Elderly nursing home residents with advanced dementia who were enrolled in a Medicare managed care insurance plan were more likely to have do-not-hospitalize orders and were less likely to be hospitalized for acute illness than those residents enrolled in traditional Medicare, according to a study published by JAMA Internal Medicine, a JAMA Network publication.
Recent health care reform in the United States increases opportunities to improve the quality and cost-effectiveness of care provided to nursing home residents with advanced dementia. Because nursing homes do not receive higher reimbursement to manage acutely ill long-term-care residents on site, nursing homes have had financial incentives to transfer residents to hospitals, according to the study background.
Keith S. Goldfeld, Dr.P.H., M.S., M.P.A., of the NYU School of Medicine, New York, and colleagues compared care and outcomes for nursing home residents with advanced dementia covered by managed care and those covered by traditional fee-for-service Medicare. The analysis included 291 residents from 22 nursing homes in the Boston area.
Residents enrolled in managed care (n=133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare (n=158) (63.7 percent vs. 50.9 percent); were less likely to be transferred to the hospital for acute illness (3.8 percent vs. 15.7 percent); had more nursing home-based primary care visits per 90 days (average 4.8 vs. 4.2); and had more nursing home-based nurse practitioner visits (3.0 vs. 0.8), according to the study results. Survival did not differ between groups.
"This study provides novel data suggesting that the model of health care delivery in a nursing home has important effects on the type of care received by individual residents. Intensive primary care services may be a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome and affordable care, especially at the end of life. Ultimately, it may require a change in the underlying financial structure to institute those changes," the study concludes.
Commentary: The Right Care in the Right Place
In an invited commentary, William J. Hall, M.D., M.A.C.P., writes: "Two key factors stand out from this study. First, more onsite nurse practitioners in nursing homes resulted in better outcomes irrespective of insurance status. Second, present Medicaid reimbursement creates perverse incentives against the delivery of appropriate comfort and palliative care such as hospital services."
"Design of a long-term system that will provide our patients with advanced dementia the right care at the right time will require more than patches and fixes to the payments systems," Hall continues.
"Finally, no individual is admitted to a hospital or nursing home without the authorization of a physician. We, more than any other members of the health care team, have the authority and responsibility to advocate for the appropriate level of care for our patients during the terminal phase of advanced dementia," Hall concludes.
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