Dying nursing home (NH) residents are frequently hospitalized within the last 30 days of their lives, resulting in worse health outcomes and high Medicare costs. While it has been shown that hospice use leads to lower hospitalization rates among hospice enrollees, it is unclear how the attributes of NH-hospice collaborations - specifically the volume of hospice use and exclusivity of the collaboration (i.e. whether a NH primarily collaborates with one versus two or more providers) - are associated with hospitalizations among all NH dying residents (NH-hospice collaborations may also benefit non-hospice residents through spill-over effects). The rapid growth of hospice providers in NH markets and substantial geographic variations in such growth provide us with an opportunity to study the relationship between changing attributes of NH-hospice collaborations and end-of-life (EOL) hospitalizations. The long-term goal is to understand the approaches that can be used to improve palliative care for dying residents and to reduce costs. The objective of this study is to understand how specific attributes of NH-hospice collaborations are associated with EOL hospitalizations in NH. The rationale is that this study will pave the way for further in-depth studies of the causal relationship between NH-hospice collaborations and EOL hospitalizations, and ultimately provide guidance for better hospice palliative care delivery to all dying NH residents. Using national data from 2000-2009, this study has two aims.
Aim -1 is to examine the relationship between attributes of NH-hospice collaborations and EOL hospitalizations by testing the following 2 hypotheses among ALL NH decedents. (1) A resident is less likely to be hospitalized in the 30 days before death if residing in a NH with a higher volume of hospice use, accounting for the level of exclusivity of NH-hospice collaborations;and (2) A resident is likely o be hospitalized in the 30 days before death if residing in a NH with an exclusive relationship with a hospice provider, accounting for the volume of hospice use.
Aim -2 is to explore whether the relationship identified in Aim-1 varies across states with different growth rates of hospice providers. This study is innovative because it is the first study to examine the relationship between exclusivity of NH-hospice collaborations and EOL hospitalizations, and it extends existing research by examining the effect of hospice use among all NH dying residents rather than only hospice enrollees. It also takes advantage of both longitudinal data and the geographic variations in the growth rates of hospice providers to minimize the potential bias in the estimated relationship between NH-hospice collaborations and EOL hospitalizations. This study is significant because it will add to our understanding of how NH-hospice collaborations can improve care, specifically EOL hospitalizations, for all dying NH residents. The findings will be important both for policymakers to evaluate the costs and benefits of hospice use, and for NH providers to make informed decisions about collaborating with hospices. Ultimately, reducing EOL hospitalizations will not only improve the quality of life for dying residents, but alo save Medicare costs.
The proposed study is highly relevant to public health because knowledge about the association between nursing home-hospice collaborations and end-of-life hospitalizations will enlighten our understanding of how to improve nursing home palliative care provision. These findings from this study are important both for policymakers to evaluate costs and benefits of hospice use, and for NH providers to make informed decisions about collaborating with hospices. This proposal is consistent with the Mission of the National Institute on Aging in that it addresses the special needs of aging individuals at the end of their life, specifically, reducing potentially unnecessary hospitalizations so that their quality of lifewill be improved and Medicare costs may be reduced.