Patients receiving hospice in one of the most common end-of-life care settings may not be receiving adequate services.

Researchers from Ohio University and the University of Rochester recently examined Medicare claims and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data of 51,303 assisted living residents who received hospice care from 2018 to 2019.

Quality of life and insufficient support were found as leading concerns for families of hospice patients in assisted living facilities, according to the study, which was recently published in the Journal of the American Geriatrics Society (JAGS). A lack of staffing infrastructure may be a root cause of negative outcomes, the study found.

“At least half of assisted living (AL) residents receive hospice services before death, yet much remains unknown about the quality of hospice care in this residential setting,” the researchers wrote in the study. “Hospice services are widely used by assisted living residents at the end of life, yet concerns exist about the adequacy and quality of hospice care in this setting.”

The study primarily focused on the number of both clinical and nonclinical hospice staff visits that patients received within the last three days of life.

Increased hospice clinical staff visits during the last days of life were associated with several areas of quality improvement, the research found. Emotional support scores saw a 0.04-point increase per visit, family’s ratings of quality and a willingness to recommend a hospice each rose by 0.03 points, while outcomes of feeling respected saw a 0.02-point rise, according to the findings.

Meanwhile, greater frequency of patient visits from nonclinical staff had stronger associations compared to those from clinicians, the study found. Researchers stated “comparatively larger impacts” in the nonclinical visit findings such as a 0.14-point increase in emotional support, a 0.28-point increase in willingness to recommend and a 0.18-point increase in average quality scores.

Researchers examined the association between hospice visits and quality ratings. Among the reasons they cited were two major hospice reports in 2019 from the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG). The first report found that roughly 20% of hospices had a condition-level deficiency that posed a serious safety risk, while the second report examined those deficiencies in greater depth.

The OIG reports ignited regulatory change in the hospice space, with increased oversight and revamped compliance processes in recent years. The regulatory changes have included increased auditing and enforcement activities that have complicated hospices’ pathways to compliance. Some providers have cited staffing challenges, increased administrative burden and burnout associated with rising regulatory scrutiny.

Patients in assisted living settings may be at greater risk of insufficient and poorer quality of care compared to others, the JAGS study found. The OIG reports revealed that hospice staff typically provided fewer than five hours of care per week in assisted living facilities, which raises concerns about the adequacy of services for these patients, the researchers indicated.

An overhaul of policies that support greater clinical and nonclinical hospice staff engagement may enhance quality in assisted living settings, according to the researchers. Policymakers should consider revising current hospice payment models and quality measures to include more incentivization of increased interdisciplinary staff visits at the end of life, they said.

“Higher frequency of hospice staff visits was associated with better perceived hospice quality,” the researchers stated in the study. “The findings highlight the importance of both clinical and nonclinical hospice staff in providing emotional and practical support at the end of life. Understanding the impact of hospice staff visits on perceived care quality can inform policies and resource allocation to improve end-of-life experiences for assisted living residents.”