National Home And Hospice Care Survey Research Articles

When Home Hospice Patients Discharge to Nursing Home: A Mixed Method

Background: Hospice care is to provide necessary medical care and support for patients and the families at the end of life (EOL). Hospice care patients typically withdraw from aggressive treatment. Even though home hospice has been shown to improve the quality of care, home hospice patients still revoke the services for various reasons. A little is known about where home hospice patients are being transferred. This study aims to address this gap and explore common reasons for home hospice discharge and placements, where patients being transferred other than home. Methods: Data were retrieved from the 2007 National Home and Hospice Care Survey (NHHCS). NHHCS is one in a series of nationally representative sample surveys of U.S. home health and hospice agencies. Results: Within identified home hospice patients, approximately 82.1% were deceased at discharge, and 846 (18.2%) were discharged for other reasons, including patients being stabilized or improved (30.2%), aggressive treatment (31.8%), moved (e.g., geographically, 13.5%) and others. Patients lived with a spouse were less likely to utilize external resources, like volunteers, thereby more likely to discharge patients to long-term facilities. Discussion: The current study suggest that it is difficult for the family to give all remaining care for their loved ones despite the support and resources for those home hospice patients. The characteristics of those who transferred to nursing facilities from home hospice will be discussed throughout.

Addressing the Gap: OT in Hospice Care

Abstract Date Presented 03/27/20 This study addresses a gap in knowledge regarding OT in hospice care. We examined patient profiles and services provided and compared demographics and outcomes for patients with versus without OT in the context of hospice care. We analyzed the de-identified data retrieved from a large national survey: The National Home and Hospice Care Survey (NHHCS) of 2007. Primary Author and Speaker: Emily Mueller Additional Authors and Speakers: Chih-Ying Li

PC-FACS

PC-FACS

Cost effectiveness in palliative care setting

PurposeThe purpose of this paper is to determine the cost effectiveness of palliative care on patients in a home health and hospice setting. Secondary data set was utilized to test the hypotheses of this study. Home health care and hospice care services have the potential to avert hospital admissions in patients requiring palliative care, which significantly affects medicare spending. With the aging population, it has become evident that demand of palliative care will increase four-fold. It was determined that current spending on end-of-life care is radically emptying medicare funds and fiscally weakening numerous families who have patients under palliative care during life-threatening illnesses. The study found that a majority of people registering for palliative and hospice care settings are above the age group of 55 years old.Design/methodology/approachDifferent variables like length of stay, mode of payment and disease diagnosis were used to filter the available data set. Secondary data were utilized to test the hypothesis of this study. There are very few studies on hospice and palliative care services and no study focuses on the cost associated with this care. Since a very large number of the USA, population is turning 65 and over, it is very important to analyze the cost of care for palliative and hospice care. For the purpose of this analysis, data were utilized from the National Home and Hospice Care Survey (NHHCS), which has been conducted periodically by the Centers for Disease Control and Prevention’s National Center for Health Statistics. Descriptive statistics, χ2 tests and t-tests were used to test for statistical significance at the p<0.05 level.FindingsThe Statistical Package for Social Sciences (SPSS) was utilized for this result. H1 predicted that patients in the age group of 65 years and up have the highest utilization of home and hospice care. This study examined various demographic variables in hospice and home health care which may help to evaluate the cost of care and the modes of payments. This section of the result presents the descriptive analysis of dependent, independent and covariate variables that provide the overall national estimates on differences in use of home and hospice care in various age groups and sex.Research limitations/implicationsThe data set used was from the 2007 NHHCS survey, no data have been collected thereafter, and therefore, gap in data analysis may give inaccurate findings. To compensate for this gap in the data set, recent studies were reviewed which analyzed cost in palliative care in the USA. There has been a lack of evidence to prove the cost savings and improved quality of life in palliative/hospice care. There is a need for new research on the various cost factors affecting palliative care services as well as considering the quality of life. Although, it is evident that palliative care treatment is less expensive as compared to the regular care, since it eliminates the direct hospitalization cost, but there is inadequate research to prove that it improves the quality of life. A detailed research is required considering the additional cost incurred in palliative/hospice care services and a cost-benefit analysis of the same.Practical implicationsWhile various studies reporting information applicable to the expenses and effect of family caregiving toward the end-of-life were distinguished, none of the previous research discussed this issue as their central focus. Most studies addressed more extensive financial effect of palliative and end-of-life care, including expenses borne by the patients themselves, the medicinal services framework and safety net providers or beneficent/willful suppliers. This shows a significant hole in the current writing.Social implicationsWith the aging population, it has become evident that demand of palliative/hospice care will increase four-fold. The NHHCS have stopped keeping track of the palliative care requirements after 2007, which has a negative impact on the growing needs. Cost analysis can only be performed by analyzing existing data. This review has recognized a huge niche in the evidence base with respect to the cost cares of giving care and supporting a relative inside a palliative/hospice care setting.Originality/valueThe study exhibited that cost diminishments in aggressive medications can take care of the expenses of palliative/hospice care services. The issue of evaluating result in such a physically measurable way is complicated by the impalpable nature of large portions of the individual components of outcome. Although physical and mental well-being can be evaluated to a certain degree, it is significantly more difficult to gauge in a quantifiable way, the social and profound measurements of care that help fundamentally to general quality of care.

