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Reckrey JM, McKendrick K, Morrison RS, Osakwe ZT, Ornstein KA, Aldridge M. Variation in Hospice Aide Care by Residential Setting. J Palliat Med 2024; 27:1018-1025. [PMID: 38647702 DOI: 10.1089/jpm.2023.0585] [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: 04/25/2024] Open
Abstract
Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings.
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Affiliation(s)
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zainab Toteh Osakwe
- Adelphi University College of Nursing and Public Health, New York, New York, USA
| | | | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Siraw BB, Meyahnwi D, Tafesse YT, Siraw BB, Yasmeen J, Melka S. Trends of Acute Myocardial Infarction Mortality in People Over 65 Years Old in the United States From 1999-2020: Insight From the CDC-WONDER Database. Cureus 2024; 16:e58225. [PMID: 38745786 PMCID: PMC11091843 DOI: 10.7759/cureus.58225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Background Over the past two decades, there have been numerous advances in acute myocardial infarction (AMI) care. We assessed the impact of these advances on the trend of AMI-related mortality. Methods This retrospective analysis of the Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research (CDC_WONDER) database focused on AMI-related mortality in individuals aged 65 and older in the United States from 1999 to 2020. Trends -n crude and age-adjusted mortality rates (AAMR) were assessed based on socio-demographic and regional variables using Joinpoint Regression software (Joinpoint Regression Program, Version 5.0.2 - May 2023; Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute Bethesda, Maryland). Annual percentage change (APC) with 95% confidence intervals (CIs) for the AAMRs were calculated for the line segments linking a Joinpoint using a data-driven weighted Bayesian Information Criterion (BIC) model. Results There were 2,354,971 AMI-related deaths with an overall decline in the AAMR from 474.6 in 1999 to 153.2 in 2020 and an average annual percentage change (AAPC) of -5.3 (95% CI -5.4 to -5.2). Notable declines were observed across gender, race, age groups, and urbanization levels. However, the rate of AMI-related deaths at decedents' homes slowed down between 2008 and 2020 and climbed up between 2018 and 2020. In addition to this, nonmetropolitan areas were found to have a significantly lower decline in mortality when compared to large and medium/small metropolitan areas. Conclusion While there is an overall positive trend in reducing AMI-associated mortality, disparities persist, emphasizing the need for targeted interventions.
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Affiliation(s)
- Bekure B Siraw
- Internal Medicine, Ascension Saint Joseph Hospital, Chicago, USA
| | - Didien Meyahnwi
- Public Health, University of California Berkeley, Berkeley, USA
| | | | - Biruk B Siraw
- Medical Biotechnology, University of Eastern Piedmont, Novara, ITA
| | - Juveriya Yasmeen
- Internal Medicine, Ascension Saint Joseph Hospital, Chicago, USA
| | - Samrawit Melka
- Biological Sciences, The University of Chicago Medicine, Chicago, USA
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Melekis K, Weisse CS, Alonzo JD, Cheng A. Social Model Hospice Residential Care Homes: Whom Do They Really Serve? Am J Hosp Palliat Care 2023; 40:1317-1323. [PMID: 36599102 DOI: 10.1177/10499091221150769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Most prefer to die at home, but the Medicare Hospice Benefit does not cover custodial care, making it difficult for terminally ill patients with housing insecurity and/or caregiver instability to access hospice care at home. OBJECTIVES To examine the characteristics of patients who received end-of-life care in community-run, residential care homes (RCHs) operating under the social model hospice. METHODS A retrospective chart review of 500 residents who were admitted to one of three RCHs in Upstate New York over a 15-year period (2004-2019). RESULTS Patients served by the RCHs included 318 (63.6%) women and 182 (36.4%) men aged 34-101 (M = 77.8). The majority (94.9%) were Caucasian and most had cancer diagnoses (71.6%). Prior to admission, most (93%) patients resided in a private residence, and nearly half (47%) lived alone, but most (81.7%) had full- or part-time caregivers. Nearly all patients were admitted either directly from a hospital (47.5%) or private home (47.2%). Over half (52%) were admitted to RCHs within a month of hospice enrollment, and 20.1% enrolled concurrent with admission. While the average length of stay was 21 days, 50% died within 10 days of admission. CONCLUSIONS Community-run RCHs represent a unique approach for improving access to hospice home care for patients with home insecurity and/or caregiver instability, yet most patients had prior caregiver coverage and were admitted from a hospital or home setting, suggesting there is a need for community care settings for patients unable to remain at home in the final weeks or days prior to death.
