Nearly one in five nursing home residents with advanced dementia experiences burdensome transitions in the last 90 days of life, according to a new study in the New England Journal of Medicine.
The researchers—from Brown University, Harvard University and Dartmouth College—are suggesting that the way Medicare reimburses nursing homes may be a reason for the prevalence of such transitions, saying the providers receive “perverse incentives” under Medicare and Medicaid to encourage nursing homes to send patients to the hospital.
The incentives researchers referred to involve nursing homes earning “higher payments for patients who have been transferred to a hospital for three days” and who may qualify for skilled nursing services paid by Medicare rather than Medicaid upon their return.
“Our research calls for efforts to reform healthcare payment that create incentives to improve advance care planning and care coordination,” said Pedro Gozalo, a Brown University health economist and lead author of the study. “Current reform efforts like accountable care organizations that bundle both the hospital and post-acute care payments could begin to address some of these perverse incentives. We need financial incentives to make sure that people are getting the right care in the right place at the right time.”
The research team analyzed federal databases of nursing home and Medicare records accumulated between 2000 and 2007. In all, they found 474,829 patients who were older than 66, had advanced cognitive impairment and lived in a nursing home 120 days before their death.
Of these, 90,228 residents experienced at least one burdensome transition, defined as either a transfer in the last three days of life, returning to a different nursing home than the one they lived in before they went to the hospital or multiple hospitalizations in the last 90 days of life.
Blacks and Hispanics were also more likely than whites to experience burdensome transitions, researchers said.
Researchers said the transitions are burdensome because they raise the risk of medical errors, interrupt continuity of care for patients and are “often unnecessary,” referring to conditions that may not require patient hospitalization, such as pneumonia, urinary tract infection or dehydration.
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