Medicare hospice in the US is a palliative care alternative to curative and/or aggressive treatment near the end of life. It focuses on managing physical and psychosocial distress and includes counseling and support for patients and their families. The US Medicare system began financing hospice to patients in the early 1980s to improve end-of-life experiences and to reduce the high cost associated with curative treatment during the last several months of life. Eligible nursing home (NH) residents can receive hospice services, as provided by contracted hospice providers,1
in addition to services received by NH staff. Since its inception, Medicare hospice utilization has increased dramatically and spending on this Medicare benefit has more than tripled between 2000 and 2007, reaching US$10 billion in 2007.2
During this time, there was also an increase of more than 1000 hospice providers.2
Hospice care is provided in a number of different settings including patients’ homes, free-standing hospice facilities, NHs, and hospitals. Persons are eligible for hospice if they are Medicare eligible, and most of these persons are older adults although disabled younger persons may also qualify for Medicare. Some private insurance may cover hospice benefits as well. In order to receive the Medicare hospice benefit, two physicians must certify that the beneficiary has a 6-month terminal prognosis, if the disease runs its normal course. Certification periods include two initial 90-day periods and an unlimited number of 60-day periods, with no capped duration. To continue with each additional period, two physicians must certify that the beneficiary has a 6-month terminal diagnosis.
Research has found NH residents who enrolled in Medicare hospice were less likely than non-hospice NH residents to be hospitalized in the last 30 days of life or to die in a hospital.3,4
Additionally, NH residents enrolled in hospice more consistently received daily pain treatment than non-hospice NH residents.5
Finally, lower proportions of hospice patients versus non-hospice patients experienced physical restraints or had feeding tubes inserted.6
A previous study of NH persons who died in 1992–1996 conducted in five US states (Kansas, Maine, Mississippi, New York, and South Dakota) found 6% of dying persons received Medicare hospice care at some point prior to death.7
It also found an estimated 24% of all Medicare hospice patients in these five states received hospice in NHs in 1996. A more recent study shows Medicare hospice use by all deceased US NH residents was 33% by 2006.8
However, in 2006 it is still estimated that NH residents comprise approximately one-quarter of all Medicare hospice recipients, reflecting growth in hospice use both in the community and in NHs.8
Our study aimed to understand how the characteristics of NH residents using hospice may have changed over time, given the large growth in NH hospice use. Specifically, we compared the 1992–1996 data from the five-state study7
to the 2006 data drawn from the same US states. Also, we present data on NH hospice participants who died in 2006 in the 50 US states and the District of Columbia and, as in the previous five-state study, we examine how NH hospice characteristics and lengths of hospice stay differ among persons who died while in hospice depending on where they first entered hospice (i.e. in the community or in the NH).