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Affiliation(s)
- Kelly Melekis
- Department of Social Work, University of Vermont College of Education and Social Services, Burlington, VT, USA
| | - Carol S Weisse
- Department of Psychology, Union College, Schenectady, NY, USA
| | | | - Alice Cheng
- Leadership in Medicine Program, Union College, Schenectady, NY, USA
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Odejide OO, Aldridge MD. Access to High-Quality Hospice Care in a For-Profit World. Oncologist 2023; 28:743-745. [PMID: 37487057 PMCID: PMC10485296 DOI: 10.1093/oncolo/oyad205] [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: 04/05/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Evidence supporting the relief of suffering and improved end-of-life care provided by hospice is in contrast with recent media reports of cases of poor-quality care driven by profit-motivated hospices. This commentary presents a brief history of hospice and potential solutions to address the current challenges affecting access to high-quality hospice care.
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Affiliation(s)
- Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, NYUSA
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5
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Braun RT, Unruh MA, Stevenson DG, Prigerson HG, Fernandez R, Yao LZ, Casalino LP. Changes in Diagnoses and Site of Care for Patients Receiving Hospice Care From Agencies Acquired by Private Equity Firms and Publicly Traded Companies. JAMA Netw Open 2023; 6:e2334582. [PMID: 37747735 PMCID: PMC10520742 DOI: 10.1001/jamanetworkopen.2023.34582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
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.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
| | - Mark A. Unruh
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
| | - David G. Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Rahul Fernandez
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
| | - Leah Z. Yao
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
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Mair CA, Thygesen LC, Aldridge M, Tay DL, Ornstein KA. End-of-Life Experiences Among "Kinless" Older Adults: A Nationwide Register-Based Study. J Palliat Med 2023; 26:1056-1063. [PMID: 36893217 PMCID: PMC10440640 DOI: 10.1089/jpm.2022.0490] [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: 01/25/2023] [Indexed: 03/11/2023] Open
Abstract
Background: The population of older adults who are unpartnered and childless (i.e., "kinless") is increasing across the globe, and may be at risk for lower quality end-of-life (EoL) experiences due to lack of family support, assistance, and advocacy. Yet, little research exists on the EoL experiences of "kinless" older adults. Objectives: To document associations between family structure (i.e., presence or absence of partner or child) and intensity of EoL experiences (i.e., visits to medicalized settings before death). Design: The study design is a cross-sectional population-based register study of the population of Denmark. Subjects: Participants include all adults age 60 years and older who died of natural causes in Denmark from 2009 to 2016 (n = 137,599 decedents). Results: "Kinless" older adults (reference = has partner, has child) were the least likely group to visit the hospital (two or more times; odds ratio [OR] = 0.74, confidence interval [CI] = 0.70-0.77), emergency department (one or more times; OR = 0.90, CI = 0.86-0.93), and intensive care unit (one or more times; OR = 0.71, CI = 0.67-0.75) before death. Conclusions: "Kinless" older adults in Denmark were less likely to experience medically intensive care at the EoL. Further research is needed to understand factors associated with this pattern to ensure that all individuals receive high quality EoL care regardless of their family structure and family tie availability.