Use of Medical Devices in Hospice for Symptom Management.

Home health services in the United States(US) have been on a rise. Hospice patients cope with diverse physical and pain symptoms; medical devices are used for symptom management to improve their quality-of-care at end-of-life. Using the National Home and Hospice Care Survey (NHHCS), the study summarizes medical device use for symptom management and tracks various demographic variables for home hospice patients. A cross-sectional analysis of data using the 2007 NHHCS was conducted. There were 4733 hospice discharges which corresponded to 2,505,011 individuals in US with sampling weights. The data was analyzed using chi square tests and confounding factors adjusted with logistic regression. Eighty-nine percent of hospice discharges were evaluated for pain at first assessment. The regression model for pain at first assessment was significantly associated with use of patient controlled analgesia (OR = 1.82, 95% CI = 1.28, 2.59) and urinary catheters (OR = 1.16, 95% CI = 1.02, 1.33). Patient with dyspnea were associated with significant use of oxygen (OR = 3.00, 95% CI = 2.64, 3.40) and metered dose inhaler (OR = 2.43, 95% CI = 1.92, 3.07). There was negligible use of total parenteral nutrition (TPN) noted in the study. In conclusion, the study highlights medical device use in home hospice care for end-of-life symptom management. It noted the significant use of IV infusion pumps and patient controlled analgesia. Conversely, there is little use of TPN or CPAP in patients with anorexia or dyspnea. While missing data on critical symptom evaluations regrettably raises questions about the validity of the study, the NHHCS serves as an important reservoir of data on the growing population of home hospice patients.

Prevalence, Patterns and Predictors of Psychotropic Polypharmacy Among Elderly Individuals with Parkinson's Disease In Long Term Care Settings In The United States.

Elderly individuals with Parkinson's disease (PD) generally suffer from more than one psychiatric comorbidity, which necessitates the use of concurrent psychotropic medications. To the best of the author's knowledge there are no nationally representative estimates of psychotropic polypharmacy among elderly individuals with PD in the United States (US). Therefore, the primary objective of this study was to examine the prevalence, patterns and predictors of psychotropic polypharmacy among elderly individuals with PD in the (US). A retrospective, cross-sectional study design with 2004 National Nursing Home Survey (NNHS) and 2007 National Home and Hospice Care Survey (NHHCS) data was used. The analytic sample included elderly (age ≥65 years) individuals with PD. Antidepressants, antipsychotics, sedative/hypnotics, and anti-anxiety medications constituted the psychotropic medication classes. Concurrent use of two or more psychotropic medications was classified as psychotropic polypharmacy. Approximately 93,648 and 37,439 elderly individuals with PD resided in nursing homes and home health settings respectively. Among elderly nursing home residents with PD, the nationally representative prevalence of psychotropic polypharmacy was 26.28%, whereas, it was 21.36% in the home health setting. Use of antidepressant medications constituted the majority of the psychotropic medication use among both nursing home (48.91%) and home health (40.98%) residents with PD. Multiple logistic regression analyses revealed that specific comorbidities were significantly associated with psychotropic polypharmacy among elderly nursing home residents with PD. These findings underscore the importance of evidence-based prescribing when psychotropic medications are used in elderly individuals with PD to reduce unnecessary polypharmacy.

