Nursing Home Capabilities and Decisions to Hospitalize: A Survey of Medical Directors and Directors of Nursing

Joan L. Buchanan, PhD, Rachel L. Murkofsky, MD, MPH, Alistair James O’Malley, PhD, Sarita L. Karon, PhD, David Zimmerman, PhD, Daryl J. Caudry, SM, and Edward R. Marcantonio, MD, SM

Objectives: To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents.

Design: Cross-sectional survey.

Setting: Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states.

Participants: Medical directors and directors of nursing (DONs).

Measurements: Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice.

Results: The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive.

Conclusion: Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable. J Am Geriatr Soc 2006;54(3):458-465.

Is Hospice Associated with Improved End-of-Life Care in Nursing Homes and Assisted Living Facilities?

Jean C. Munn, MSW, Laura C. Hanson, MD, MPH, Sheryl Zimmerman, PhD, Philip D. Sloane, MD, MPH, and C. Madeline Mitchell, MURP

Objectives: To examine whether hospice enrollment for nursing home (NH) and residential care/assisted living (RC/AL) residents near the end of life is associated with symptoms and symptom management, personal care, spiritual support, and family satisfaction.

Design: Structured, retrospective telephone interviews with family and staff who attended to NH and RC/AL residents in the last month of life.

Setting: A stratified sample of 26 NH and 55 RC/AL facilities in four states.

Participants: Family members (n=97) and long-term care (LTC) staff (n=104) identified as most involved in care of 124 residents who died over a 15-month period.

Measurements: A variety of reported measures of care and symptoms before death, including the Discomfort Scale for Dementia of the Alzheimer’s Type.
nResults: Of 124 decedents, 27 (22%) received hospice services. Dementia was less common in hospice enrollees than in decedents who did not receive hospice care. Hospice enrollees more often had moderate/severe pain and dyspnea and received pain treatment and were more likely to receive assistance with mouth care and eating and drinking. There were no differences related to unmet need, and observed differences were largely eliminated when comparisons were limited to residents whose deaths were expected.

Conclusion: Rates of hospice use observed in this study (22%) were considerably higher than previously reported, although persons with dementia may continue to be underreferred. Hospice use is targeted to dying residents with higher levels of reported pain and dyspnea. Because difference in care largely disappears in cases when death was expected, LTC staff seem to be well positioned to provide end-of-life care for their residents and are advised to remain sensitive to instances in which death may be expected. J Am Geriatr Soc 2006;54(3):490-495.