http://www.denverpost.com/nationworld/ci_18999626?source=rss


One-fifth of Medicare nursing-home patients with advanced Alzheimer's or other dementias were sent to hospitals or other nursing homes for questionable reasons in their final months, often enduring tube feeding and intensive care that prolonged their demise, a new study found.

Nursing homes may feel hospital care is warranted when a frail, elderly patient develops swallowing problems, pneumonia or a serious infection, but researchers suspect a different motive for many transfers: money. After a patient is hospitalized for at least three days, Medicare pays about three times the normal daily rate for nursing homes to take patients back — three times the rate paid by Medicaid, which funds such long-term care for many.

"I think that's unfortunately a factor in what's happening here," said Dr. Joan Teno, a palliative-care physician and health policy professor at Brown University​. "A lot of this care just feels like in and out, in and out. You really have to question, is the health care system doing a good job or not."

Teno is a co-author of the study, published in today's New England Journal of Medicine and done with researchers from Harvard University and Dartmouth Medical School.

Among the nearly 475,000 patients studied, 19 percent were moved for questionable reasons. The study provided no evidence that money motivated such transfers or that there was wrongdoing involved. However, the large variation that researchers saw from state to state suggests money may be playing a role.

Rates of such transfers varied from 2 percent in Alaska to more than 37 percent in Louisiana. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration — conditions that usually can be treated in a nursing home. That compares with just 1 percent of patients in Grand Junction.

The researchers used Medicare records from 2000 through 2007 to identify "burdensome" transitions of care: moving patients in the last three days of life, moving them multiple times in the last three months of life, or moving them so they landed in a new nursing home afterward.

Medicaid pays on average $175 per day, depending on the state, for long-term care, but Medicare will pay three times that for skilled nursing care after a patient returns from three days or more in a hospital.

"If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people," Teno said.

Researchers found that patients who had a dubious transfer were more likely to have a feeding tube inserted, to spend time in intensive care in the last month of life, to have a severe bedsore or to be enrolled in hospice late (three days or less before they died).

Dubious transfers were more common with black patients, Hispanics and those without advance directives, legal documents spelling out care wishes.

The National Institute on Aging sponsored the study. One author consults for a nursing- home system and owns stock in a long-term-care information services company.

Beth Kallmyer, who runs programs for caregivers for the Alzheimer's Association, said the most important thing is to have a plan in place, with legal documents like "do not hospitalize" directives, before a nursing home has to make a decision about whether to hospitalize someone or instead focus on comfort care and not try to prolong life.

Caregiver tips

• Involve patients in planning their care while they're still able to do so, and make sure wishes like "do not resuscitate" or "do not call 911" are spelled out in legal documents.

• Develop good relationships with nursing home staff and attending physicians so they understand the family's goals of care.

• Consider hospice care when seniors with advanced dementia are admitted.

• Revisit and review the plan whenever there is a change in a loved one's status. Someone may not be end-stage when they enter a nursing home, but that can change.

• Seek advice. The Alzheimer's Association has a 24-hour toll-free number, 800-272-3900, with counselors to help families.
The Associated Press