Two earlier reports by the OIG that examined nursing home hospice provision during the 1990s detailed the potential conflicts that could enter into contractual arrangements between nursing homes and hospice providers.^8,9 A main concern was the potential for decisions about hospice provision to be influenced more by financial considerations than by clinical considerations.⁸ The OIG was particularly concerned with the possibility of kickbacks provided by hospice providers to nursing homes in exchange for referrals. One kickback mentioned in the OIG reports was the nursing home “receiving additional staff hours at no additional cost” (p. 6).⁸ The suggestion here is that hospice staff could provide some of the hands-on care previously provided by nursing home staff, thereby allowing the nursing home to reduce staffing. However, no research has yet addressed this important issue.

When a nursing home resident receives hospice services, the hospice is expected to provide services, such as nursing care specific to the terminal illness, medical social services, counseling, occupational and/or physical therapy, and any other services necessary for the management of the terminal illness. The nursing home is expected to continue providing room and board and any hands-on care not related to the terminal illness.¹⁰ OIG reports suggest that hospice staff could provide some of this hands-on care allowing the nursing home to reduce staffing as a means of incentivizing referrals to hospice.^8,9

Over the 7-year study period, 131,458 nursing home observation years were identified. Nursing home observation years were excluded if the nursing home was hospital-based (n=15,464), had fewer than 30 beds or more than 500 beds (n=3337), had fewer than 3 years of observation (n=11,607), had fewer than five deaths in any year (n=17,167), or was missing data on covariates (n=11,776). This resulted in 72,107 nursing home observation years among 10,759 nursing homes.

The dependent variable was defined as the number of CNA minutes per resident per day (MPRD), a measure of nursing home direct-care staffing. Facilities report the number of CNA hours during the 2 weeks prior to their annual survey. CMS converts the number of hours into full-time equivalents (FTEs; based on a 35-hour work week) and this is reported in the annual OSCAR data. Nursing home staffing data derived from OSCAR have been used in numerous previous studies.¹³

For this study, we converted the FTEs back into hours, by multiplying by 35, and divided the total number of CNA hours by the number of residents in the facility (also drawn from the OSCAR) to arrive at the CNA hours per resident day (HPRD). For ease of interpretation, we further transformed HPRD into MPRD by multiplying by 60. We also cleaned this variable when the FTEs reported were implausible (when total FTEs were 995 or higher or if there were more than three times the number of CNAs reported than the number of beds in a facility). If data were missing in a particular year, we imputed the values by randomly choosing a value from the quartile of nursing homes having the most similar values (to the “missing value” nursing home) in the subsequent year. Less than one-half of 1% of facilities had missing values each year (and in most years it was between 0.1% and 0.2%).

We operationalized the introduction of hospice services as a nursing home transitioning from having less than 1% of its total resident days in a calendar year covered by hospice to more than 1%. The RHF was used to identify the number of nursing home days for all residents in each facility in the calendar year as well as the number of those days that were hospice days. The proportion of days that were hospice was calculated using these two counts. A dichotomous variable was then created to indicate when a nursing home reached the 1% threshold that signified “adding hospice.” Hospice volume was operationalized by totaling the number of resident hospice days in the nursing home in a calendar year. For ease of interpretation, this variable was standardized to 1000 nursing home hospice days.

We controlled for numerous nursing home attributes including the total number of resident days per calendar year, and for other time varying nursing home characteristics including a yearly indicator of whether more than two thirds of a nursing home's hospice residents were cared for by for-profit hospices, the proportion of residents on Medicaid, the proportion of residents on Medicare, occupancy rate, resident case mix, nurse staffing, existence of a special care unit, and existence of a physician extender (nurse practitioner or physician's assistant). To control for secular trends, we also included indicator variables for each year. We included two measures of resident case mix, one based on all MDS admission assessments (i.e., the case mix for all newly admitted residents in a year) and one based on all MDS annual assessments (i.e., the case mix for long-stay residents). We used the resource utilization group (RUG III) system, which classifies residents into categories based on their estimated resource utilization. This approximates the relative staff time associated with caring for the average resident in each group. Thus, the higher the case mix score, the more severe the average acuity profile of the residents in a nursing home. These measures were standardized, so that the regression results reflect the influence of a one standard deviation change in case mix.

To examine the influence of hospice competition, we included a variable indicating the number of hospices in the nursing home's county providing services in nursing homes each year. We identified hospice providers who provided services to nursing home residents each year as identified on Medicare claims in the RHF. We then grouped residents by their nursing home's county and added up the unique number of hospices that were providing care to those residents.

Table 2 shows the results of the fixed-effects regression analysis. Our main independent variable of interest, adding hospice, was shown to not significantly affect CNA MPRD (95% confidence interval [CI]: −1.19–0.01). However, increasing hospice volume in nursing homes was related to statistically significant increases in CNA MPRD. Specifically, for every 1000 hospice days added in the nursing home during a calendar year, CNA MPRD increased by more than three-quarters of a minute (95% CI: 0.37–1.21).

These findings are consistent with what would be expected in terms of direct-care staffing as a nursing home increases its hospice use. By definition, residents receiving hospice services are at the end-of-life and likely suffering from multiple comorbid conditions. These residents are sicker and in need of more care than nursing home residents not at the end of life, so a nursing home caring for more of these residents will need additional direct-care staff. That is as long as the hospice provider is not supplying the nursing home with substitute staff, and our findings support this contention.

Our findings regarding the impact of hospice provider competition on CNA staffing are less straightforward. We found that with each additional hospice provider in the county, CNA MPRD decreased by just over a quarter of a minute. For example, again considering a nursing home with 120 residents, this would translate into a reduction of just over 15 minutes of CNA staffing each day. However, this would apply to all nursing homes in the county, not just those providing hospice services. Our measure of hospice competition, the number of hospices in the county providing services in nursing homes, is somewhat crude and does not take into account differences in county populations or the number of nursing homes in counties. Additional research that more precisely measures hospice competition is needed.

Consistent with any observational study, our study is limited by data constraints. Specifically, our observations began in 1999 and hospice provision in nursing homes began growing well before 1999; therefore, many of the nursing homes in our study had added hospice prior to our study period. These early adopters may have been different from later hospice adopters in important ways and hospice relationships with nursing homes may have been different during the early years of hospice provision in the nursing home setting. In addition, our results may have been affected by the nature of the nursing home staffing data. Staffing is self-reported by nursing homes as part of the annual inspection process and could, therefore, be biased. However, there is no reason to believe that this reporting bias would change over time. Therefore, the study's longitudinal design, and examination of change, serves to lessen concerns about reporting bias.