Research has documented that end-of-life health care may be impacted by poor coordination and communication among healthcare providers. In fact, a report from the Institute of Medicine has suggested that people nearing the end of their lives--even those enrolled in hospice (a special type of care for people who are likely in their final months of life)--can experience multiple transitions between places where they receive care (also called "care settings"). Transitions--such as going from home to an emergency room or hospital--can be difficult for seriously ill older adults and their family members. However, until now, little has been known about the number and types of transitions people in hospice experience.
A new study published in the Journal of the American Geriatrics Society examined this issue. The research team analyzed Medicare data for patients who used hospice in the last six months of their lives and who died in 2011. The researchers wanted to learn how often care transitions occur in hospice care, and whether this happens more often to particular groups of patients.
Such transitions included transferring from and to a hospital, skilled nursing facility, home health agency, hospice, or home. The researchers said that they considered these specific transitions because they were those most likely to mean changes in the patient's care team, which could lead to uncoordinated care.
Of the 311,090 people included in the study:
- 10.2 percent (31,675) experienced at least one healthcare transition after their hospice enrollment.
- 6.6 percent of hospice patients had more than one care transition, some up to 19 transitions.
- Of those transitions, more than half were to a hospital.
Those who experienced care transitions tended to be younger or non-white, had more than one chronic condition, or received in-patient hospice care compared to those who did not experience transitions.
The number of transitions varied widely from state to state, ranging from 6.9 percent of study subjects in Idaho to 20.6 percent of study subjects in Florida. The proportion of people who had a transition to a hospital ranged from 1.6 percent in North Dakota to 13.4 percent in Mississippi.
People who had mental disorders, nervous system diseases or symptoms, and "ill-defined" conditions were less likely to experience transitions than were people diagnosed with cancer.
"Even after being enrolled in hospice, Medicare beneficiaries may have numerous transitions between different healthcare settings. These transitions are not only expensive, but also may not lead to better care or quality of life. Many of these transitions may be avoidable through advance care planning, appropriate provider-to-provider communication, and proper hospice inpatient care," said study co-author Shiyi Wang, MD, PhD, Assistant Professor of Epidemiology, Yale School of Public Health.