Nursing Homes Impact Hospice Care for Connecticut Medicaid Decedents with Serious Illnesses

TL;DR

This study explores why hospice care is underused in nursing homes for Medicaid patients in Connecticut and identifies factors that influence hospice utilization.

Contribution

The study combines quantitative and qualitative methods to reveal how nursing home characteristics and workflows affect hospice care use.

Findings

Nursing home residents had higher hospice use rates than non-residents, but long-term stays were linked to lower odds of hospice use.

Facilities with chains, Alzheimer’s units, and lower quality ratings were more likely to use hospice care.

Barriers included rehabilitation focus, staffing issues, and policy disincentives, while facilitators included acute care triggers and education.

Abstract

Hospice care is underutilized in nursing home (NH) populations for unclear reasons. This mixed methods study analyzed Connecticut Medicaid, Medicare, Minimum Data Set, and NH characteristics data; and thematically analyzed 14 in-depth interviews with hospice and NH professionals about hospice care in NHs. The cohort included 39,633 Medicaid-insured decedents with serious illnesses in Connecticut from 2017-2023. Overall, 24,512 (61.9%) individuals had NH stays and 18,428 (46.5%) received hospice care ≤ 6 months of death, 7,265 (39.4%) with short hospice length of stay (≤ 7 days). Individuals with NH stays (versus without) had higher rates of hospice use (49.0% versus 42.4%). However, in multivariable analysis long-term NH stays were associated with reduced odds of hospice use. Among those with NH stays, the odds of receiving hospice care were higher for individuals with stays at NHs that were part of a chain, had an Alzheimer’s unit, and had lower CMS quality ratings. Interviews revealed barriers to hospice use including the focus on rehabilitation, policy disincentives, NH workflows/priorities, and staffing: “They miss the fact that someone’s declining if it’s a slow decline or if there’s a lot of different nurses caring for residents.” Facilitators include acute care use triggering hospice discussions, hospice benefitting NH patients and staff, and leveraging care planning meetings for hospice education/discussions. Overall, Connecticut Medicaid individuals with NH stays had lower odds of receiving hospice care, but certain NH characteristics, workflows, education, and policies influenced the likelihood of receiving hospice care and could be mechanisms for policy and practice change.