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A dearth of coordination or integration between rehab teams and palliative care teams routinely forces some patients into a cycle between the hospital and the nursing home in their last year of life.
These results appeared in a 2019 New England Journal of Medicine study titled “Rehabbed to Death.” Rehabilitation therapy, or post-acute care, aims to assist patients in recovering daily life skills — such as walking or swallowing — following an injury or illness. Older adults frequently utilize such services, often in skilled nursing facilities (SNF).
Even more so, specific Medicare and Medicaid policies perpetuate this cycle. As the study explains, nursing homes are incentivized to hospitalize residents eligible for both Medicare and Medicaid because those patients can later return to the nursing home with a higher-paying Medicare benefit before transitioning back to long-term care with lower Medicaid day rates.
“Hospice services right now really can’t be provided concurrent with SNF care, which means if a person is approaching the end of their life, if they’re really doing poorly, many times the easiest route is back to the hospital,” the study’s lead author, Dr. Lynn Flint, told Palliative Care News.
In the study, researchers present the case of an independent 87-year-old woman with moderate dementia admitted to the hospital with pneumonia. After experiencing a functional decline at the hospital, the woman, no longer able to live at home safely, was sent to an SNF for post-acute care, covered by Medicare. There, she developed an infection and was readmitted, continuing the cycle. After exhausting her Medicare benefits, she depleted her assets and paid out of pocket until qualifying for Medicaid. The repeated hospitalizations persisted until her death — she never returned home.
“Because this is such a vulnerable time for people, I think that having palliative care available, at the very least, can help address some of those issues, which are really not addressed in the current model at all,” Flint, clinical professor in the Division of Geriatrics at the University of California at San Francisco and an outpatient palliative care physician, said.
According to statistics cited in the study, 23% of hospitalized Medicare beneficiaries were discharged to a post-acute care facility in 2013. Additionally, among beneficiaries who died between 2006 and 2011, one in eight toggled between a hospital and an SNF during their final year of life, the study found.
Dr. Sarguni Singh, a hospitalist researcher and assistant professor in the division of Hospital Medicine at the University of Colorado School of Medicine, argues that providers are increasingly sending sicker and sicker patients to skilled nursing facilities for rehab without fully understanding who truly benefits from it.
“A lot of those patients who are in that facility are kind of on the cusp, meaning they could do well but if they have one kind of insult … it could really tip them over the edge and they could pass away quickly,” Singh said. “There are many people who are walking this tightrope in the nursing facility.”
According to Singh, integrating palliative care into rehab therapy could involve implementing some kind of measure in nursing facilities to identify high-risk patients and then requiring palliative care and SNF clinicians to see those patients and their families regularly.
In a GeriPal Podcast episode sponsored by UCSF’s Division of Palliative Medicine, Singh explains that care teams likely struggle to identify patients stuck in this hospital-SNF cycle given all the shift work and team transitions. Remedying this dilemma could involve providing nursing teams with more information about the patients in general, including their medical diagnoses and past patterns of health care utilization, Singh said.
Both Singh and Flint also advocate for initiating goals of care conversations earlier in the process to better understand the wishes of the patients and their families.
Such an integrated care model would give providers a better understanding of patients’ goals and what outcomes they’re likely to achieve with rehab therapy, Singh said. Additionally, toward the end of their stay, clinicians could evaluate whether the patients met those goals and then reassess care strategies as needed.
“Palliative care can help you better understand who is benefiting from therapy, and then who is not and how we can best support them in that space,” Singh said.
Flint said she has seen models with palliative care practitioners who provide in-person consultations to patients referred for services, as well as outside teams who offer remote consultations. But in general, these are extremely uncommon within the short-stay SNF setting, she said.
Flint added that additional training for nursing home staff and rehab professionals could help bridge the gap between the two specialties without adding more personnel or programs.
“I think there is definitely a growing interest among rehab professionals to learn more about palliative care and how to bring that to the therapies they’re doing and conversations they’re having with families and patients,” Flint said.
However, current health policies don’t necessarily encourage a close collaboration between these two teams.
As noted in the study, home health benefits provided by Medicare do not adequately cover hands-on care for daily living activities. Medicaid offers a more extensive range of home and community-based services, but eligibility and coverage differs. Furthermore, Medicare SNF benefits emphasize short-term rehab stays, leaving few viable options for end-of-life patients other than spending down assets for post-acute care to eventually qualify for Medicaid.
“If I could wave a magic wand, I would love to see palliative care included in the package of short stay skilled nursing services, because I think that would help people to get care that’s more aligned with their goals and maybe even help more people get out of a nursing home,” Flint said.
Singh added that addressing the dysfunction within the nursing home industry itself is crucial to improving palliative care outcomes in rehabilitation settings.
“They kind of go hand in hand, this idea that if you want to improve quality of care and equity of care, you also have to improve the equity of the nursing home staff … while a focus on palliative rehab is very important, it’s steeped in this bigger kind of nursing home dysfunction,” Singh said.
