increased use and spending on a per episode basis-suggest that changing patterns of care affect both populations.

The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes.

In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.

Changes in Diagnoses and Site of Care for Patients Receiving Hospice Care From Agencies Acquired by Private Equity Firms and Publicly Traded Companies.

Importance: Private equity firms and publicly traded companies have been acquiring US hospice agencies; an estimated 16% of US hospice agencies are owned by private equity (PE) firms or publicly traded companies (PTC). Objective: To examine the association of PE and PTC acquisitions of hospices with Medicare patients' site of care and clinical diagnoses. Design, Setting, and Participants: This cohort study of US hospice agencies used a novel national database of acquisitions merged with the Medicare Post-Acute Care and Hospice Public Use File for 2013 to 2020. Changes in sites of care and patient characteristics for hospice agencies acquired by PE or PTCs were compared with changes for patients in nonacquired for-profit hospice agencies. Exposure: Private equity and publicly traded company acquisitions. Main Outcomes and Measures: This study used a difference-in-differences approach within an event-study framework to examine the association of PE and PTC acquisitions of hospice agencies with changes in patient diagnoses and sites of care. Dependent variables were annual hospice-level measures of the Hierarchical Condition Category (HCC) score and proportion of patients diagnosed with cancer or dementia. Sites of care included the proportion of patients receiving hospice care in their personal home, nursing home, or assisted living facility. Results: A total of 158 hospice agencies acquired by PEs, 250 acquired by PTCs, and 1559 other for-profit hospice agencies were included. Preacquisition, hospice agencies that would later be acquired by PE or PTC served a mean (IQR) 30.1% (12.0%-44.0%) and 29.4% (13.0%-43.0%) of their patients in nursing homes respectively, a greater proportion compared with the 27.1% (8.0%-43.8%) served by for-profit hospices that were never acquired. Agencies acquired by PE between 2014 and 2019 saw a significant relative increase of 5.98% in dementia patients (1.38 percentage points; 95% CI, 0.35-2.40 percentage points; P = .008). In PTC-owned hospices, the proportion of patients receiving care at home increased by 5.26% (2.98 percentage points; 95% CI, 1.46-4.51 percentage points; P < .001), the proportion of dementia patients rose by 13.49% (3.11 percentage points; 95% CI, 2.14-4.09 percentage points; P < .001), and the HCC score decreased by 1.37% (-3.19 percentage points; 95% CI, -5.92 to -0.47 percentage points; P = .02). Conclusions and Relevance: These findings suggest that PE and PTCs select patients and sites of care to maximize profits.

Aligning Medicaid and Medicare Advantage Managed Care Plans for Dual-Eligible Beneficiaries.

To coordinate Medicare and Medicaid benefits, multiple states are creating opportunities for dual-eligible beneficiaries to join Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and Medicaid plans operated by the same insurer. Tennessee implemented this approach by requiring insurers who offered Medicaid plans to also offer a D-SNP by 2015. Tennessee's aligned D-SNP participation increased from 7% to 24% of dual-eligible beneficiaries aged 65 years and above between 2011 and 2017. Within a county, a 10-percentage-point increase in aligned D-SNP participation was associated with 0.3 fewer inpatient admissions (p = .048), 13.9 fewer prescription drugs per month (p = .048), and 0.3 fewer nursing home users (p = .06) per 100 dual-eligible beneficiaries aged 65 years and older. Increased aligned plan participation was associated with 0.2 more inpatient admissions (p = .004) per 100 dual-eligible beneficiaries younger than 65 years. For some dual-eligible beneficiaries, increasing Medicare and Medicaid managed plan alignment has the potential to promote more efficient service use.

Establishing Medicaid incentives for liberating nursing home patients from ventilators.

BACKGROUND: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives. METHODS: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. RESULTS: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. CONCLUSIONS: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

High-Quality Nursing Home and Palliative Care-One and the Same.

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

Integrating the Financing and Delivery of Medical and Supportive Services for People Living With Dementia.

The number of people living with dementia (PLWD) is expected to grow considerably in the coming years. PLWD often have substantial medical and supportive service needs and face fragmentation of services across payers and across health and social service systems; recently, efforts have been made to achieve greater integration of care and financing. This article considers issues related to integrating long-term services and supports (LTSS), medical care, and financing for PLWD; reviews the policy context and key clinical and delivery system challenges to these efforts; and describes key lessons regarding integration learned from examples in the field. Recommendations are provided and include the following: (1) assess carefully whether integration of medical and LTSS is required to achieve the intended outcomes of an intervention or program targeted at PLWD; if integration is needed, select carefully the types of medical and LTSS to integrate and the mode of integration; (2) use measures that evaluate quality across LTSS settings in which PLWD receive care; (3) assess whether and how eligibility and payment policies pose barriers to PLWD from receiving services they need, and evaluate ways in which policies might be reformed to meet beneficiaries' needs; and (4) conduct research examining the potential of value-based payment efforts to improve the quality and efficiency of care received by PLWD, including their potential impact on out-of-pocket expenses and caregiving burden for PLWD and their families.