Hospice Referral after Inpatient Psychiatric Treatment of Individuals with Advanced Dementia from a Nursing Home

Abstract

This report addresses the discharge disposition following inpatient psychiatric treatment for advanced dementia. The total population included 685,305 Medicare fee for service decedents with advanced cognitive and functional impairment with a mean age of 85.9 years who had resided in a nursing home. In the last 90 days of life, 1,027 persons (0.15%) received inpatient psychiatry treatment just prior to the place of care where the individual died. Discharge dispositions included: 132 persons (12.9%) to a medical hospital, 728 (70.9%) to nursing home without hospice services, 73 (7.1%) to hospice services in a nursing home, 32 (3.1%) to home without hospice services, and 16 (1.6%) to hospice services at home. Overall, the rate of referral to hospice services for advanced dementia was relatively low.

Introduction

Dementia is a chronic, progressive terminal illness. Individuals with dementia are at risk for multiple transitions of care and aggressive interventions (1, 2). These interventions are burdensome to the patients and families, and do not alter the ultimate clinical course of the disease (1). Therefore, one avenue for improving the quality of dementia treatment in the United States is to improve access to palliative care and hospice services (3). Use of palliative care (4) and hospice is important because, without it, individuals with advanced dementia are at risk for burdensome care transitions (1), healthcare costs are higher (5), and family caregivers report worse satisfaction with outcomes (6).

Despite the known benefits of hospice, there has been controversy surrounding the promotion of advance care planning and palliative care services for individuals under Medicare (7). Also, specifically regarding dementia, concerns have been raised regarding eligibility criteria for the hospice benefit (8, 9). Nevertheless, use of hospice is generally accepted as an empirically supported beneficial strategy for end-of-life care in advanced dementia.

Psychiatrists have historically supported the use of palliative care and hospice for individuals with advanced dementia (10 – 13). Inpatient psychiatry treatment for behavioral disturbance associated with dementia provides a unique opportunity to consider palliative care (14). Considering hospice eligibility for individuals with advanced dementia, and including this consideration in the treatment plan, can improve the quality of the long-term care of patients while also helping families. Such discussions of advance care planning and shared decision making about hospice can be one important component of the transition to post-hospital services after inpatient psychiatry treatment (15).

In the current study, we sought to determine the frequency of referral to hospice for individuals with advanced dementia following inpatient psychiatric treatment. The purpose of this investigation was to identify the rate of referral to hospice during the observation period (before 2008), in order to consider future studies of factors associated with hospice referral, and the potential development of educational campaigns or interventions to increase access to hospice for individuals with advanced dementia and their families.

Methods

The study population included nationwide data from the Medicare Minimum Data Set (MDS) of individuals residing in a nursing home in the United States. This MDS data was linked with Medicare claims files from 2000 through 2007. The data set was previously studied (1) and eligibility for the current analysis was identical to the original investigation. Specifically, to be included individuals must have been a resident in a nursing home, enrolled in a Medicare fee-for-service plan, be older than 66 years, received a cognitive performance score of 5 or 6 (on a scale ranging from 0 = “intact” to 6 = “very severe impairment”) on the MDS assessment completed closest to 120 days prior to death, and to have died during the observation period. For the current study, we examined the transition for all nursing home residents with advanced cognitive impairment whose next to last location prior to death was the inpatient psychiatric hospital. By definition, this subsample represents nursing home residents with advanced dementia who display behavioral disturbance resulting in admission for acute psychiatric treatment.

This study utilized the Residential History File, which is an algorithm that assigns a location of care for Medicare beneficiary based on Medicare Claims data and the Minimum Data Set (16). A descriptive analysis characterized the rate of persons that had a hospitalization in an inpatient psychiatry facility that preceded the site of death. Univariate analysis examined the sociodemographic characteristics associated with the discharge location using the Chi Square test and student t-test. Analyses were conducted with Stata, version 12.