Abstract 270: Emergency Service Use in Heart Failure Patients on Hospice

Introduction: Emergency service use should be almost non-existent among hospice patients, as hospice is intended to provide for all care needs at the end of life. Cancer patients comprise almost 50% of hospice patients nation-wide and have relatively low rates of emergency service use while on hospice care. Hospice enrollment has been steadily increasing among patients with heart failure, but concerns have been raised about how well hospice care meets these patients’ needs. Emergency service use is one indicator of how well heart failure patients’ needs are met on hospice. Objective: To explore whether emergency service use is higher among heart failure patients on hospice as compared to cancer patients on hospice and reasons for this potential disparity. Methods: This is a secondary analysis of the 2007 National Home and Hospice Care Survey (NHHCS). Only hospice patients with heart failure (n=311) and hospice patients with breast, prostate, colon or lung cancer (n=946) were included in the analysis. Emergency service use was measured by response to NHHCS question 73 (“did the patient use one or more types of emergent care?”) and includes the use of both emergency room and outpatient (urgicenter) services. Multiple logistic regression was used to examine the relationship between emergency service use and diagnosis. All analyses were adjusted for hospice length of stay, patient age, race/ethnicity, caregiver relationship, number of comorbidities, functional status, cognitive function and place of care. Results: Subjects (M age 75.3, SD 12.68) were 51% female and 89% white. The rate of emergency service use was 9.6% among the cancer patients and 17.36% among heart failure patients. Heart failure patients were almost two times more likely to utilize emergency services (OR 1.96, p&lt;.002). Among the covariates examined, only hospice length of stay was significantly associated with emergency service use (p&lt;.000), but did not appear to make a clinically significant difference (OR 1.003). Conclusions: While this study lends support to the hypothesis that heart failure patients suffer unmet care needs while on hospice, the nature of these unmet needs should be further explored. Outcome disparities have previously been suggested to be due to differences in age, comorbidities and functional status between the heart failure and cancer populations, but this study does not support that hypothesis. Hospice care plans unique to the heart failure patient should be considered.

Infections in Long‐Term Care Populations in the United States

To estimate infection prevalence and explore associated risk factors in nursing home (NH) residents, individuals receiving home health care (HHC), and individuals receiving hospice care. Cross-sectional. Nationally representative samples of 1,174 U.S. NHs in the 2004 National Nursing Home Survey (NNHS) and 1,036 U.S. HHC and hospice agencies in the 2007 National Home and Hospice Care Survey (NHHCS). A nationally representative sample of 12,270 NH residents, 4,394 individuals receiving HHC, and 4,410 individuals receiving hospice care. International Classification of Diseases, Ninth Revision, Clinical Modification, codes were used to identify the presence of infection, including community-acquired infection and those acquired during earlier healthcare exposures. Unweighted response rates were 78% for the 2004 NHHS and 67% for the 2007 NHHCS. Approximately 12% of NH residents and 12% of individuals receiving HHC had an infection at the time of the survey interview, and more than 10% of individuals receiving hospice care had an infection when discharged from hospice care. The most common infections were urinary tract infection (3.0–5.2%), pneumonia (2.2–4.4%), and cellulitis (1.6–2.0%). Short length of care and recent inpatient stay in a healthcare facility were associated with infections in all three populations. Taking 10 or more medications and urinary catheter exposure were significant in two of these three long-term care populations. Infection prevalence in HHC, hospice, and NH populations is similar. Although these infections may be community acquired or acquired during earlier healthcare exposures, these findings fill an important gap in understanding the national infection burden and may help inform future research on infection epidemiology and prevention strategies in long-term care populations.

