Palliative Care Consultations in Nursing Homes and End-of-Life Hospitalizations

Abstract

Context: Although specialty palliative care in hospital and outpatient settings is associated with lower acute care use, its impact in U.S. nursing homes (NHs) is unknown.

Objectives: To understand how NH use of palliative care consults is associated with end-of-life hospitalizations.

Methods: Seven consult providers in four states and 24 counties shared data on the number of consult visits and residents served (per NH) in study years 2000-2010. All NHs in the 24 counties were studied (n = 286). An NH-level longitudinal file included consult data, aggregated Medicare resident assessment and claims data, and NH characteristics. Consult introduction was "yes" when 1% of residents received consults. Volume was the number of consult visits per 100 residents, annually. Panel multivariate regression with NH fixed effects examined whether rates of hospital deaths and hospitalizations in the last 30 days of life differentially changed for NHs introducing consults, or increasing consult volume.

Results: One hundred seventy (59%) of the 286 NHs introduced consults by 2010. NHs with consults, compared to others, had residents with higher acuity and functional impairment, and lower nurse but higher nursing assistant staffing. Controlling for covariate differences and compared to NHs without consults, NHs introducing consults had a 1% (95% CI -0.021, 0.002) greater reduction in hospital death rates and a 1.6% (95% CI -0.031, -0.002) greater reduction in hospitalizations in the last 30 days of life. No statistically significant associations between volume and study outcomes were observed.

Conclusion: The introduction of specialty palliative care consults in NHs is associated with overall reductions in end-of-life hospitalizations.

Keywords: Medicare; Palliative care; consults; hospice; nursing homes.

Figure 1. The Changing Palliative Care Visit Volume^a: Nursing Homes That Introduced Consults At Some Point during Study Years 2000–2010^b

^aNumber of palliative care visits annually per 100 unduplicated nursing home residents ^bIncludes 1,835 nursing home study years. Many nursing homes did not have (external) palliative care consults available in the early years and some facilities introducing consults reduced their use in the later years.