Research Finds Home-Based Care Among Top End-of-Life Trajectories for Americans

A recent study dug into the most common care setting trajectory patterns among older adults in the United States approaching the end of life.

Many elderly Americans follow one of three place of care trajectories during the last three years of life, researchers from Rutgers, The State University of New Jersey, found in a study recently published in BMC Geriatrics. These include the home, skilled home care and institutional care.

The study spanned data among 199,828 Medicare decedents 50 and older who died in 2018. More than half (59%) spent the last three years of life in the home. About 27% were in skilled nursing home care with “heavy use” of home health and hospice. The remaining 14% of Medicare decedents spent these years in institutional settings, particularly in nursing facility-based care and inpatient care.


The findings could help to inform personal and societal care planning at the end of life, researchers stated in the study.

“Where and when patients receive care in institutional versus home settings has important implications for personal and societal care planning, health care costs and quality of life,” the researchers wrote in the study. “

The study aimed to characterize patterns in the time and duration of facility-based and skilled home care utilization in each quarter of the last three years of life. Researchers examined the sociodemographic, clinical and regional factors associated with variations in place of care trajectories.


Several factors impact where a patient receives end-of-life care, including medical, socioeconomic, geographic and demographic aspects, the study found.

Black patients, women, individuals with a dementia-related diagnosis and those with Medicaid insurance were some of the most common factors associated with both skilled home and institutional care settings in the last years of life, according to the research.

“The ability of patients, caregivers and communities to support aging in place is impacted by advanced illness and the presence of multiple chronic conditions, including Alzheimer’s disease and other dementias,” researchers stated. “Place of care decisions are impacted by patients’ clinical condition, availability of family caregiving, insurance factors and local community and health system characteristics.”

Longer skilled home care stays were more prevalent in specific regions across the country, specifically southern states. This compared to a trend of more facility-based care utilization in the Midwest. Extended use of skilled home care or facility-based care was more frequent among seniors with multiple chronic conditions, including dementia, the research found.

Overall, the majority of older adults with advanced illness in the United States are hospitalized at least once during the last six months of life, researchers found.

A need exists for greater insights and understanding around care setting trajectory during the last year of life as aging populations swell nationwide, researchers indicated. Additional data could help to improve access and utilization of home-based care and reduce rising health care costs at the end-of-life, they said.

“Of particular importance from a clinical and state health policy perspective is eligibility and access to long-term support and services, including home- and community-based care and institutional care,” researchers said. “A better understanding of the health care systems and policy factors that influence place of care trajectories may help to advance the triple aim of improving the experience of care and health of the population and reducing the costs of care.”

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