Characteristics of hospice patients utilizing hospice inpatient/residential facilities.

Given the increasing popularity of a hospice inpatient/residential facility (HIRF) among hospice patients and their family members, examining who uses HIRFs has been of increasing importance. Using the 2007 National Home and Hospice Care Survey (NHHCS), we found that about 14% of the hospice patients received care in an HIRF in 2007. Characteristics of patients associated with HIRF use largely match the industry norm for a general inpatient level of care and include having no caregiver or having an incapable caregiver; having imminent death; and being directly admitted to a hospice after discharge from a hospital. Given a recent stricter enforcement of reimbursement rules, however, we call for close monitoring of any change in the number of HIRF beds--particularly in rural and low-income urban areas.

P04.08. Predictors of dietary supplement (DS) use among persons receiving home health care: findings from the 2007 national home and hospice care survey (NHHCS)

Methods Data were from the 2007 NHHCS a nationally representative probability sample survey. Medical records of 4,683 current home health patients (Weighted N=1,459,900) were sampled from 677 participating home health agencies (Weighted N=12,300). Therapeutic classes analyzed were Nutritional Products (NP) (vitamins and minerals alone or in combination) and Non-vitamin, Non-mineral Dietary Supplements (NVNMDS). Multivariate analyses were used to examine the independent roles of demographic and health factors with use of NP and NVNMDS, and the association of NP and NVNMDS with pain and pain management strategies. Variables in the multivariate analyses were age, sex, race, number of chronic conditions, whether the patient lived alone and/or had a caregiver, mobility, cognitive impairment, medication assistance and primary payor.

Inappropriate Medication in Home Health Care

To the Editor: We read with interest the study by Bao and colleagues examining the use of Beers-defined potentially inappropriate medications among older patients receiving home health care (HHC) services in the United States.1 Ensuring proper medication use especially in older adults remains a public health priority, and the authors argue that HHC patients may be at high risk for using ineffective or unsafe medications likely due to their often complex medication regimens and multiple physician prescribers. The study analyzes the 2007 National Home and Hospice Care Survey (NHHCS), a nationally representative survey of U.S. home health and hospice care agencies that collected data on current HHC patients and hospice care discharges.2 Bao and colleagues restricted their analysis to HHC patients who were age 65 or older and used at least one medication (n = 3,124). The authors, however, did not differentiate between patients receiving and patients not receiving end-of-life (EOL) care. According to NHHCS, we calculated that 15% (weighted) of HHC patients in their study had a medical prognosis indicating a six-month-or-less life expectancy and received “palliative, end of life, or terminal care instead of active or curative treatment.” It is important for the Bao et al. study to distinguish between HHC patients who did and who did not receive EOL care. While the 2003 Beers list is commonly used to define medications to avoid among older patients3 (albeit not without controversy), there is no clear consensus about which medications are unsuitable for older patients receiving EOL care. The validity of the Beers list as a prescribing quality indicator to assess EOL treatment is disputable in principle and evidence.4 Research has argued that short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines that are on the Beers list may be clinically appropriate for older patients receiving EOL care whose goal of care is to manage pain and other distressing symptoms.5 Furthermore, although long half-life benzodiazepines generally should be avoided in older patients according to Beers, withdrawing a long half-life benzodiazepine may pose unnecessary, significant risk for major withdrawal symptoms in older patients receiving EOL care.6 Consequently, the examination of inappropriate medication use among HHC patients without differentiating between those receiving and those not receiving EOL care raises concerns about the Bao et al. study findings and their suggested policy and practice implications. In general, applying the Beers list to examine medication appropriateness in older adults should be performed judiciously in settings where EOL care is provided.

