The U.S. Office of Inspector General created controversy by questioning the equity of hospice visits provided in nursing homes versus in the community. However, there were no available hospice visit data or empirically based information to address OIG's concern. Unknown is how visit volume varies by care setting (nursing home versus community), and within care setting, by patient characteristics, length of stay, and time periods prior to death. The influence of local healthcare markets and state regulatory environments on visit utilization and site of care provision (nursing home versus community) is also unknown. The proposed study will use data from a national hospice provider organization to examine site of care and visit utilization for close to 39,000 hospice patients. The evaluation of market and state regulatory influences on site of care and visit utilization will result in hypotheses to be tested in planned subsequent research including a wider range of hospice providers.
The specific aims of this study are: 1) Controlling for a market's number of nursing home beds: i) to describe how a program's proportion of patients cared for in nursing homes varies by hospice market penetration and state of patients cared for in nursing homes. 2) To describe how visit intensity (i.e., ratio of visits to routine days of care) varies by care setting (nursing home versus community), and within care setting, by patient race/ethnicity, gender, age, diagnosis, length of stay, whether discharge or death, and by time periods prior to death. 3) To jointly model the rates of visits and survival within nursing home and community settings to determine the effect of patient characteristics on rates of visits, controlling for survival time; and 4) Too examine hospice visit intensity (i.e., ratio of visits to routine home care days) in order to generate testable hypotheses for the observed differences in relation to: i) local nurse and aid labor market, ii) hospice penetration (i.e., providers and their size) in the local healthcare market, and iii) state differences in survey/oversight regarding the allowed flexibility in the use of agency staff. The information emanating from the proposed and subsequent planned work is important to policymakers and hospice providers in assuring equitable and appropriate serve provision and payment.
