Palliative Care should be incorporated into SNF

From Medscape: Palliative Care Should Be Incorporated Into SNF Care

Almost one third of elderly adults are cared for in a skilled nursing facility (SNF) in the last 6 months of life and receive the Medicare post-hospitalization benefit. Of those, 1 in 11 die, suggesting that palliative care should be incorporated into SNF care, according to a new analysis.
Katherine Aragon, MD, from the Division of Palliative Care at the University of California, San Francisco, and colleagues reported their findings online October 1 in the Archives of Internal Medicine.

According to the researchers, SNF is used in cases where patients’ symptoms are difficult to manage during hospitalization, and it often serves as a bridge "between the hospital and the home."

Medicare beneficiaries are entitled to up to 100 days of SNF care if they have been hospitalized for 3 or more days and have a need for skilled care at discharge, such as "rehabilitation, intravenous medications, and wound care." However, if a patient is in a nursing home under the Medicare SNF benefit, Medicare regulations prohibit concurrent enrollment in the hospice benefit for the same diagnosis. In addition, switching from SNF care to hospice care may have financial implications for the patient because the hospice benefit does not cover room and board.

The current study sought to determine more about SNF use near the end of life by analyzing data from the Health and Retirement Study, a nationally representative longitudinal survey of older adults, collected from January 1994 through December 2007.

Among 5163 individuals included in the analysis, the mean age at death was 82.8 years. Just more than half were female, and about one fourth had lived in a nursing home.

Of the participants, 30.5% had used the SNF benefit in the last 6 months of life, and 9.2% died while in an SNF. A greater use of the SNF benefit was associated with patients who were older than 85 years and who had at least a high school education. Patients were also more likely to use SNF care if they did not have cancer, they resided in a nursing home, they used home health services, or they were expected to die soon (P < .01 for all).

Among participants living in the community who had received the SNF benefit, 42.5% died in a nursing home, 10.7% died at home, 38.8% died in the hospital, and 8.0% died elsewhere.

By contrast, among those living in the community who did not use the SNF benefit, only 5.3% died in a nursing home, 40.6% died at home, 44.3% died in the hospital, and 9.8% died elsewhere.

"Our finding that Medicare decedents commonly used SNF care at the end of life suggests a need to better understand who is using the SNF benefit and whether they are receiving care that matches their goals," Dr. Aragon and colleagues conclude.

They add that "the needs that necessitate SNF use are the same indicators of an end-of-life trajectory seen in frail elders. Honest and frank discussions about goals of care not only in the hospital but once they are admitted to a SNF may allow an earlier introduction to palliative care."

In a related editorial, Peter A. Boling, MD, from the Division of General Medicine, at the Virginia Commonwealth University, Richmond, points out that the "findings in this study indicate a need for additional attention to trajectories, goals of care, and payment policy in the context of long-term care."

"Without doubt, the SNF benefit is too often used on admission to nursing homes for patients in whom the expected outcome is death because of incentives for the facility and financial burdens on the family that come from using the Medicare hospice benefit at the outset of nursing home care."

Arch Intern Med. Published online October 1, 2012.