Three San Francisco-based clinicians are raising the red flag about dying patients being unnecessarily cycled back and forth between hospitals and nursing homes, and they have some ideas to fix the practice.
In a Thursday perspective piece in the New England Journal of Medicine, the authors give the example of 87-year-old “Ms. P.” to make their point. After an initial hospitalization for pneumonia, she experienced three transfers back to nursing homes, getting C .Diff and delirium along the way before dying a year after her first hospital encounter.
Authors said they have “seen this cycle in practice” in their work with the San Francisco Veterans Affairs Medical Center, and the Department of Community Health Systems, University of California. They note that, of Medicare beneficiaries who died between 2006 and 2011, one in eight cycled from hospital to SNF back to hospital during the last year of life.
“Often, no one mentions the possibility of death or discusses the goals of care,” wrote Lynn Flint, M.D., Daniel David, R.N., and Alexander Smith, M.D. “In treating discharge to a post-acute care facility as a routine event, we are missing an opportunity to improve care for seriously ill older adults.”
The letter writers offer three possible solutions to end this cycle and stop residents from being “rehabbed to death”:
(1) CMS policies should ensure that financing meets the functional needs of older adults with serious illness. Currently, the Medicare home health benefit does not provide continuous assistance with activities of daily living.
(2) Medicare could pay for nursing home-level care and hospice for persons with functional disability who are nearing the end of life. Under today’s regulations, a Medicare short stay in a post-acute facility must be geared toward improvement. If one’s health is not expected to improve, the only option besides paying out of pocket is spending down one’s savings to quality for Medicaid.
(3) Policy could continue to move toward removing incentives for nursing homes to hospitalize long-stay residents covered by Medicaid. “Higher Medicaid day rates for long-term care might reduce the churn of long-stay residents between hospital and nursing home near the end of life,” they write.
The authors acknowledged that such policy changes would take time, but they said to get started, clinicians should work to improve communication between patients and caregivers.
“Discharge to a post-acute care facility is a pivotal life event for many older adults. Rather than treating it as mundane, we can embrace the opportunity to address crucial issues related to quality of life and goals of care. Existing policy is disease-focused and ignores the critical needs stemming from disability near the end of life. But policy change won’t work if we don’t improve communication at key transition points,” they conclude.
The perspective echoes some concerns raised in an October study last year, contending that nursing homes were increasingly pushing residents into “unnecessary rehab” at the end of life. Providers bristled at last year’s article, but David Gifford, senior VP of quality and regulatory affairs for the American Health Care Association, said this latest piece “makes a number of good points” on addressing the issue.
“Providers need to consider care options for each individual person, based on where they are health-wise and their goals,” Gifford told McKnight’s. “While these discussions should be occurring with all elderly before they get sick, the event of hospitalization or rehospitalization should be a trigger for these kind of important discussions with patients and families.
“It is also important that CMS payment policies support patients remaining in a SNF and covering care, even if they are not improving, when the care helps the patient meet their own health goals, which may be for hospice care,” he added.
