Specialty Palliative Care Consultations for Nursing Home Residents with Dementia

Abstract Context U.S. nursing home (NH) residents with dementia have limited access to specialty palliative care beyond Medicare hospice. Objectives To examine the value of expanded palliative care access for NH residents with moderate to very severe dementia. Methods We merged palliative care consultation data in 31 NHs in two states to Medicare data to identify residents with consultations, moderate to very severe dementia, and deaths in 2006-2010. Initial palliative consultations were identified as occurring later and earlier (1-30 days and 31-180 days before death, respectively). Three controls for each consultation recipient were selected using propensity-score matching. Weighted multivariate analyses evaluated the effect of consultations on hospital or acute care use 7 and 30 days before death, and on (potentially) burdensome transitions (i.e., hospital or hospice admission 3 days before death or two plus acute care transitions 30 days before death). Results With earlier consultation (versus no consultation), hospitalization rates in the 7 days before death were on average 13.2 percentage points lower (95% confidence interval (CI): -21.8%, -4.7%); and, with later consultation 5.9 percentage points lower (95% CI: -13.7%, +4.9%). For earlier consultations (versus no consultations), rates were 18.4 percentage points lower (95% CI: -28.5%, -8.4%) for hospitalizations and 11.9 lower (95% CI: -20.7%, -3.1%) for emergency room visits 30 days before death; they were 20.2 percentage points lower (95% CI: -28.5%, -12.0%) for burdensome transitions. Conclusion Consultations appear to reduce acute care use and (potentially) burdensome transitions for dying residents with dementia. Reductions were greater when consultations were earlier.