Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.T hose writing on the quality of nursing home care have, for the most part, framed the discussion in terms of its uniformly poor quality and have largely ignored the prospects and implications of a two-tiered system differentiated by quality. In contrast, our article provides evidence of a two-tiered system of nursing home care. The lower tier consists of facilities with high proportions of Medicaid residents and, as a result, very limited resources. Thus, stratification affects the number, type, and quality of services provided to residents of lower-tier facilities, who are disproportionately poor and from minority

Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n=270 202), 2005 (n=291 819), or 2009 (n=286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Comparing 2000, 2005, and 2009 shows a decrease in deaths in acute care hospitals and increases in intensive care unit (ICU) use in the last 30 days, hospice use at the time of death, and health care transitions at the end of the life (test of trend P < .001 for each). 200020052009No. of decedents270 202291 819286 282Deaths in acute care hospitals, % (95% CI)32.6 (32.4–32.8)26.9 (26.7–27.1)24.6 (24.5–24.8)ICU use in last month of life, % (95% CI)24.3 (24.1–24.5)26.3 (26.1–26.5)29.2 (29.0–29.3)Hospice use at time of death, % (95% CI)21.6 (21.4–21.7)32.3 (32.1–32.5)42.2 (42.0–42.4)Health care transitions in last 90 d of life per decedent, mean (median) (IQR)2.1 (1.0) (0–3.0)2.8 (2.0) (1.0–4.0)3.1 (2.0) (1.0–5.0)Health care transitions in last 3 days of life, % (95% CI)10.3 (10.1–10.4)12.4 (12.3–12.5)14.2 (14.0–14.3) In 2009, 28.4% (95% CI, 27.9%–28.5%) of hospice use at the time of death was for 3 days or less. Of these late hospice referrals, 40.3% (95% CI, 39.7%–40.8%) were preceded by hospitalization with an ICU stay. Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

The majority of older Americans whose underlying cause of death is attributable to dementia on their death certificate die in nursing homes. State-level factors, including the availability of hospital and nursing home beds and the age of decedents in the population, explain, in part, the wide state-to-state variability in the proportion of dementia-related deaths occurring in the hospital.