Hospice Use, Hospice Quality, and Related End-of-Life Outcomes in Nursing Homes (Hospice in NH)

The "Hospice Use, Hospice Quality, and Related End-of-Life Outcomes in Nursing Homes (Hospice in NH)" study will address the gaps in knowledge about differences in nursing home hospice use, quality of hospice care, and end-of-life outcomes.

Columbia University School of Nursing is conducting the study in partnership with MJHS Health Systems and the RAND Corporation.

The National Institutes of Health’s National Institute of Nursing Research is funding this project (R01NR020601).

Background:

In the US, approximately 15,600 NHs provide long-term care to more than 1.3 million older adults.^1-4More than 40% of NH residents have advanced illness, which is defined as occurring when one or more conditions become serious enough that general health and functioning decline and treatments begin to lose their impact.^5-7Prior to the 2020 public health emergency, 27% of US deaths in adults aged 65 and older occurred in NHs, making EOL care important in this setting.⁸Differences have been found across NHs including in EOL care.^9-12

Hospice, a government benefit program that provides EOL services delivered by an interdisciplinary specialist team, is available in most NHs.^1,13Hospice care decreases resident symptom burden, reduces unnecessary and burdensome care near the EOL, and increases the quality of life for the resident and family.^14-17Hospice enrollment is a best practice for EOL care and is recommended for all patients with advanced illness with a life expectancy ≤ 6 months.^18,19Yet, only 33% of those dying in NHs have enrolled in hospice, and 31% of NH residents that enrolled did so in the last week of life.²⁰

Little is known about the multiple factors (i.e., individual, NH, hospice and community level variables) influencing differences in hospice enrollment or hospice quality of care among NH residents.^21-25NH mortality tragically increased by 32% during the 2020 public health emergency, raising concerns about what happened to hospice enrollment, hospice quality of care, and related EOL outcomes in NHs. ^26-29Furthermore, as mortality increased in 2020, in most states the percent of those dying who enrolled in hospice decreased; yet, there is no information about how the public health emergency changed the use of hospice in NHs or if any changes had lasting effects. 

Study Goals

To address these gaps, we will conduct a mixed-methods (administrative data and qualitative interviews with administrators, hospice care professionals, and caregivers at nursing homes), sequential explanatory study guided by Donabedian’s Quality Framework.^30-31

The results from this study will inform evidence-based policies at the national, state, and nursing home level as well as influence practice-based initiatives that can promote access to high-quality hospice for Americans living and dying in nursing homes.

Study Aims:

1. Identify the multiple factors associated with differences in hospice enrollment and hospice quality of care over time, and how these relationships changed during the public health emergency.
2. Identify differences in NH EOL outcomes over time, the multiple factors that influence these differences, including hospice enrollment and the quality of hospice care, and how the public health emergency changed these differences.
3. Describe perceived facilitators and barriers that contribute to hospice use, the quality of hospice care, and related EOL outcomes among NH residents.