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Baugh CW, Ouchi K, Bowman JK, Aizer AA, Zirulnik AW, Wadleigh M, Wise A, Remón Baranda P, Leiter RE, Molyneaux BJ, McCabe A, Hansrivijit P, Lally K, Littlefield M, Wagner AM, Walker KH, Salmasian H, Ravvaz K, Devlin JA, Brownell KL, Vitale MP, Firmin FC, Jain N, Thomas JD, Tulsky JA, Ray S, O’Mara LM, Rickerson EM, Mendu ML. A Hospice Transitions Program for Patients in the Emergency Department. JAMA Netw Open 2024; 7:e2420695. [PMID: 38976266 PMCID: PMC11231795 DOI: 10.1001/jamanetworkopen.2024.20695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/02/2024] [Indexed: 07/09/2024] Open
Abstract
Importance Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). Conclusions and Relevance In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.
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Affiliation(s)
- Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jason K. Bowman
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Ayal A. Aizer
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander W. Zirulnik
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Martha Wadleigh
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Angela Wise
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Richard E. Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Andrea McCabe
- Mass General Brigham Home Hospital, Boston, Massachusetts
| | - Panupong Hansrivijit
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kate Lally
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Melissa Littlefield
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexei M. Wagner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Hojjat Salmasian
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kourosh Ravvaz
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jada A. Devlin
- Mass General Brigham Home Hospital, Boston, Massachusetts
| | - Karen Lewis Brownell
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Matthew P. Vitale
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frantzie C. Firmin
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jane deLima Thomas
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Soumi Ray
- Department of Analytics, Planning, Strategy and Improvement, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lynne M. O’Mara
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elizabeth M. Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
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Kim H(D, Duberstein PR, Lin H, Wu B, Zafar A, Jarrín OF. Home Health Care and Hospice Use Among Medicare Beneficiaries With and Without a Diagnosis of Dementia. J Palliat Med 2024; 27:776-783. [PMID: 38359388 PMCID: PMC11310562 DOI: 10.1089/jpm.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.
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Affiliation(s)
| | - Paul R. Duberstein
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York, New York, USA
- NYU Aging Incubator, New York University, New York, New York, USA
| | - Anum Zafar
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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Osakwe ZT, Calixte R, Peterson ML, Young SG, Ikhapoh I, Pierre K, McIntosh JT, Senteio C, Girardin JL. Association of Hospice Agency Location and Neighborhood Socioeconomic Disadvantage in the U.S. Am J Hosp Palliat Care 2024; 41:309-317. [PMID: 37644697 DOI: 10.1177/10499091231195319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Despite the growing increase in the utilization of hospice in the U.S, disparities exist in the utilization of hospice. Accumulating evidence has shown that neighborhood characteristics have an impact on availability of hospice agencies. OBJECTIVE To assess the association between neighborhood social vulnerability and hospice agency availability. METHODS Using the Medicare Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files (PAC PUF) for 2019. Hospice agency addresses were geocoded to the census tract level. Multivariable Poisson regression models were used to assess the association between socioeconomic status SVI theme and hospice agency availability adjusting for number of home health agencies, primary care health profession shortage, per cent Black, and Percent Hispanic at the census tract level and rurality. RESULTS The socioeconomic status SVI subtheme was associated with decreased likelihood of hospice agency availability (adjusted IRR (aIRR), .56; 95% CI, .50- .63; P < .001). Predominantly Black, and predominantly Hispanic neighborhoods had lower rates of hospice agency availability (aIRR, .48; 95% CI, .39-.59; P < .001 and aIRR, .29; 95% CI, .24-.36; P < .001), respectively. CONCLUSION Neighborhood socioeconomic disadvantage was associated with lower availability of hospice agencies. Policies aimed at increasing access to hospice should be cognizant of neighborhood socioeconomic disadvantage.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Rose Calixte
- Department of Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mandi-Leigh Peterson
- North Dakota Healthcare Workforce Group, University of North Dakota, Grand Forks, ND, USA
| | - Sean G Young
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - Izuagie Ikhapoh
- School of Engineering and Applies Sciences, University of Buffalo, Buffalo, NY, USA
| | - Kaydeen Pierre
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Jennifer T McIntosh
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
- Yale University School of Nursing, Orange, CT, USA
| | - Charles Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - Jean-Louis Girardin
- Department of Psychiatry and Neurology at the Miller School of Medicine, University of Miami, Miami, FL, USA
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Oh A, Hunt LJ, Ritchie CS, Ornstein KA, Kelley AS, Rajagopalan S, Ankuda CK. Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice? J Palliat Med 2023; 26:385-392. [PMID: 36137095 PMCID: PMC9986009 DOI: 10.1089/jpm.2022.0272] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.
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Affiliation(s)
- Anna Oh
- San Francisco VA Health Care System, San Francisco, California, USA
- Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
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Osakwe ZT, Oni-Eseleh O, Rosati RJ, Stefancic A. “The Crossover to Hospice”: Perspectives of Home Healthcare Nurses and Social Workers. Am J Hosp Palliat Care 2022:10499091221123271. [DOI: 10.1177/10499091221123271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Although home healthcare(HHC) clinicians increasingly provide care to a homebound population with advanced illness and high symptom burden, we know little about how HHC clinicians navigate discussions about hospice with patients and families in this setting. Objective We sought to explore perspectives on transition from HHC to hospice among HHC nurses and social workers. Design PQualitative study using semi-structured interviews and thematic analysis. Results: Fifteen nurses and 3 Social workers participated in the study. Four main themes emerged from the interviews: (1) Regulatory Forces of Hospice and HHC; (2) Structure of HHC; (3) Individual beliefs—Hospice means giving up; and (4) Dynamics of Communication in HHC to Facilitate Transitions to Hospice. Conclusion Introducing the option of hospice to patients and families nearing end-of-life in the HHC setting is complex and challenging. Facilitators of hospice discussions in the HHC setting include interdisciplinary team-based clinical review, clinical decision support tools to identify patients who are hospice-eligible, and staff training. These factors provide targets for future interventions.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Ohiro Oni-Eseleh
- School of Social Work, Hudson Valley Center, Adelphi University, Fairview, NY, USA
| | - Robert J. Rosati
- The Visiting Nurse Association Health Group Inc., Holmdel, NJ, USA
| | - Ana Stefancic
- Columbia University, Department of PsychiatryNew York, NY, USA
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