Healthcare use and out-of-pocket costs for rural family caregivers and care recipients in a randomized controlled trial

BACKGROUND

Rural family caregivers (FCGs) in the United States often experience high economic costs. This randomized controlled trial compared a transitional palliative care intervention (TPC) to support FCGs of seriously ill care recipients (CRs) to an attention control condition. We evaluated the TPC's effect on healthcare use and out-of-pocket spending for both FCGs and CRs.

METHODS

TPC FCGs received teaching, guidance, and counseling via video calls for 8 weeks following CR discharge from the hospital. After discharge, a research assistant called all FCGs once a month for up to 6 months or CR death to collect self-reported healthcare utilization (e.g., outpatient, emergency department, and hospital), out-of-pocket healthcare spending (e.g., deductibles and coinsurance), and health-related travel costs (e.g., transportation, lodging, food) for FCGs and CRs. Incidence rate ratios (IRRs) were estimated using negative binomial regressions.

RESULTS

The study included 282 FCG-CR dyads across three U.S. states. Follow-up over the 6-month period was shortened by high CR mortality rates across both arms (29%), but was similar across arms. TPC reduced nights in the hospital for CR (IRR = 0.75; 95% confidence interval [CI] = 0.56-0. 99). Total out-of-pocket spending was not significantly different for TPC versus control. Across both groups, mean out-of-pocket spending for dyads was $1401.85, with healthcare payments contributing $1048.58 and transportation expenses contributing $136.79. TPC dyads reported lower lodging costs (IRR = 0.71; 95% CI = 0.56-0.89).

CONCLUSIONS

This study contributes to evidence that palliative care interventions reduce the number of nights in the hospital for seriously ill patients. Yet, overall rural FCGs and seriously ill CRs experience substantial out-of-pocket economic costs in the 6 months following hospitalization. Transitional care intervention design should consider impacts on patient and caregiver spending.

CLINICALTRIALS

gov # is NCT03339271.

Do end-of-life outcomes differ by assisted living memory-care designation?

BACKGROUND

Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL).

METHODS

Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents.

RESULTS

The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02).

CONCLUSION

We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.

Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data

BACKGROUND

The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes.

METHODS

The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators.

RESULTS

Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S.

PROGRAM

Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment.

CONCLUSION

The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.

Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study

BACKGROUND

Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values.

AIM

To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI.

METHODS

A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality.

RESULTS

1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001).

CONCLUSION

The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.

End-of-life care management for older adults at home by multidisciplinary professionals in Japan

Background

Population aging is a global phenomenon, and there is an urgent need to establish community-based integrated care systems for a sustainable society. In particular, the needs of home-dwelling older adults are multifaceted, encompassing areas such as medical care, nursing care, and welfare. Therefore, it is necessary to implement comprehensive care management that utilizes social resources suitable for diverse needs. This study aims to comprehensively describe care management practices by various professionals for home-dwelling older adults in the end-of-life (EOL) period.

Methods

This study adopted a qualitative analysis method using conventional content analysis. We conducted semi-structured interviews of 20 multidisciplinary professionals from February to March 2020.

Results

Multidisciplinary professionals ensured continuity of care by implementing care management as necessary when providing care to older adults who desired to stay at home until the end. Seven categories of EOL care management practices for home-dwelling older adults by multidisciplinary professionals were generated: (1) support to enable discharge to home; (2) decision-making support that captures the intention of the older adult without missing opportunities; (3) building a team system to realize the desired life and EOL; (4) family support for the entirety of the EOL period, (5) symptom control aimed at the realization of wishes; (6) emotional support for acceptance of the EOL period; (7) spiritual support.

Conclusions

Multidisciplinary professionals, including care managers, collaborating in a mutually complementary manner by sharing a comprehensive understanding of care management might prevent knowledge fragmentation and ensure that older adults receive home-based EOL care.

COVID-19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end-of-life care

OBJECTIVE

To characterize the national distribution of COVID-19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end-of-life care.

METHODS

Cross-sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID-19 pandemic, by trained study investigators using standardized instrument.

RESULTS

Of the 352 hospitals studied, 326 (93%) had a COVID-19 hospital-wide visitor restriction policy and 164 (47%) also had an ED-specific policy. Hospital-wide policies were more prevalent at academic than non-academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED-specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end-of-life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%).

CONCLUSION

Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages.

Addressing end-of-life care in the chronically ill: Conversations in the emergency department

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.

Exploring costs, cost components, and associated factors among people with dementia approaching the end of life: A systematic review

INTRODUCTION

Understanding costs of care for people dying with dementia is essential to guide service development, but information has not been systematically reviewed. We aimed to understand (1) which cost components have been measured in studies reporting the costs of care in people with dementia approaching the end of life, (2) what the costs are and how they change closer to death, and (3) which factors are associated with these costs.