Results

The total population under investigation included 685,305 individuals with a mean age of 85.9 years (SD = 7.6 years); the population was 75.7% female, 85.2% white not Hispanic, 10.5% African-American not Hispanic and 3.0% Hispanic. During the last year of life 520,293 individuals (75.9%) experienced at least one transition of care to a new treatment environment. Considering the total population, during the last year of life, 2,421 individuals (0.35%) received inpatient psychiatry treatment just prior to the place of care where the individual died. In the last 90 days of life, 1,027 persons (0.15%) received inpatient psychiatry treatment just prior to the place of care where the individual died. For these 1,027 individuals, the mean age was 82.8 years (SD = 7.6 years) and the population was 55.0% female, 93.6% white not Hispanic, 4.0% African-American not Hispanic and 2.1% Hispanic.

Of these 1,027 individuals who were discharged from a psychiatric hospital to the place where death occurred within 90 days, the discharge dispositions included: 132 persons (12.9%) to a medical hospital, 728 (70.9%) to nursing home without hospice services, 73 (7.1%) to hospice services in a nursing home, 32 (3.1%) to home without hospice services, and 16 (1.6%) to hospice services at home (see Table 1). There was no change in the rate of referral to hospice during the observation period.

Table 1.

Percentage of Individuals Not Referred or Referred to Hospice

Referrals Non-Hospice	Referrals Hospice
71% to Nursing Home Without Hospice	7% to Nursing Home With Hospice
3% to Home Without Hospice	2% to Home With Hospice
13% to Medical Hospital
Total: 87% Non-Hospice	9% Hospice

This table represents the discharge disposition of individual with advanced dementia who died within 90 days of discharge from inpatient psychiatry. The percentage are of the total sample (N = 685,305) of individuals with advanced dementia who were residing in a nursing home prior to admission for inpatient psychiatric treatment.

Discussion

Individuals with advanced dementia who reside in a nursing home are a vulnerable population. When a person with advanced dementia is admitted to inpatient psychiatric care, it is important to consider if the person may be near the end of life. There are reliable methods for determining whether an individual with advanced dementia is eligible for hospice (9), and, in general, the time and infrastructure exists during inpatient psychiatric treatment to engage family caregivers in discussions about hospice (13). Yet this investigation shows that for those individuals who undergo inpatient psychiatry treatment and are then discharged to the care environment in which the individual dies within 90 days, only a small percentage (8.7%) are referred to hospice.

The primary limitation of this brief report is that we have no information regarding the factors contributing to the choice of discharge to hospice services. Specifically, this study lacks information regarding the preferences of patients and family caregivers, and similarly lacks information about the opinions of inpatient psychiatry clinicians and the providers of nursing home care during the period of investigation. The study dataset examined decedents in 2000 to 2007 and there have been changes in advocacy and practice regarding hospice services since that time. However, the strengths of this study are in the unique nature of the decedent nursing home cohort and its large sample size; therefore, the results may contribute to healthcare planning for individuals with severe cognitive impairment.

There is room to improve on the quality of care provided to individuals with advanced dementia at the end of life. Evidence has demonstrated they undergo burdensome interventions, that hospice care is underutilized and that they have symptoms that would benefit from hospice care (17 – 19). Estimated rates of hospice use among nursing home patients with advanced dementia vary between 6 – 43% (19); in this context, the current study confirmed a low rate of referral to post-hospital hospice services, showing that for individuals with advanced dementia who undergo inpatient psychiatry treatment within 90 days of death, fewer than 1 in 10 individuals was referred to hospice.

Inpatient psychiatry treatment of advanced dementia provides a unique opportunity to discuss advance care planning. The inpatient psychiatry treatment setting can include support and infrastructure not always present in other hospital environments (such as inpatient medical hospitalization). Clinicians should consider hospice during inpatient psychiatric treatment for advanced dementia and take steps to engage family caregivers in shared decision-making about the potential benefits of palliative care.

In addition to giving greater consideration to hospice as a component of psychiatric post-hospital care for advanced dementia, more research is needed to establish the ability to predict life expectancy for individuals with advanced dementia who undergo inpatient psychiatric treatment for behavioral disturbance. Better understanding of acute psychiatric symptoms during the natural course of advanced dementia will contribute to broad efforts to improve the quality of end-of-life care for individuals with severe cognitive impairment.