Improving Quality of Life and Care at the End of Life

Purpose: Hospitalization of nursing home residents can be traumatic and lead to iatrogenic problems and lowered quality of life. Hospitalization also places an enormous economic burden on an already overtaxed healthcare system. Hospitalization for “ambulatory care sensitive” (ACS) conditions is considered unnecessary, as these are physical health conditions that can be treated safely in a nursing home. Despite concerns about the frequency with which elders are transferred to hospitals for ACS conditions, the prevalence, risk factors and cost of these transfers among nursing home residents are not well understood. This retrospective study examined prevalence rates and risk factors of ACS hospitalizations. Specifically, we examined resident characteristics (i.e., age, race, diagnosis, and service use) and nursing home characteristics (e.g., ownership and quality of care) in relation to hospitalization for ACS conditions. We also investigated potential disparities by examining ACS hospitalization rates by race and mental health status.

Methods: This study used three years of Medicaid eligibility, fee-for-service, and Online Survey Certification and Reporting (OSCAR) data to identify nursing home resident and facility characteristics. Resident characteristics including age, gender, and race/ethnicity were extracted from Medicaid enrollment data. Physical and mental health diagnoses were determined by ICD-9-CM codes found in the Medicaid outpatient and inpatient claims files. We estimated relative risk of ACS hospitalization using Cox proportional hazards regression. A 95% confidence interval was used, setting the significance level at a two-tailed .05. All available individual and facility characteristics were mutually controlled in the analysis.

Results: We identified at least one ACS hospitalization for 8,382 residents (11.6% of residents in the study) for a total of 10,091 ACS hospital admissions (18.2% of all hospitalizations). Average age of subjects was 77 years, average time to an ACS hospitalization from admission to the nursing home was 487 days (standard deviation [SD] = 349 days, median = 418 days). Average length of stay in the nursing home for residents was 677 days. The Cox proportional hazard analysis showed that being non-White was associated with a 35% increased risk of ACS hospitalization, and having a dementia diagnosis, major psychotic disorder, bipolar disorder, and major depressive disorder increased the risk by 44%, 44%, 79%, and 54%, respectively. Alcohol and drug use disorders were also independently associated with increased risk. With regard to facility characteristics, ACS hospitalization rates were higher in for-profit facilities, facilities with a higher proportion of Medicaid enrolled residents, and those with less than 120 beds.

Implications: Reducing unnecessary hospitalizations of nursing home residents represents an important opportunity for social workers, policy makers, and providers to reduce costs while improving quality of life and care for residents at the end of life. Data suggest unnecessary hospitalization might be prevented by improved quality of care and access to psychiatric treatment within the nursing home. Findings support a need for increased social worker involvement to ensure that the mental health needs of residents are addressed.