RPD124 - Nursing Homes Impact Hospice Care for Connecticut Medicaid Decedents with Serious Illnesses

Key Message : Hospice care is underutilized in Connecticut, which has 19,430 residents living in nursing homes (NHs) of whom 71% with care paid for by Medicaid.
This mixed methods study examines how NHs stays and NH characteristics influence use of hospice care for adults with serious illnesses and Medicaid insurance in Connecticut.

Abstract: Hospice care is underutilized in nursing home (NH) populations for unclear reasons1. 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 42,717 Medicaid-insured decedents with serious illnesses in Connecticut from 01/01/2017-09/30/2024. Overall, 26,302/42,717 (61.6%) individuals had a NH stay ≤6 months of death, 19,935 (46.7%) received hospice care ≤6 months of death, and 7,876/19,935 (39.5%) had short hospice care (≤ 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 lowest for individuals with stays at NHs that had the highest (vs lowest) CMS quality measures rating (Odds Ratio:0.59 [Confidence Interval 0.49,0.71]), and higher at NHs that were part of a chain (1.16 [1.09,1.22], or had an Alzheimer’s unit (1.1 [1.04,1.19]). 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 hospice benefiting NH patients and staff, leveraging care planning meetings for hospice education/discussions, and acute care use triggering hospice discussions. Overall, Connecticut Medicaid individuals with (vs without) 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. The inverse relationship between CMS ratings and hospice use may warrant additional research and consideration of how current CMS ratings might capture end-of-life care.

References: 1. Dillon, E., Shugrue, N., Migneault, D., Lee, C.M., Wakefield, D., Charles, D., Richards, B., & Robison, J. (2024). Less Hospice Use and Shorter Hospice Lengths of Stay for Connecticut Medicaid Decedents With Short-Term and Long-Term Nursing Home Stays Compared with Decedents Remaining in Community Homes. Journal of Palliative Medicine. doi: 10:1089/jpm.2024.0244.