Objective Use of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff towards hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers towards hospice care in nursing homes. Design, Setting and Participants We conducted a survey of 1,859 staff from 52 Indiana nursing homes. Measurements Study data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: 1) makes their job easier; 2) is responsive when a patient has symptoms or is actively dying; 3) makes care coordination smooth; 4) is needed; 5) taught them something; 6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never. Results 1229 surveys met criteria for inclusion. Of respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was ‘patient/family appreciate added care’ (84%); the lowest was ‘hospice makes my job easier’ (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (p=.03 and p=.05 respectively). Conclusion A majority of staff responded favorably regarding hospice care in nursing homes. About 1/3 of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.
BACKGROUND:For nursing home patients, hospice use and associated costs have grown dramatically. A better understanding of hospice in all care settings, especially how patients move across settings, is needed to inform debates about appropriateness of use and potential policy reform. OBJECTIVE: Our aim was to describe characteristics and utilization of hospice among nursing home and nonnursing home patients. DESIGN AND PARTICIPANTS: Medicare, Medicaid and Minimum Data Set data, 1999-2008, were merged for 3,771 hospice patients aged 65 years and above from a safety net health system. Patients were classified into four groups who received hospice: 1) only in nursing homes; 2) outside of nursing homes; 3) crossover patients utilizing hospice in both settings; and 4) "near-transition" patients who received hospice within 30 days of a nursing home stay. MAIN MEASURES: Differences in demographics, hospice diagnoses and length of stay, utilization and costs are presented with descriptive statistics. KEY RESULTS: Nursing home hospice patients were older, and more likely to be women and to have dementia (p<0.0001). Nearly one-third (32.3 %) of crossover patients had hospice stays > 6 months, compared with the other groups (16 % of nursing home hospice only, 10.7 % of nonnursing home hospice and 7.6 % of those with near transitions) (p<0.0001). Overall, 27.7 % of patients had a hospice stay <1 week, but there were marked differences between groups-48 % of near-transition patients vs. 7.4 % of crossover patients had these short hospice stays (p<0.0001). Crossover and near-transition hospice patients had higher costs to Medicare compared to other groups (p<0.05). CONCLUSIONS: Dichotomizing hospice users only into nursing home vs. non-nursing home patients is difficult, due to transitions across settings. Hospice patients with transitions accrue higher costs. The impact of changes to the hospice benefit on patients who live or move through nursing homes near the end of life should be carefully considered.
Objectives To examine impact of hospice use on costs, we analyzed costs for long-stay (> 90 days) nursing home decedents with and without hospice care. Design Retrospective cohort study using a 1999-2009 dataset of linked Medicare, Medicaid claims and Minimum Data Set Assessments. Setting Indiana nursing homes. Participants 2,510 long stay nursing home decedents. Measurements Medicare costs were calculated for multiple time periods prior to death – 2, 7, 14, 30, 90, and 180 days; Medicaid costs were also calculated for dual eligible patients. Total costs and costs for hospice, nursing home and inpatient care are reported. Results Of 2,510 long stay nursing home decedents, 35% received hospice. Mean length of hospice was 103 days (median 34 days). Compared to non-hospice patients, hospice patients were more likely to have cancer (p<.0001), a DNR order in place (p<.0001), higher levels of cognitive impairment (p=.0002) and worse activities of daily living function (p<.0001). Hospice patients were less likely to have had a hospitalization in the year prior to death (p<.0001). In propensity score analyses, hospice users had lower total Medicare costs for all time periods up to and including 90 days prior to death. For dual eligibles, overall costs and Medicare costs were significantly lower for hospice patients up to 30 days prior to death. Medicaid costs were not different between the groups except for the 2 day time period. Conclusion In this analysis of costs to Medicare and Medicaid among long stay nursing home decedents, use of hospice did not increase costs in the last 6 months of life. Evidence supporting cost savings are sensitive to analyses that vary the time period before death.
In a linear, bureaucratic world, accountability in the public service should be readily defined-assigned to public actors with one level reporting to, and accountable to, the next higher level. In reality, in a constitutional republic of shared and fragmented power with both government and non-governmental actors, the question of accountability is more complex. Public administrators working in a bureaucratic framework clearly answer directly to their managers/executives and the political agency heads. But does that answer the question of accountability? This Roundtable will explore the question of whom leaders in the public service are accountable to and how they acquire their normative foundation for ethics and accountability.
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