One fifth of Medicare nursing home patients with advanced Alzheimer’s or dementia were sent to hospitals for questionable reasons in their final months, often enduring tube feeding and intensive care.
Researchers suspect that it’s not a coincidence, since Medicare pays a nursing home about three times the normal daily rate when it takes patients back after brief hospitalizations. A group of researchers from Brown University, Harvard University and Dartmouth Medical School studied about 475,000 nursing home patients who had been transferred to hospitals. Among them, 19 percent were moved for questionable reasons.
The large state-by-state variation suggested that extra Medicare money may be playing a role. The rates of dubious transfers ranged from 2 percent in Alaska to more than 37 percent in Louisiana. (Dubious or “burdensome” transfers occured when a patient was moved in the last three days of life, moved several times in the last three months of life, or moved into a new nursing home after hospitalization.)
Transfer rates also varied greatly among cities. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration — conditions that usually can be treated in a nursing home. That figure compares to just 1 percent in Grand Junction, Colo.
(Interestingly, McAllen was the subject of a 2009 story in The New Yorker because it spends more per person on healthcare than any other city with the exception of Miami, which has much higher labor and other costs. In 2006. Medicare spent $15,000 per enrollee in McAllen, nearly twice the national average.)
Medicare pays on average $175 per day, depending on the state, for long-term care. Nursing homes can receive three times that amount after patients return from hospitalizations of at least three days. For nursing homes just scraping by, this opportunity creates a tremendous incentive to hospitalize patients.
Researchers found that patients who had dubious transfers were more likely to have feeding tubes inserted, to spend time in intensive care in the last month of life, to have a severe bedsore, or to be enrolled in hospice late (three days or less before they died).
Dubious care was more common with blacks and Hispanics and those without advance directives that spell out the patient’s care wishes.
The study was published in the New England Journal of Medicine. See http://www.nejm.org/doi/full/10.1056/NEJMsa1100347
Tips for Getting the Best Nursing Home Care
Beth Kallmeyer , who runs programs for caregivers for the Alzheimer’s Association, has these suggestions for caregivers whose patients are admitted to nursing homes:
- Have a plan in place, with legal documents like a “do not hospitalize” directive.
- Whenever possible, involve patients in planning the care they want, and make sure their directives — like “do not resuscitate” or “do not call 911” — are carefully observed.
- Develop good relationships with nursing home staff and physicians, so they understand the patient’s and family’s goals of care.
- Consider hospice care for seniors with advanced dementia (see “The Best Way To Die” post below).
- Review and revise the plan whenever there’s a change in a loved one’s status.
- Seek advice. The Alzheimer’s Association has a 24-hour toll-free number (800-272-3900) with counselors to help families.