Dying nursing home residents often find themselves living out their final days in rehab, where they are subjected to grueling treatment, according to a new study by the University of Rochester Medical Center.
From the study’s results emerged interesting patterns: The proportion of residents subjected to this treatment increased (between 2012 and 2016) by 65 percent, and prevalence is twice as high at for-profit homes than nonprofit ones.
These trends, however, raise an unsettling question. Are rehabilitation services helpful to residents, or are they nursing homes’ last chance to exploit residents for extra revenue?
For the study, published this month, researchers analyzed data from 55,691 long-stay deceased residents at 647 New York nursing homes. They focused on residents who received “very high” (defined by Medicare as almost 9 hours per week of intensive therapy) to “ultrahigh” (exceeding 12 hours) of rehabilitation services – including physical, occupational, and speech therapy – in the last 30 days of their lives.
Nearly 14 percent of residents (or 7,600) received rehabilitation treatment in the month before they died, the study found. Of that group, 2,667 received therapy at high to ultrahigh levels, most of which was concentrated in the last week before death.
“Some of these services are being provided in the last week and sometimes on the day of their death,” said Dr. Thomas Caprio, an associate professor at UR and one of the study’s authors.
Even to patients who aren’t expected to recover from a condition, Caprio’s team noted, rehabilitation therapy has proven beneficial when properly prescribed. Speech therapy, for example, can help patients maintain their ability to swallow. But for those approaching death, high-intensity treatment poses several problems. Not only could rehab postpone more appropriate and comfortable end-of-life care (like hospice or palliative care), but it could accelerate a vulnerable patient’s decline.
Given the risk, researchers set out to establish who really benefits.
The more complex and time-intensive the rehabilitation treatment for long-term patients, research showed, the higher the Medicare reimbursements for for-profit nursing homes. But when care plans shift to hospice or palliative care? That revenue stream disappears.
“There’s a possibility that nursing homes know a patient is approaching end of life, but the financial pressures are so high that they use these treatments so they can maximize revenue,” said the lead author, Helena Temkin-Greener. Or, “if it’s being driven by a failure to recognize that a resident is approaching end-of-life, then it calls for improving the skills of nursing home teams.”
The University of Rochester wouldn’t be the first to question for-profit facilities’ motivations, of course. Financial incentives have long plagued the long-term care industry, in part driving staffing problems and ensuing poor standards of care. In at least 30 percent of U.S. nursing homes, poor standards lead to resident neglect and abuse.
Yet lobbyist groups refuted UR’s study, saying researchers tried to draw generalizations from too narrow a population of long-stay residents. Temkin-Greener disagreed.
“With about 30 percent of all Americans dying in nursing homes, this can hardly be described as a ‘very narrow SNF population,’” she said. Though her team studied a relatively small sample of patients in 1 state, they and patient advocates believe it represents a much greater problem.
What Do Findings Mean for Residents’ Families?
Researchers suspect the problem extends beyond New York for a few reasons. For 1 thing, most states impose less stringent regulatory oversight on nursing homes, Bloomberg reported. And every year, more and more Americans are dying in nursing homes across the U.S. Lastly, of course, Medicare’s payment system is national.
The team concluded that their findings only mirror what the Centers for Medicare and Medicaid Services (CMS) and other federal health regulators found years ago: that the scope and intensity of treatment for elderly nursing home residents might be excessive, possibly even distressing.
On October 1, 2019, CMS is due to implement a long-overdue “Patient-Driven Payment Model,” based on a patient’s needs rather than the amount or intensity of treatment. In theory, the new system could remove financial incentives.
However, patient advocates warn, UR’s study serves as an important reminder to families that they should keep tabs on their elderly loved ones’ nursing home care and whether it’s appropriate.
“Residents should receive therapy and other services that can help them attain, and maintain, their highest practicable well-being,” said Richard Mollot, executive director of a New York-based nonprofit advocacy group. “However, these services must always be tailored to the personal needs, goals and wishes of the individual.”