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Affiliation(s)
- Christine A. Mair
- Department of Sociology, Anthropology, and Public Health, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Lau C. Thygesen
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Melissa Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Djin L. Tay
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Osakwe ZT, Jacobowitz W, Horton JR, Klainberg M, Calixte R, Jacobs C, Hickey MT. Hospice and Palliative Care for Undergraduate Nursing Education: Results from a Delphi Study. Home Healthc Now 2023; 41:197-206. [PMID: 37417571 DOI: 10.1097/nhh.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
There is an urgent need to strengthen the nursing workforce through hospice and palliative care education to support patients living with serious illness. The aim of this study was to identify skills/topics in hospice and palliative care for undergraduate nursing education. We conducted a two-round online Delphi Survey of hospice and palliative care leaders and clinicians in New York State between June and August 2022. Participants were asked to list and rate the importance of clinical skills and topics in hospice and palliative care for undergraduate nursing education. Twenty-eight participants completed Round One and 21 participants completed Round Two. Topics ranked as extremely important were goals of care, patient/family education, communication skills, advance directives, medication management, pain management, and symptom management. Our findings highlight the importance of including the perspective of healthcare systems leaders and clinicians in discussions about training of future nurses to meet the needs of patients with serious illness and their families.
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Walton L, Courtright K, Demiris G, Gorman EF, Jackson A, Carpenter JG. Telehealth Palliative Care in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2023; 24:356-367.e2. [PMID: 36758619 PMCID: PMC9985816 DOI: 10.1016/j.jamda.2023.01.004] [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: 10/07/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy. DESIGN Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review. SETTINGS AND PARTICIPANTS Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians. METHODS We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents. RESULTS The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden. CONCLUSIONS AND IMPLICATIONS Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.
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Affiliation(s)
- Lyle Walton
- The University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Katherine Courtright
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | - Amy Jackson
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Joan G Carpenter
- University of Maryland School of Nursing, Baltimore, MD, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
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9
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Harrison KL, Cenzer I, Ankuda CK, Hunt LJ, Aldridge MD. Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:821-830. [PMID: 35666964 PMCID: PMC9662595 DOI: 10.1377/hlthaff.2021.01985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison , University of California San Francisco, San Francisco, California
| | - Irena Cenzer
- Irena Cenzer, University of California San Francisco
| | - Claire K Ankuda
- Claire K. Ankuda, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco
| | - Melissa D Aldridge
- Melissa D. Aldridge, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
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11
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Davis MA, Chang CH, Simonton S, Bynum JPW. Trends in US Medicare Decedents’ Diagnosis of Dementia From 2004 to 2017. JAMA HEALTH FORUM 2022; 3:e220346. [PMID: 35977316 PMCID: PMC8976239 DOI: 10.1001/jamahealthforum.2022.0346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/09/2022] [Indexed: 12/22/2022] Open
Abstract
Question To what degree did the diagnosis of Alzheimer disease and related dementias (ADRD) change at the end of life between 2004 and 2017? Findings Among 3 515 329 Medicare fee-for-service decedents, the percentage who received an ADRD diagnosis within 2 years of death increased from 34.7% in 2004 to 47.2% in 2017. The likelihood of receiving an ADRD diagnosis particularly increased in the inpatient, hospice, and home health settings; individual characteristics and service use were stable over time, while the intensity of end-of-life care declined on most measures. Meaning Dying with an ADRD diagnosis has become more common among older US decedents, potentially owing to increased awareness and temporal changes in billing. Importance Alzheimer disease and related dementias (ADRD) have received considerable attention among clinicians, researchers, and policy makers in recent years. Despite increased awareness, few studies have documented temporal changes in the documentation of ADRD diagnoses despite its new importance for risk adjustment for health plans in Medicare. Objective To assess trends in frequency of ADRD diagnosis in the last 2 years of life from 2004 to 2017, as well as any associated changes in billing practices, characteristics of the population with diagnosed ADRD, and intensity of end-of-life care. Design, Setting, and Participants