1. Robin E. Remsburg, PhD, APRN, BC Beth Han, PhD, MD, MPH National Center for Health Statistics U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention Hospice and Palliative/End of Life Care in Nursing homes

2. Introduction (1) Hospice, a form of end-of-life care, emphasizes comfort, pain relief, and emotional and spiritual support. Hospice care in nursing homes offers a collaborative opportunity for nursing homes and hospices to provide end-of-life care to nursing home residents, including high-quality pain and other symptoms management. About 76% of nursing homes in the U.S. contracted with hospices in 2000. Less than 5% of those who died in nursing homes in 1997-1998 received hospice care based on data from either the National Center for Health Statistics or the National Hospice and Palliative Care Organization. About 25% of the Americans who died in 2000 were under hospice care at the time of death.

3. Introduction (2) Providers face challenges in coordination and care planning for hospice and EOL patients in nursing homes, including high staff turnover and limited hospice/EOL training among nursing home staff; cultural and philosophical differences between hospices and nursing homes; Medicare nursing home regulations and reimbursement rules which encourage skilled nursing care over the Medicare Hospice Benefit programs.

4. Purposes The purposes of this study are: To estimate the prevalence of skilled nursing homes with special programs and trained staff for hospice and EOL care in the U.S. To examine facility characteristics associated with skilled nursing homes with special programs and trained staff for hospice.

5. Methods (1) Study Population and Survey Data from 2004 National Nursing Home Survey Cross-sectional study Nationally representative data on hospice, palliative/end of life care Universe of approximately 17,000 nursing homes –Licensed by the state; 3 or more beds Sample of 1,500 nursing homes A total of 1,174 nationally representative nursing homes were examined. Data collection methods –In-person interview –Administrator –Staff informant –Medical and facility records

6. Question Please tell me if this facility has a special program that has specially trained personnel dedicated to the program for anything listed on this card. Hospice Palliative/End of Life Care/Terminal Condition-Not hospice Pain management ………

7. Methods (2) We examined ownership statusownership status chain affiliationchain affiliation bed sizebed size formal contract for hospiceformal contract for hospice characteristics of top management (administrator, DON, medical director)characteristics of top management (administrator, DON, medical director) regionregion MSA statusMSA status percentage of Medicaid residentspercentage of Medicaid residents medical caremedical care staffing stabilitystaffing stability Cochran-Mantel-Haenszel tests at the bivariate level and multivariate logistic regression modeling were used. SUDAAN software was used to adjust for the complex sampling design and sampling weights.

8. Preliminary Result (1) In 2004, 78% (95% CI: 76%-80%) of nursing homes had formal contracts with outside hospice programs 26% (95% CI: 24%-28%) of nursing homes had special programs and trained staff for pain management 19% (95% CI: 17%-21%) of nursing homes had special programs and trained staff (SPTS) for hospice 17% (95% CI: 15%-19%) of nursing homes had special programs and trained staff for palliative/end of life care

9. Facility characteristics associated with special programs and trained staff for hospice: Bivariate analysis Facility Characteristics Has special program for hospice, n=222 Does not have special program for hospice, n=952 P value Facility ownership For-profit Private nonprofit Government 54% 40% 6% 63% 29% 8% 0.0098 Bed size <=99 >=100 45% 55% 53% 47% 0.0383 Chain affiliation Yes (%)53%54% 0.8591 Formal contract with outside hospice programs Yes (%)87%76% <0.0001 Program for pain management Yes (%)57%18% <0.0001

10. Facility Characteristics (cont.) Special program for behavior problems Yes (%) 48%18%<0.0001 Region Northeast Midwest South West 18% 27% 44% 11% 17% 34% 31% 18% 0.0025 No. days/ month medical director works 1 2-3 4 >=5 Unknown 11% 13% 42% 26% 8% 14% 19% 28% 29% 10% 0.0049 Physician on staff (not medical director) Yes No Unknown 23% 76% 11% 16% 75% 9% 0.0273

11. Facility characteristics associated with nursing homes with special programs and trained staff for hospice care: Multivariate analysis Facility Characteristics OR (95% CI) OR (95% CI) OwnershipFor-profitNot-for-profitGovernment Reference group 1.76 (1.21-2.58) 0.97 (0.48-1.94) RegionNortheastMidwestSouthWest 0.62 (0.37-1.04) 0.43 (0.28-0.66) Reference group Reference group 0.51 (0.30-0.88) Physician on staff (excluding medical director) YesNoUnknown 1.66 (1.10-2.51) Reference group 1.00 (1.00-1.01)

12. Facility characteristics (cont.) No. days per month medical director works at the facility 12-34>=5Unknown 1.65 (0.94-2.92) 1.24 (0.72-2.15) 2.11 (1.33-3.33) Reference group 1.18 (0.50-2.77) Special programs and trained staff for pain management Yes vs. No 4.41 (2.97-6.55) Special programs and trained staff for behavior problems Yes vs. No 2.40 (1.61-3.58) Formal contract with outside hospice programs Yes vs. No 1.96 (1.20-3.20)

13. Discussion Strengths –Nationally representative data –New information on EOL care Limitations –Facility report –No information on personnel or training (e.g., ELNEC)

14. Summary Preliminary analyses indicate that not-for-profit ownership status, formal contract with outside hospice, special programs and trained staff for pain management and behavior management, physician(s) (non-medical director) on staff, medical director who works four days, and being located in South are associated with having a special program and trained staff on hospice care.

15. Implications These data provide some insight into ways end of life care is being provided in nursing homes that may beyond traditional hospice care Physician involvement may be important in establishing EOL care programs/practices Nursing home residents can present special care giving challenges, e.g., symptom and pain management in residents with dementia; specially trained staff and special may be a way to meet these special needs More recent approaches to EOL care include blending of aggressive and palliative care; special training and programs may be a way to address this new care approach