Nursing Home Culture Influences Hospice Utilization

Abstract

What determines whether an eligible nursing home resident receives hospice care? Familial reluctance and financial disincentives can play a role in hospice underutilization, but so can staff attitudes about end-of-life care. A small-scale, qualitative study involving interviews with staff at two nursing homes — facilities in the same state and part of the same for-profit company — illustrates the role of staff beliefs and daily work routines on hospice utilization. Both nursing homes had the same policies and access to hospice care, yet 76% of residents in one facility died on hospice while only 24% in the other facility did so. Staff attitudes and organizational practices are a “crucial factor in shaping whether or not a person gets hospice in a nursing home when clinically appropriate,” said Jason Rodriquez, PhD, and Kathrin Boerner, PhD, both of the University of Massachusetts (J Aging Stud 2018;46:76–81). Their sample comprised 21 staff members who had a role in hospice utilization, from the medical directors, directors of nursing, and unit managers, to floor nurses, social workers, and directors of social services. Investigators used a conversational “responsive interviewing” technique in which they asked staff to describe their experiences — including interactions about hospice with residents, family members, and colleagues — and to share any challenges they perceived. The staff at both facilities told the researchers that families could be skeptical about the benefits of hospice care or reluctant to consent to hospice for their loved one because it seemed like a “death wish.” Staff at both homes also said cracks in the reimbursement system created financial barriers for some residents and prevented their hospice utilization. In both facilities, they brought up an example of a post-acute resident who was deemed to be at the end of life but had to choose whether to take Medicare’s coverage for skilled nursing or its hospice benefit, yet the staff recalled this happening rarely. At the site with high hospice use, the staff conveyed with “near uniformity” that hospices provide valuable care that goes above and beyond what the nursing home could provide. Some spoke specifically about the bereavement care provided to the families. The facility’s administrator credited their social workers for the high rate of hospice use, saying they “go into great detail” in explaining hospice care. Notably, the medical director also was a board member of a nearby hospice organization that had a working relationship with several nursing homes, including his. At the site with lower hospice use, some staff shared these positive views, but an “influential group” — which included the medical director and the director of social services — “insisted that hospice was essentially the same as nursing homes’ own end-of-life care . . . and was an unnecessary duplication of services.” They viewed it as a potential disruptor of the continuity of care, the investigators wrote. Staff at the site with low hospice use took a reactive approach, generally waiting for families to broach the topic. By contrast, the staff at the other facility took a proactive approach and initiated the conversations with residents and families when clinically appropriate. Recent data suggest that nearly 20% of all hospice enrollees in the U.S. are receiving care in nursing homes, the investigators noted. “To increase hospice utilization, efforts should be made to educate nursing staff [about] the extra benefits hospice provides, particularly to families of residents, which go beyond what nursing homes can do with their in-house staff,” they wrote. Christine Kilgore is a freelance writer in Falls Church, VA.