This is a serial cross-sectional study of older adult decedents (67 years or older) from 2004 to 2017 using a 20% sample of fee-for-service Medicare decedents. An ADRD diagnosis within the last 2 years of life was identified using diagnosis codes from inpatient, professional service, home health, or hospice claims, requiring the standard claims algorithm that required at least 1 claim and a more stringent algorithm that required at least 2 claims. Trends in ADRD diagnosis among decedents were used to lessen influence of new diagnostic technologies for early stage disease. Demographic characteristics, selected comorbidities, place of death, and health service use at the end-of-life were also examined. Data were analyzed from July 9, 2020, to May 3, 2021. Exposures Calendar year 2004 to 2017. Main Outcome and Measure An ADRD diagnosis within 2 years of death. Results Among the included 3 515 329 Medicare fee-for-service decedents, when adjusted for age and sex, the percentage of older decedents with an ADRD diagnosis increased from 34.7% in 2004 to 47.2% in 2017. The trend was attenuated (25.2% to 39.2%) using a stringent ADRD definition. There was an inflection in the curve from 2011 to 2013, the time at which additional diagnoses were added to Medicare claims and the National Alzheimer Care Act was enacted. The ADRD diagnosis frequency increased considerably in inpatient (49.0% to 67.3%), hospice (12.2% to 42.0%), and home health (10.1% to 28.7%) claims. However, individual characteristics, number of visits, and hospitalizations were similar across the study period, and the intensity of end-of-life care declined on most measures. Conclusions and Relevance In this cross-sectional study, nearly half of older Medicare decedents had a diagnosis of ADRD at the time of death. From 2004 to 2017, the percentage of older adult decedents who received an ADRD diagnosis increased substantially prior to announcement of the addition of ADRD to Medicare risk adjustment strategies.
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Affiliation(s)
- Matthew A. Davis
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Chiang-Hua Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Sharon Simonton
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Julie P. W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Ornstein KA, Ankuda CK, Leff B, Rajagopalan S, Siu AL, Harrison KL, Oh A, Reckrey JM, Ritchie CS. Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism. J Am Geriatr Soc 2022; 70:1127-1135. [PMID: 34936087 PMCID: PMC8986555 DOI: 10.1111/jgs.17621] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/22/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access. METHODS Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia. RESULTS Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas. CONCLUSION Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.
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Affiliation(s)
- Katherine A Ornstein
- 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
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, The Center for Transformative Geriatric Research, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Anna Oh
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Jennifer M Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
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Reckrey JM, Ornstein KA, McKendrick K, Tsui EK, Morrison RS, Aldridge M. Receipt of Hospice Aide Visits Among Medicare Beneficiaries Receiving Home Hospice Care. J Pain Symptom Manage 2022; 63:503-511. [PMID: 34954065 PMCID: PMC8930441 DOI: 10.1016/j.jpainsymman.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Hospice aides provide essential direct care to hospice patients, yet there is minimal research examining hospice aide visits. OBJECTIVES describe the prevalence and frequency of hospice aide visits, and 2) evaluate patient, community, and hospice characteristics associated with these visits. METHODS Longitudinal cohort study of Medicare Current Beneficiary Survey (MCBS) participants who died between 2010-2018 and received routine hospice care in the 6 months prior to death (n = 674). We characterized prevalence and frequency of hospice aide visits over time and used generalized linear modelling to identify factors associated with visits. RESULTS 64% of hospice enrollees received hospice aide visits and average visit frequency (1.3 per week) remained stable throughout enrollment. The only patient characteristic associated with receipt of hospice aide visits was primary hospice diagnosis (respiratory diagnosis vs. dementia: OR 0.372, P = 0.040). Those living in community-based residential housing and those cared for by hospices with aides employed as staff were more likely to receive any hospice aide visits (OR 2.331, P = 0.047 and OR 4.612, P = 0.002, respectively.) CONCLUSION: Hospice aide visits are a common component of hospice care, but visit frequency does not increase as death approaches. Receipt of hospice aide visits was primarily associated with community and hospice agency (rather than patient) characteristics. Future work is needed to ensure that hospice aides are integrated in the hospice interdisciplinary team and that access to hospice aide visits is meaningfully driven by patient and family needs, rather than the practice norms and business models of individual hospice agencies.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York.
