Hospice enhances nursing home care

Although nursing homes have been slow to offer hospice care to their terminal residents, Brown gerontologists say the program clearly benefits those patients.

by Cynthia Ferguson

Nurses are trained to heal and restore their patients. When they're suddenly asked to help a patient die, it's often a difficult transition.

Ensuring that patients live their final months in physical and emotional comfort has long been a goal of hospice organizations, but until the past decade this care was provided almost exclusively in the home. With one in four older Americans now dying in nursing homes, hospice care increasingly takes place in these settings as well, but not at the rate some would like to see.

In Rhode Island, according to a 1999 study, less than 24 percent of all nursing homes had at least one resident on hospice care, and less than five percent of all Rhode Island nursing homes had more than five percent of their residents enrolled in the program. Nationally, these percentages were 30 percent and 4.2 percent respectively, despite the fact that Medicare has offered hospice as a nursing home benefit since 1985.

"I believe partnerships between nursing homes and hospice can really improve end-of-life care," says Susan Miller, assistant professor in the Center for Gerontology and Health Care Research."On the whole, nursing homes try to do a good job, but they're often short-handed and the turnover of staff is high. Working with hospice gives them an extra set of hands."

It also brings additional expertise in the care of the dying. Miller, who has participated in several studies focusing on hospice and nursing homes, including one that appears in this month's Palliative Medicine, is now working on a model that will help facilitate collaborations of the two organizations. Among the issues hindering wider use of hospice in nursing homes, she says, is the current system of government reimbursement.

In the case of Medicare nursing home residents, who can't access Medicare hospice while in a Medicare bed, there are financial disincentives — for both the facilities and the families — to signing up with hospice. When these residents enroll in Medicare hospice, they must pay for the room and board previously paid by Medicare. Many are then eligible for Medicaid, but because Medicaid payments are lower than those from Medicare, nursing homes receive less for their care. A cumbersome system of passing Medicaid payments through the various parties further deters many nursing homes from contracting with hospice.

In addition, coupling two organizations that each have their own goals and administrative structures is not always easy. Miller's model will address these issues as well, providing guidelines to minimize the bureaucratic obstacles.

Patients are eligible for hospice if a physician certifies that they are within six months of dying from a terminal illness. Traditionally that illness has been cancer, but hospice caregivers increasingly see patients in the final stages of chronic diseases — Alzheimer's and congestive heart failure, for example — where a precise prognosis is far more difficult. Miller notes that the unpredictability of these diseases can lengthen the duration of hospice care, but, she adds,"it is precisely these people, whose numbers are increasing, for whom high-quality end-of-life care may be most lacking."

Central to the hospice concept is the elimination of unwanted and aggressive medical intervention, which often involves costly end-of-life stays in the hospital. Miller and co-authors Pedro Gozalo, also of the Center for Gerontology and Health Care Research, and Vince Mor, professor and chairman of the Department of Community Health, published a study in August showing that nursing home residents who receive hospice care through Medicare are less likely to be hospitalized in their final days of life than those who don't.

In the study published this month, Miller and Mor conclude that the average duration of hospice care for a nursing home resident is comparable to that of a home-based patient — about 90 days. This was half the duration observed in a previous study conducted by the Office of the Inspector General. Unlike that study, which examined stays in a one-month timeframe, Miller and Mor looked at statistics over several years.

Since some nursing homes choose not to contract Medicare hospice care, Miller says this is something to ask about when selecting a residence for a loved one. Miller also found that in facilities that do contract with a hospice organization, referrals to hospice often occur just days before a patient's death. In a survey conducted by Miller, Mor and Joan Teno, also of the Center for Gerontology and Health Care Research, many family members bemoaned the fact that hospice was brought in too late to be of much comfort to them or the patient. In other cases, however, family members praised hospice nurses for advocating more effective pain management and providing additional support.

Miller believes nursing home staff and administrators are becoming more and more receptive to hospice care within their walls. In interviews with Miller, for example, they noted that hospice nurses and caregivers are able to give "extra TLC" and can serve an important role for the family. While some took a more defensive stand, many administrators said the presence of hospice had helped change the attitudes of staff.

"Most nurses want to save the world," observed one administrator. "Seeing patients die in comfort has changed them."