METHODS

We searched the electronic databases CINAHL, Medline, Cochrane, Web of Science, EconLit, and Embase and reference lists of included studies. We included any type of study published between 1999 and 2019, in any language, reporting primary data on costs of health care in individuals with dementia approaching the end of life. Two independent reviewers screened all full-text articles. We used the Evers' Consensus on Health Economic Criteria checklist to appraise the risk of bias of included studies.

RESULTS

We identified 2843 articles after removing duplicates; 19 studies fulfilled the inclusion criteria, 16 were from the United States. Only two studies measured informal costs including out-of-pocket expenses and informal caregiving. The monthly total direct cost of care rose toward death, from $1787 to $2999 USD in the last 12 months, to $4570 to $11921 USD in the last month of life. Female sex, Black ethnicity, higher educational background, more comorbidities, and greater cognitive impairment were associated with higher costs.

DISCUSSION

Costs of dementia care rise closer to death. Informal costs of care are high but infrequently included in analyses. Research exploring the costs of care for people with dementia by proximity to death, including informal care costs and from outside the United States, is urgently needed.

Practices, challenges, and opportunities when addressing the palliative care needs of people living with dementia: Specialty memory care provider perspectives

INTRODUCTION

Palliative care focuses on reducing suffering and improving quality of life for individuals with serious illness and their families. In an effort to develop palliative care interventions for specialty memory care clinics, this study characterizes memory care providers' perspectives on addressing palliative care needs of people living with dementia (PLWD).

METHODS

Qualitative interviews with specialty memory care providers were followed by thematic analysis by a multidisciplinary research team.

RESULTS

Provider approaches overlap with key domains of palliative care. Approaches unique to dementia include having a detailed understanding of dementia syndromes, behavioral symptoms, and caregiver burden. Challenges were identified related to disease progression, provider-level factors, and systems and cultural issues. Respondents identified training needed to strengthen a palliative care approach.

DISCUSSION

There are many strengths of using memory care teams to address palliative care needs of PLWD. However, they may require additional knowledge and training to strengthen their work.

Qualitative research on end-of-life communication with family carers in nursing homes: A discussion of methodological issues and challenges

Aim

To identify and summarize the challenges of conducting qualitative research exploring end-of-life communication between healthcare providers and bereaved family carers in nursing homes.

Design

A descriptive qualitative study based on in-the-field-notes and research diaries collected during a primary study involving 32 bereaved family carers and 14 nurses across 13 Italian nursing homes in 2018-2019.

Methods

Two trained female nurses conducted semi-structured, in-depth, open-ended interviews and recorded "in action" (i.e. reflections reported as in-the-field-notes) and "on action" (i.e. retrospective reflections within the team reported immediately in the research diaries) narratives, with the aim of identifying challenges encountered during the research process. A content analysis process was performed to analyse the narratives collected.

Results

We identified three major categories of challenges: (a) obtaining approval from the ethical committee; (b) approaching nursing homes and family carers; and (c) dealing with participant-related impairments (i.e. memory, emotional, physical).

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

Treatment Preferences at the End-of-Life in Parkinson's Disease Patients

Background

Few studies have been performed on palliative care in Parkinson's disease (PD). This study was undertaken to understand treatment preferences of PD patients toward end-of-life care.

Methods

A questionnaire modified from the Willingness to Accept Life-Sustaining Treatment instrument was administered to participants. Four different scenarios based on the burden of care and outcome of the treatment were presented in detail to obtain decisions for end-of-life care. The responses in each scenario were compared between PD patients and controls. Further analyses were performed to identify factors that influenced treatment preferences among PD patients.

Results

In total, 136 PD patients and 60 controls were recruited. Parkinson's disease patients and controls were demographically similar, except that PD patients had more previous hospital admissions (P = 0.0195). Parkinson's disease patients were more likely to opt for high-burden care with poor outcome than controls (odds ratio [OR] = 2.11, P = 0.04).In the subgroup analysis for PD patients, the factors that influenced treatment preference toward end-of-life care were belief in religion (OR: 7.43, 95% confidence interval:1.97-28.07), higher Unified Parkinson's Disease Rating Scale (UPDRS) motor score (2.51, 1.14-5.50) in scenario B; belief in religion (6.93, 2.23-21.43), married patients (6.93, 2.23-21.43) in scenario C; and Chinese patients (0.29, 0.10-0.79), better PD knowledge (0.37, 0.17-0.80), and higher UPDRS motor scores (3.05, 1.35-6.9) in scenario D.

Conclusion

Parkinson's disease patients were more likely to agree to high-burden care with a poor outcome compared to controls. Among PD patients, race, marital status, religious status, knowledge about PD, and severity of motor impairment significantly influenced their end-of-life treatment preferences.