| | - Katherine A Ornstein
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Emma K Tsui
- CUNY Graduate School of Health and Health Policy (E.K..T.), New York, New York
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
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14
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Aldridge MD, Hunt L, Husain M, Li L, Kelley A. Impact of Comorbid Dementia on Patterns of Hospice Use. J Palliat Med 2022; 25:396-404. [PMID: 34665050 PMCID: PMC8968839 DOI: 10.1089/jpm.2021.0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: The evidence base for understanding hospice use among persons with dementia is almost exclusively based on individuals with a primary terminal diagnosis of dementia. Little is known about whether comorbid dementia influences hospice use patterns. Objective: To estimate the prevalence of comorbid dementia among hospice enrollees and its association with hospice use patterns. Design: Pooled cross-sectional analysis of the nationally representative Health and Retirement Study (HRS) linked to Medicare claims. Subjects: Fee-for-service Medicare beneficiaries in the United States who enrolled with hospice and died between 2004 and 2016. Measurements: Dementia was assessed using a validated survey-based algorithm. Hospice use patterns were enrollment less than or equal to three days, enrollment greater than six months, hospice disenrollment, and hospice disenrollment after six months. Results: Of 3123 decedents, 465 (14.9%) had a primary hospice diagnosis of dementia and 943 (30.2%) had comorbid dementia and died of another illness. In fully adjusted models, comorbid dementia was associated with increased odds of hospice enrollment greater than six months (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI]: 1.11-2.09) and hospice disenrollment following six months of hospice (AOR = 2.55, 95% CI: 1.43-4.553). Having a primary diagnosis of dementia was associated with increased odds of hospice enrollment greater than six months (AOR = 2.62, 95% CI: 1.86-3.68), hospice disenrollment (AOR = 1.82, 95% CI: 1.32-2.51), and hospice disenrollment following six months of hospice (AOR = 4.31, 95% CI: 2.37-7.82). Conclusion: Approximately 45% of the hospice population has primary or comorbid dementia and are at increased risk for long hospice enrollment periods and hospice disenrollment. Consideration of the high prevalence of comorbid dementia should be inherent in hospice staff training, quality metrics, and Medicare Hospice Benefit policies.
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Affiliation(s)
- Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Bronx VA Medical Center, New York, New York, USA.,Address correspondence to: Melissa D. Aldridge, PhD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Lauren Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Mohammed Husain
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lihua Li
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Bronx VA Medical Center, New York, New York, USA
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15
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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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16
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Aldridge MD, Moreno J, McKendrick K, Li L, Brody A, May P. Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018. JAMA HEALTH FORUM 2022; 3:e215104. [PMID: 35977281 PMCID: PMC8903119 DOI: 10.1001/jamahealthforum.2021.5104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/07/2021] [Indexed: 12/19/2022] Open
Abstract
Importance Use of hospice has been demonstrated to be cost saving to the Medicare program and yet the extent to which hospice saves money across all payers, including whether it shifts costs to families, is unknown. Objective To estimate the association between hospice use and total health care costs including family out-of-pocket health care spending. Design Setting and Participants This retrospective cohort study of health care spending in the last 6 months of life used data from the nationally representative Medicare Current Beneficiary Survey (MCBS) between the years 2002 and 2018. Participants were MCBS participants who resided in the community and died between 2002 and 2018. Exposures Covariate balancing propensity scores were used to compare participants who used hospice (n = 2113) and those who did not (n = 3351), stratified by duration of