Datapoints: Psychotropic Drug Use Among Elderly Patients in Home Care in the United States

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Psychotropic Drug Use Among Elderly Patients in Home Care in the United StatesVishal Bali, M.S., Satabdi Chatterjee, M.S., and Rajender R. Aparasu, Ph.D.Vishal BaliSearch for more papers by this author, M.S., Satabdi ChatterjeeSearch for more papers by this author, M.S., and Rajender R. AparasuSearch for more papers by this author, Ph.D.Published Online:1 Jan 2012https://doi.org/10.1176/appi.ps.2012000p6AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail An estimated 1.5 million persons in the United States receive home-based care involving a range of therapeutic and medical services (1). Most patients who receive home-based health care are elderly, with various levels of functional impairment. Although psychotropic medications are extensively used in the elderly population, limited data exist on the psychotropic needs of elderly home health patients.Psychotropic medication use was examined among elderly home health care patients age 65 and older by using the 2007 National Home and Hospice Care Survey (NHHCS), a national survey of U.S. home health and hospice agencies (2). Patient data for the NHHCS were obtained from interviews with designated agency staff members, who provided information from medical and medication administration records. Descriptive statistics, including 95% confidence intervals (CIs), were used to examine prevalence patterns of psychotropic drug use.More than a half million of the elderly home health care patients received at least one psychotropic agent—.54 million patients (CI=.50–.58) or 53.52% of the elderly patients (CI=50.60–56.44). As shown in Figure 1, antidepressants were the most frequently prescribed psychotropic agents (33.51%, CI=30.71–36.31), followed by sedatives-hypnotics-anxiolytics (30.65%, CI=27.96–33.34), mood stabilizers (9.87%, CI=8.15–11.59), and antipsychotics (7.55%, CI=6.08–9.03). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently prescribed antidepressants (21.83%, CI=19.39–24.28), and benzodiazepines constituted a majority of the sedatives-hypnotics-anxiolytics prescribed (21.30%, CI=18.93–23.68).This study found that the overall prevalence of psychotropic use among elderly home health care patients was 54%, nearly 10 percentage points less than psychotropic use in nursing homes (63%) (3). The high prevalence of psychotropic use among home health care patients was mainly driven by the use of SSRIs and benzodiazepines. Given the inappropriate use of psychotropic agents among elderly patients and the poor health status of those receiving home health care, there is a need to monitor use of psychotropic drugs in this vulnerable population.The authors are affiliated with the Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, TX 77030 (e-mail: [email protected]edu). Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column.Acknowledgments and disclosuresThe authors report no competing interests.References1 Caffrey C , Sengupta M , Moss A , et al.: Home Health Care and Discharged Hospice Care Patients: United States, 2000 and 2007. National Health Statistics Reports, 38. Hyattsville, Md, National Center for Health Statistics, 2011 Google Scholar2 2007 National Home and Hospice Care Survey and National Home Health Aide Survey. Atlanta, Ga, Centers for Disease Control and Prevention, 2007. Available at www.cdc.gov/nchs/data/nhhcsd/NHHCS_NHHAS_web_documentation.pdf Google Scholar3 Bhattacharjee S , Karkare SU , Kamble P , et al.: Psychotropic drug utilization among elderly nursing home residents in the United States. Psychiatric Services 61:655, 2010 Link, Google ScholarFigures and TablesFigure 1 Psychotropic medication use among elderly home health care patients in 2007 FiguresReferencesCited byDetailsCited ByEuropean Geriatric Medicine, Vol. 8, No. 1 Volume 63Issue 1 January 2012Pages 6-6 Metrics Acknowledgments and disclosuresThe authors report no competing interests.PDF download History Published online 1 January 2012 Published in print 1 January 2012

Ethnic Variation in Timing of Hospice Referral: Does Having No Informal Caregiver Matter?

