Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life

J Am Geriatr Soc. 2016 Feb;64(2):314-22. doi: 10.1111/jgs.13939.


Objectives: To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care.

Design: Retrospective cohort study.

Setting: One hundred percent fee-for-service Medicare decedent claims data.

Participants: Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life.

Measurements: Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings.

Results: Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition.

Conclusion: A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.

Keywords: end-of-life care; hospice; transitions in care.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Continuity of Patient Care*
  • Female
  • Hospice Care / statistics & numerical data*
  • Hospitalization / statistics & numerical data*
  • Humans
  • Male
  • Medicare
  • Patient Transfer
  • Retrospective Studies
  • Terminal Care / statistics & numerical data*
  • United States