hospice use. Main Outcomes and Measures Total health care expenditures were measured across payers (family out-of-pocket, Medicare, Medicare Advantage, Medicaid, private insurance, private health maintenance organizations, Veteran's Administration, and other) and by expenditure type (inpatient care, outpatient care, medical visits, skilled nursing, home health, hospice, durable medical equipment, and prescription drugs). Results The study population included 5464 decedents (mean age 78.7 years; 48% female) and 38% enrolled with hospice. Total health care expenditures were lower for those who used hospice compared with propensity score weighted non-hospice control participants for the last 3 days of life ($2813 lower; 95% CI, $2396-$3230); last week of life ($6806 lower; 95% CI, $6261-$7350); last 2 weeks of life ($8785 lower; 95% CI, $7971-$9600); last month of life ($11 747 lower; 95% CI, $10 072-$13 422); and last 3 months of life ($10 908 lower; 95% CI, $7283-$14 533). Family out-of-pocket expenditures were lower for hospice enrollees in the last 3 days of life ($71; 95% CI, $43-$100); last week of life ($216; 95% CI, $175-$256); last 2 weeks of life ($265; 95% CI, $149-$382); and last month of life ($670; 95% CI, $530-$811) compared with those who did not use hospice. Health care savings were associated with reductions in inpatient care. Conclusions and Relevance In this population-based cohort study of community-dwelling Medicare beneficiaries, hospice enrollment was associated with lower total health care costs for the last 3 days to 3 months of life. Importantly, we found no evidence of cost shifting from Medicare to families related to hospice enrollment. The magnitude of lower out-of-pocket spending to families who enrolled with hospice is meaningful to many Americans, particularly those with lower socioeconomic status.
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Affiliation(s)
- Melissa D. Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Bronx VA Medical Center, Bronx, New York
| | - Jaison Moreno
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lihua Li
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ab Brody
- NYU Rory Meyers College of Nursing, New York, New York
- NYU Grossman School of Medicine, New York, New York
| | - Peter May
- Trinity College Dublin, Dublin, Ireland
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17
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Belanger E, Teno JM, Wang XJ, Rosendaal N, Gozalo PL, Dosa D, Thomas KS. State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life. J Am Med Dir Assoc 2021; 23:1383-1388.e1. [PMID: 34971591 PMCID: PMC9237186 DOI: 10.1016/j.jamda.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. DESIGN Retrospective cohort study of fee-for-service Medicare beneficiaries who died in 2018 and resided in an RC/AL community with ≥25 beds at least 1 day during the last month of life. SETTING/PARTICIPANTS 23,285 decedents who spent time in 6274 RC/AL communities with 146 state license classifications. METHODS Descriptive statistics about hospice use; logistic regression models to test the association between regulations supportive of hospice care or registered nurse (RN) staffing requirements and the odds of hospice use in RC/AL in the last month of life. RESULTS More than half (56.4%) of the study cohort received hospice care in RC/AL at some point during the last 30 days of life, including 5.7% who received more intensive continuous home care (CHC). A larger proportion of decedents who resided in RC/ALs with supportive hospice policies received hospice (57.3% vs 52.6%), with this difference driven by more CHC hospice programs. This association remained significant after controlling for sociodemographic characteristics, comorbidities, time spent in RC/AL, and Hospital Referral Region fixed effects. Decedents in RC/ALs with explicit RN staffing requirements had significantly less CHC use (2.0% vs 6.8%). CONCLUSIONS AND IMPLICATIONS A large proportion of RC/AL decedents received hospice care in RC/AL regardless of differing regulations. Those in licensed settings with explicitly supportive hospice regulations were significantly more likely to receive hospice care in RC/AL during the last month of life, especially CHC level of hospice care. Regulatory change in states that do not yet explicitly allow hospice care in RC/AL may potentially increase hospice utilization in this setting, although the implications for quality of care remain unclear.