The length of hospice stay, as an indicator of timing of hospice referral, is an important outcome to examine in end-of-life care because it is relevant to the quality and cost efficiency of end-of-life care that patients receive. Although the majority receives nonmedical care from informal caregivers, many elderly hospice users rely on paid caregivers or staff of residential facilities. This study examined whether availability of informal primary caregiver interact with ethnicity to affect length of hospice stay. A retrospective cross-sectional study. Data on 3024 hospice patients aged 65 and older discharged between 1997 and 2000 was extracted from the National Center for Health Statistics' National Home and Hospice Care Survey (NHHCS). Length of hospice stay prior to death or discharge. Survival analysis revealed that among patients with formal caregivers, minority patients were likely to have significantly shorter hospice stays than non-Hispanic whites. There were no significant ethnic differences in length of stay among patients with informal caregivers. Our findings suggest that ethnic differences in length of stay should be discussed in terms of type of caregiver, not just type of setting, since patients in residential facilities can have informal primary caregivers who are vigilant advocates for their dying relatives. We discuss possible reasons for the influence of having formal caregivers on length of stay of minority elders.

Charity for the dying: who receives unreimbursed hospice care?

Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey. We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset. Overall, only 3% of hospice patients received unreimbursed care. Because 98% of older adults are eligible for Medicare, we stratified multivariate analysis on age greater or less than 65 years. Among persons less than 65 years of age, younger, nonwhite persons were more likely to receive unreimbursed care, as were persons with cancer. Agencies providing unreimbursed care to persons over the age of 65 years were more likely to be not-for-profit and freestanding. Recipients of unreimbursed hospice care are demographically similar to the uninsured, and whether uninsured persons receive unreimbursed hospice care depends on clinical and agency organizational factors related to the motivation to provide unreimbursed care.

Predictors of live hospice discharge: data from the National Home and Hospice Care Survey (NHHCS).

In the context of the current regulatory environment, patients may be discharged from hospice if their condition stabilizes or improves over time and the certifying physician is unable to provide a conscientious recertification of the six-month prognosis. Little is known about the characteristics or outcomes of patients who are determined by physicians to no longer be eligible for hospice care. This retrospective study was designed to characterize the rates and predictors of live hospice discharge using data from the 1996 and 1998. National Home and Hospice Care Survey (NHHCS). We compare records of live hospice discharge with hospice discharges due to death from the discharge patient files of the 1996 and the 1998 NHHCS. Of the 807,733 patients in the combined 1996 and 1998 NHHCS discharge patient file who met study inclusion criteria, 761,858 (94 percent) were deceased and 45,875 (6 percent) were discharged alive. Those who were discharged alive were more likely to be female, have received hospice care for more than 60 days, and to have had a noncancer diagnosis, particularly advanced cardiopulmonary or neurologic disease. Mean age and total number of assistive medical devices used did not differ significantly between patients who were discharged alive and those who died in hospice care. Factors most associated with live hospice discharge, using bivariate analyses, were length of service greater than 60 days (OR, 6.60; 95 percent CI, 6.47-6.73), cardiopulmonary diagnosis (OR, 3.24; 95 percent CI, 3.19-3.30), and neurologic diagnosis (OR, 2.73; 95 percent CI, 2.67-2.79). Multivariate logistic regression identified length of service greater than 60 days, cardiopulmonary diagnosis, neurologic diagnosis, female gender, worse functional status, and living in an institutional setting as being independently associated with live hospice discharge. We found that patients who were discharged alive from hospice care were more likely to have longer lengths of service, noncancer diagnoses, and better functional status than those who died while receiving hospice care. Age was not associated with discharge disposition. Given the demonstrated differences between these patients and those who died while receiving hospice care, these data provide further impetus for careful study of the appropriateness of current hospice eligibility criteria, the determinants of hospice discharge and, most important, the outcomes of patients who are discharged alive from hospice and the impact of hospice discharge on patients and their families.