Patients in skilled nursing facilities (SNFs) can become trapped in a “rehabbed to death” cycle that could be prevented with better access to palliative care and hospice.

The Patient Driven Payment Model (PDPM) used by SNFs could be harnessed to enable more palliative care and earlier admission to hospice, according to a study published in the Journal of the American Geriatrics Society.

“The PDPM offers an opportunity for palliative care to be considered a skilled need requiring nursing care when, for example, medications are adjusted frequently and require nurse monitoring. The payment model incentivizes and can reimburse SNFs for providing this type of care that is largely absent in the SNF setting,” the study authors wrote.

Providers in urban areas are more likely to see patients in this cycle, due in part to discharge pressures placed on hospitals, Dr. Taimur Mirza, chief medical officer of New York City-based ArchCare, told Hospice News’ sister publication Skilled Nursing News.

“The pattern often reflects an underlying mismatch between the patient’s medical reality and the goals of care set at discharge,” Mirza said. “Patients arrive to subacute rehab labeled as ‘restorative’ but many have end-stage disease, profound debility or metastatic cancer, for which aggressive rehabilitation is no longer physiologically possible. Instead of functional recovery these patients endure multiple transitions, escalating interventions and unnecessary suffering in their final weeks of life.”

ArchCare, the continuing care community of the Archdiocese of New York, operates seven nursing homes in New York City and by bed count is one of the largest nonprofit nursing home providers in the United States.

Holly Bowen, chief clinical officer for Idaho-based Cascadia Healthcare, concurred with Mirza’s assessment. Across Cascadia’s market, patients arrive “too de-conditioned to meaningfully participate in rehabilitation,” she told Skilled Nursing News.

“We see the emotional and clinical toll when care transitions happen too late — the patient’s goals and the treatment plan are simply out of sync,” Bowen said.

Cascadia operates 45 facilities across several western states.

Both Mirza and Bowen said the way forward is to begin the conversation around palliative care and hospice sooner, and to work with hospitals to make sure patients know their options.

At ArchCare, particularly at its Mary Manning Walsh Nursing Home & Rehabilitation Center, early goals-of-care discussions are an ethical priority, Mirza said. The company partnered with Memorial Sloan Kettering Cancer Center (MSKCC) to create a subacute oncology and musculoskeletal rehabilitation program designed to break the cycle. The program integrates palliative care principles into skilled care that resulted in improved therapy and outcomes.

“Therapists, nurses and physicians conduct early goals-of-care conversations on admission and adjust treatment intensity to align with the patient’s actual trajectory, rather than arbitrary length-of-stay targets,” Mirza said.

A bridge not a holding facility

ArchCare’s rehabilitation programs have shown good success in helping patients achieve their goals of care and in making care transitions smoother, according Mirza.

“This model has shown that skilled nursing can serve as a bridge between acute care and hospice rather than a holding area between hospitalization and decline,” he said. “We track quality-of-life indicators, symptom burden and family satisfaction alongside traditional rehab metrics. Early data suggest fewer unplanned transfers, improved pain control and greater family understanding of prognosis.”

Bowen said the study authors were right to call attention to length of stay issues, present solutions and call for the U.S. Centers for Medicare & Medicaid Services (CMS) to issue guidance on PDPM payment options for promoting palliative care. She added that providers should advocate for clearer guidance and for concurrent SNF-and-hospice payment model demonstrations.

Bowen and Mirza agreed that the cycle of “rehab-to-death” takes a toll on clinicians, families and patients. It also affects the bottom lines of insurance companies providing Medicare Advantage plans.

“Repeated hospitalizations and mixed messages create distress and reduce quality of life,” Bowen said. “SNFs carry the burden of late-stage admissions without consistent reimbursement for the intensity of care.”

Providers find the cycle “emotionally exhausting,” said Mirza.

“Clinicians enter the field to heal not to preside over futile rehabilitation,” he said. “For insurers the cycle drives costs without meaningful outcomes. For patients and families it erodes trust in the continuum of care. Aligning payment models with patient-centered outcomes, comfort, communication and dignity would do more to fix the system than any new regulation.”

When asked, both Mirza and Bowen indicated that skilled care and palliative care do not need to be reinvented, but rather redefined. The way forward is to move away from siloed health care toward a model in which hospitals and skilled nursing providers work together to coordinate care and match patient needs, Bowen said. Redefinition also includes ensuring that reimbursement rates are stable for post-acute services. 

“Earlier palliative integration reduces hospitalizations, lowers costs and most importantly honors residents’ preferences,” Bowen said.

Mirza agreed and urged nursing homes to implement models that move the needle toward improvement.

“Our experience at Mary Manning Walsh with the MSKCC partnership shows that when rehab and palliative medicine work together, patients spend less time suffering and more time living meaningfully even at the end of life,” he said.