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Affiliation(s)
- Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Joan M Teno
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University
| | - Xiao Joyce Wang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; US Department of Veterans Affairs Medical Center, Providence, RI, USA
| | - David Dosa
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; US Department of Veterans Affairs Medical Center, Providence, RI, USA; Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; US Department of Veterans Affairs Medical Center, Providence, RI, USA
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18
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Aldridge MD, Ornstein KA, McKendrick K, Reckrey J. Service Availability in Assisted Living and Other Community-Based Residential Settings at the End of Life. J Palliat Med 2021; 24:1682-1688. [PMID: 33826855 PMCID: PMC8823677 DOI: 10.1089/jpm.2020.0625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Community-based residential settings (e.g., assisted living facilities and retirement communities), are increasing, where vulnerable older adults are living as they age and die. Despite prevalent serious illness, functional impairment, and dementia among residents, the mix and types of built-in services available are not known. Objective: To classify older adults in community-based residential settings by the types of services available and examine associations between service availability and hospice use and location of death. Design: Pooled cross-sectional analysis. Setting: Medicare Current Beneficiary Survey data (2002-2018). Subjects: U.S. adults 65 years of age and older, who lived in a community-based residential setting and died between 2002 and 2018 (N = 1006). Measurements: Availability (yes/no) of nursing care, medication assistance, meals, laundry, cleaning, transportation, and recreation. Results: Our sample resided in assisted living facilities (32.0%), retirement communities (29.0%), senior citizen housing (13.7%), continuing care facilities (13.5%), and other (11.8%). Four classes of individuals with distinct combinations of available services were identified: 48.2% lived in a residence with all measured services available; 29.1% had availability of all services, except nursing care and medication assistance; 12.6% had availability of only recreation and transportation services; and 10.1% had minimal/no service availability. Of the 51.8% of older adults residing in settings without clinical services, more than half died at home and fewer than half died with hospice. Conclusions: The majority of older adults who die in community-based residential settings do not have access to built-in clinical services. Palliative care training for staff in these settings may be warranted, given variable rates of hospice use and high rates of home death.
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Affiliation(s)
- Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Bronx VA Medical Center, New York, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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19
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Plick NP, Ankuda CK, Mair CA, Husain M, Ornstein KA. A national profile of kinlessness at the end of life among older adults: Findings from the Health and Retirement Study. J Am Geriatr Soc 2021; 69:2143-2151. [PMID: 33880751 PMCID: PMC8373783 DOI: 10.1111/jgs.17171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND/OBJECTIVES The majority of end-of-life (EOL) caregiving is provided by unpaid family members. An increasing number of older adults are kinless (without close family/partnerships) and may have insufficient caregiver support to remain at home at the EOL. We therefore determined what proportion of older adults are kinless at the EOL and assessed the association of kinlessness with EOL care. DESIGN Retrospective analysis of Health and Retirement Study decedents, 2002-2015. SETTING US population-based sample. PARTICIPANTS Decedents age 51+ who died within 1 year of interview (n = 3844) and subset who are community-dwelling at last interview. MEASUREMENTS Kinlessness was defined as lacking a spouse/partner and children. Primary outcome measure was location of death. Secondary outcome measures included contextual EOL measures such as symptom burden and caregiver support. RESULTS A total of 7.4% of decedents were kinless at the EOL. Kinless decedents were more likely to be female, nonwhite, enrolled in Medicaid, living alone, or living in a nursing home prior to death. Although community-dwelling kinless decedents received fewer hours of caregiving per week at the EOL (34.7 vs. 56.2, p < 0.05) and were more likely to die in nursing homes (18.1% vs. 10.3%, p < 0.05) than those with kin, they did not have higher EOL symptom burden or treatment intensity (e.g., intensive care unit use). In multinomial logistic analysis controlling for demographic and illness characteristics, kinless decedents living in the community before death had a twofold increased risk of dying in the nursing home (odds ratio [OR] = 2.02 [95% confidence interval (CI) = 1.09-3.72]) and a trend toward increased risk of hospital death (OR = 1.60 [95% CI = 0.96-2.69]) versus home setting. CONCLUSIONS Kinless individuals are more likely to die in nursing homes, even if they are living in the community in their last year of life. Expanded long-term care services and policies are needed to enable all older adults regardless of their family support systems to receive high-quality EOL care.
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Affiliation(s)
- Natalie P Plick
- Medical Student Research Office, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christine A Mair
- Department of Sociology, Anthropology, and Public Health, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Mohammed Husain
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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