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Wachterman MW, Smith D, Carpenter JG, Griffin HL, Thorpe J, Feder SL, Hoelter J, Ersek M, Shreve S, Kutney-Lee A. A comparison of end-of-life care quality for Veterans receiving hospice in VA nursing homes and community nursing homes. J Am Geriatr Soc 2024; 72:59-68. [PMID: 37947240 PMCID: PMC10842969 DOI: 10.1111/jgs.18606] [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] [Received: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND While the Veterans Health Administration (VA) has long provided hospice care within VA community living centers (CLCs, i.e., VA nursing homes), an increasing number of Veterans are receiving hospice in VA-contracted community nursing homes (CNHs). However, little data exist about the quality of end-of-life (EOL) care provided in CNHs. The aim of this study was to compare family ratings of the quality of EOL care provided to Veterans receiving hospice in VA CLCs and VA-contracted CNHs. METHODS We conducted a retrospective analysis of national data from VA's electronic medical record and Bereaved Family Survey (BFS) for Veterans who received hospice in VA CLCs or VA-contracted CNHs between October 2021 and March 2022. The final sample included 1238 Veterans who died in either a CLC (n = 1012) or a CNH (n = 226) and whose next-of-kin completed the BFS. Our primary outcome was the BFS global rating of care received in the last 30 days of life. Secondary outcomes included BFS items related to symptom management, communication, emotional and spiritual support, and information about burial and survivor benefits. We compared unadjusted and adjusted proportions for all BFS outcomes between those who received hospice in CLCs and CNHs. RESULTS The adjusted proportion of family members who gave the best possible rating (a score of 9 or 10 out of a possible 10) for the overall care received near EOL was more than 13 percentage points higher for Veterans who received hospice in VA CLCs compared to VA-contracted CNHs. Our findings also revealed quality gaps of even greater magnitude in specific EOL care-focused domains. CONCLUSIONS Our findings document inadequacies in the quality of multiple aspects of EOL care provided to Veterans in CNH-based hospice and illuminate the urgent need for policy and practice interventions to improve this care.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joan G Carpenter
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Hillary L Griffin
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA
- University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Shelli L Feder
- Yale University School of Nursing, Orange, Connecticut, USA
- Pain Research, Informatics, Multi-Morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Jillian Hoelter
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Scott Shreve
- US Department of Veteran Affairs, Hospice and Palliative Care Program, Washington, DC, USA
- Lebanon VA Medical Center, Lebanon, Pennsylvania, USA
| | - Ann Kutney-Lee
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Variation in Hospice Experiences by Care Setting for Patients With Dementia. J Am Med Dir Assoc 2022; 23:1480-1485.e6. [PMID: 35430207 PMCID: PMC10372780 DOI: 10.1016/j.jamda.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Use of hospice care among patients with dementia has been steadily increasing. Our objectives were to characterize quality of hospice care experiences among decedents who had a primary diagnosis of dementia and their caregivers and investigate differences across settings of hospice care. DESIGN We analyzed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from caregiver respondents whose family members received hospice care. SETTING AND PARTICIPANTS Data from 96,845 caregiver respondents whose family members had a primary diagnosis of dementia and died in 2017 or 2018 while receiving hospice care in 2829 hospices. METHODS We calculated quality measure scores overall and stratified by setting, adjusting for mode of survey administration and differences in case mix, and examined variability in hospice-level scores among decedents with dementia. RESULTS Mean quality measure scores ranged from 69.0 (Getting Hospice Care Training) to 90.9 (Getting Emotional Support). Measure scores varied significantly across settings, with caregivers of decedents who received care in a nursing home (NH), acute care hospital (ACH), or assisted living facility (ALF) consistently reporting poorer quality of care. Hospice-level scores varied substantially, with a wide range between the 10th and 90th percentiles of hospice performance (eg, 25 points). CONCLUSIONS AND IMPLICATIONS There are important opportunities to improve hospice care for patients with dementia and their caregivers, particularly with respect to caregiver training, symptom management, and across all dimensions within the NH, ACH, and ALF settings. Variability in care experiences across hospices, as well as long lengths of stay for those with dementia, highlight the importance of informed and timely hospice referral.
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Ersek M, Unroe KT, Carpenter JG, Cagle JG, Stephens CE, Stevenson DG. High-Quality Nursing Home and Palliative Care-One and the Same. J Am Med Dir Assoc 2022; 23:247-252. [PMID: 34953767 PMCID: PMC8821139 DOI: 10.1016/j.jamda.2021.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Mary Ersek
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Joan G Carpenter
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA; University of Maryland School of Nursing, Baltimore, MD, USA
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
| | | | - David G Stevenson
- Veterans Affairs Tennessee Valley Healthcare System, Murfreesboro, TN, USA; Vanderbilt School of Medicine, Nashville, TN, USA
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