Diane Meier, M.D.

Nursing homes are under mounting pressure to improve quality of care. The Centers for Medicare & Medicaid Services last year introduced new quality measures that hold nursing homes accountable for preventing or reducing hospital readmissions or emergency department visits for short-stay residents. This year, CMS is designing a value-based purchasing program for skilled nursing facilities, which will adjust reimbursement rates based on the quality of care they deliver. The program is scheduled for launch in 2019. As nursing homes work to adapt to the new payment and quality landscape, one compelling solution is to integrate palliative care, a form of person-centered interdisciplinary care focused on quality of life for the seriously ill.

Nursing homes have unique challenges in a value-driven payment system. Inadequate funding and resources, particularly in long-term care, are barriers to introducing new training and services. Nursing home residents, by definition, are typically functionally and often cognitively impaired. They also have multiple comorbidities and high prevalence of chronic pain and other distressing symptoms. High levels of pain from arthritis and skin wounds are commonplace, yet there still are no truly safe and effective analgesics available for this vulnerable population. Many residents no longer have cognitive capacity to participate in advance care planning and family members may not be prepared to serve as surrogates. When palliative care is available, it is usually limited to residents very near the end of their lives when they become eligible for hospice. As a result of these factors, as well as significant staffing and regulatory constraints, residents often experience repeated hospitalizations and burdensome care transitions..

In a recent study of nearly half a million people with advanced dementia who died in a nursing home, almost 20% underwent a hospital transfer in their last three months of life. More than 11% had a healthcare transition in the last three days of life, 2.7% were discharged from a hospital to a different nursing home, and 8.1% had multiple hospital stays in their last three months of life. These burdensome transitions were associated with a much higher risk of feeding tubes, intensive care unit stays, development of pressure ulcers and hospice referrals less than three days before death.

The same study found that 96% of family members of nursing home residents with advanced dementia think that comfort and quality of life should be the highest priority for care (Pedro Gozalo et al, N Engl J Med 2011; 365:1212-1221).

Palliative care is specialized medical care for people living with serious illness. It provides relief from symptoms and distress, addresses resident and family needs for communication and coordination and offers guidance in making treatment decisions that are aligned with the life priorities of residents. In multiple studies – including some conducted in nursing homes – palliative care has been shown to reduce pain and other symptoms, reduce depression and anxiety and avert symptom crises and their associated emergency department and hospital stays. It may even prolong life by protecting patients from the many risks of hospitalization. These elements all contribute to improvements in quality and reductions in acute care utilization.

Importantly, palliative care can be delivered at the same time as life-prolonging disease treatment, with eligibility for palliative care dependent on need, not on prognosis. This is unlike hospice care – the current dominant model of care for seriously ill nursing home residents. In contrast, palliative care is appropriate for anyone who is suffering or at risk of preventable crises. It should be available in nursing homes based on resident need, no matter how long they are expected to live.

There are several ways in which nursing homes can deliver palliative care for their residents. One is to contract with external consultation services from a dedicated palliative care provider, which can be billed fee-for-service under Medicare Part B. A recent study by Susan Miller and colleagues (Susan Miller et al, J Am Geriatr Soc. 2016 Nov; 64 (11):2280-2287) demonstrated how this model can substantially reduce acute care utilization and burdensome transitions for nursing home patients. The study drew on nursing home consultation data from palliative care providers serving 46 nursing homes in North Carolina and Rhode Island. It compared healthcare claims from residents who had received palliative care consultations while in the nursing home with claims for similar residents who had not received a consultation. The study showed that nursing home residents who received palliative care consultations had significantly lower rates of hospitalization. It also showed that the earlier the consultation occurred, the lower the likelihood of hospitalization. The great majority of hospitals with more than 100 beds have palliative care consultation teams; and increasing numbers of hospices are now delivering non-hospice palliative care consultation services in addition to hospice care. Reaching out to build a partnership with one or more of these colleagues may be the fastest way to bring palliative care expertise into your nursing home.

A second model is to integrate palliative care by contracting with a payer. This is especially feasible if there is a high penetration of Medicare Advantage participants in your region. One way to do this is as an approved provider for an Institutional Special Needs Plan (I-SNP), a Medicare Advantage plan specifically designed for long-stay nursing home patients. Some of these plans work to reduce acute care utilization among nursing home residents by providing an embedded palliative care consultation service in those nursing homes with a critical mass of Medicare Advantage residents. One such plan is Optum’s CarePlus I-SNP, which covers over 50,000 patients in more than 1,900 nursing homes in 35 states. In nursing homes contracting with Optum, the payer adds a nurse practitioner with training in symptom management, goals of care communication and advance care planning. Optum says the model has produced a 49% reduction in emergency room visits, a 60% reduction in hospitalization rates and a 48% reduction in total costs, representing $9,000 of savings per member per month. (See Optum’s white paper on the plan for more information.)

A third option is to build palliative care skills and knowledge among nursing home staff, from direct care workers, to nursing managers to medical directors. Multiple online palliative care training curricula are now available with associated continuing education credits for nurses, social workers and physicians. A similar online curriculum for direct care workers will be available soon. A list of the broad range of mid-career training alternatives for clinicians of all disciplines and at all levels of experience can be found in the accompanying table.

Palliative care produces high quality clinical and efficiency outcomes for residents, their families, nursing home staff and the health system. Nursing homes that integrate palliative care can build a track record of high quality care and low rates of readmission and emergency department use that will position them for success as reliable partners to the clinicians and the hospitals in the community. In the new value-based payment environment, these are the nursing homes that risk-bearing organizations (just about everybody, these days) will seek out for collaboration, partnerships or contracts as they seek to deliver value across the continuum of care.