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Palliative Care Consultations in Nursing Homes

By Jaimie Lazare

Older adults who receive palliative care in nursing homes experience less intensive treatments, fewer hospitalizations, better management of symptoms, and an overall improvement in quality of life greater than those who don't receive the care.

For older adults with complex medical conditions, a nursing home frequently becomes their final residence. According to the Centers for Disease Control and Prevention, the population of residents in nursing homes is expected to reach approximately 3 million by 2030. Challenges facing nursing homes include limited resources, high employee turnover rate, and undertrained staff—factors that make it difficult to manage the needs of residents who often have symptoms that go untreated and health care preferences that are unmet.

Data show that early palliative care improves quality of life by communicating with patients and their families to identify health care goals and preferences, manage symptoms such as pain, and make decisions about treatments.1 A study shows that providing palliative care to nursing home residents improves health outcomes.

Early Consults Improve Quality of Care
The three main models used to provide consults in nursing homes include externally based palliative care, hospice-nursing home partnerships, and facility-based palliative care.2 To determine the effect of early palliative care in nursing homes, researchers used data from externally based consultations, resident health assessments, and Medicare claims. The researchers evaluated the medical records of more than 1,500 deceased residents and found that patients experienced fewer hospitalizations and better quality of life when they received palliative care consultations within 180 days before they died.3 The consults were conducted by nurse practitioners who specialize in palliative care and under the supervision of physicians. While certain states require nurse practitioners to practice with direct physician involvement, many other states permit nurse practitioners to practice independently.4

These consults improve the care of nursing home residents, connecting them with palliative care that helps with the management of symptoms and promotes discussions about care preferences and goals of care, says Susan C. Miller, PhD, a professor of health services, policy, and practice at Brown University School of Public Health in Providence, Rhode Island. The study found that residents involved in a consultation within 61 to 180 days before they died experienced significantly fewer hospitalizations in the last week of life (6.9%) compared with the rate for those who didn't receive a consultation (22.9%). For residents who received their first consult eight to 30 days before death, the rate of hospitalization was 11.1%, whereas the rate for the control group was 22%. Based on these findings, the data show that the sooner palliative care discussions occur in nursing homes, the better.

Palliative care consults include two main thrusts: goals of care and management of uncontrolled symptoms, says Mary Ersek, PhD, RN, FPCN, a professor of palliative care and director of the Veterans Health Administration PROMISE (Performance Reporting and Outcomes Measurement to Improve the Standard of Care at End-of-life) Center in Philadelphia. During the consult, the palliative care expert discusses factors such as trajectory of the disease, treatment options, hospitalization, CPR, the use of feeding tubes, and the course of action to take if residents develop pneumonia, a UTI, or some other type of infection. A palliative care consultation underscores the goals of care for residents in nursing homes by asking, "How could we honor this person's values?" Ersek says.

The Costs of Palliative Care
During the last 30 or 60 days before the residents died, the study found that the costs were quite similar between residents who received a consult and those who didn't.Costs were significantly lower for those who received a consult either in the last week of life or during the 60 to 180 days before dying than for residents who opted not to receive a consult.

Hospice is a specific benefit provided by Medicare and requires that a patient has six months or less to live, a criterion that must be certified by two physicians, Miller says. Many nursing home residents receive skilled nursing care, which is a Medicare Part A benefit, but they can't access the Medicare hospice benefit and receive a Part A benefit. If residents are admitted to a hospital or if they if they desire skilled nursing care, they can't accept hospice care because that would mean patients would have to pay for nursing home care out of pocket, she says.

External palliative care experts who provide consultations to nursing home residents bill under Medicare Part B.2 For many providers, however, reimbursement is inadequate for the palliative care services they offer. Miller says the palliative care providers she meets say they do it because they have a sense of mission. These consults are mission driven because experts recognize that certain nursing home residents may need palliative care services, but they don't have a six-month prognosis, she says.

"Palliative care is a visit made to a nursing home resident, but it can be made while they're in skilled nursing. So they have access to palliative care when they are in skilled nursing because they don't have access to hospice," Miller says. "The Medicare hospice benefit is very structured, and there's no palliative care consult benefit. So providers and mostly hospices develop subsidiaries where they provide palliative care consultations in the nursing home, and the way those consults are reimbursed is they bill Medicare Part B for a visit," she explains.

Palliative care experts receive the same visit payment as others billing under a nursing home visit. There's no increase because it's delivered as palliative care. The initial consult can be lengthy because the consultant is assessing a resident's symptoms and the measures required to manage those symptoms, addressing goals of care, and meeting with the family, Miller says.

Ersek points out that some people may not want hospice care for various reasons. For example, the family and patient aren't ready to accept a terminal diagnosis; residents on the hospice benefit give up any opportunities to receive curative therapy for their terminal illnesses; and when people transition from a hospital back to a nursing home, they are often put in skilled nursing, which is a higher level of care than Medicare covers and skilled nursing care and hospice care cannot be accessed at the same time.

Miller notes that nursing homes wanting to invest in their own internal programs need to train staff or hire experts to provide palliative care consults. Creating an internal program takes time and can be costly in terms of training, especially if there's significant staff turnover. If a nursing home is located in a community with experts providing palliative care consults, there isn't a barrier in obtaining a referral for palliative care consults for residents, she says.

Research Goals
Ersek says there are emerging ways to test the effectiveness of providing palliative care consults in nursing homes such as testing models of care. The Centers for Medicare and Medicaid Innovation is funding the second phase of a study that is examining ways to reduce hospitalization and rehospitalization among nursing home residents,5 and this study has a strong palliative care component, she says.

"I would love to see a trial of concurrent care, and concurrent care is allowing people to get care that's more directed at managing the disease but also folds in principles of palliative care," Ersek says. The Centers for Medicare & Medicaid Services (CMS) is funding various concurrent care studies focusing on cancer and other diseases, and Ersek says that she'd like to see concurrent care projects with a focus on nursing homes.

"We really don't have any evidence-based models of care. We have some information about palliative care in hospice, and those are the best studies. There's a little data on external consults, but very little data about homegrown palliative programs that operate within nursing homes," Ersek says. "Typically, concurrent care is best studied in cancer, but there aren't many people with cancer in nursing homes."

Ersek adds that CMS is now allowing patients to receive palliative care and chemotherapy because once patients realize how toxic chemotherapy is, they say, "You know what? I've had enough. I'd rather have a quality of life."

1. Rowland K, Schumann S. Palliative care: earlier is better. J Fam Pract. 2010;59(12):695-698.

2. Bull J. National Hospice and Palliative Care Organization. Palliative care in the nursing home setting. http://www.nhpco.org/sites/default/files/public/palliativecare/PALLIATIVECARE_PC_NursingHome.pdf. Published 2016. Accessed October 1, 2016.

3. Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Hanson. Palliative care consultations in nursing homes and reductions in acute care use and potentially burdensome end‐of‐life transitions [published online September 19, 2016. J Am Geriatr Soc. doi: 10.1111/jgs.14469.

4. Nurse Practitioner Scope of Practice Laws. Kaiser Family Foundation website. http://kff.org/other/state-indicator/total-nurse-practitioners/?currentTimeframe=0&sortModel=%7B"colId":"Location","sort":"asc"%7D. Updated July 24, 2015. Accessed October 1, 2016.

5. Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Phase Two. Centers for Medicare & Medicaid Services website. https://innovation.cms.gov/initiatives/rahnfr-phase-two/index.html. Updated April 8, 2016. Accessed October 1, 2016.