Palliative focus needed in skilled nursing facilities

By Sarah Guy, medwireNews Reporter

US data suggest that use of Medicare benefit for skilled nursing facilities (SNF) is high during the last 6 months of life, highlighting a need to incorporate quality palliative care services in nursing homes, suggest researchers.

The SNF benefit, which is provided in nursing homes, does not provide the in-depth end-of-life services offered by hospice care, explains the team. However, financial concerns may explain why patients are using SNF and not the hospice benefit, since the latter incurs out-of-pocket expenses for room and board, and the former is free for the first 20 days.

"Perhaps having Medicare pay concurrently for postacute SNF care and hospice services for the same condition could allow earlier incorporation of palliative care for these medically complex patients," suggest Alexander Smith (University of California, San Francisco, USA) and colleagues in the Archives of Internal Medicine.

The team's findings emerge from data recorded by the Health and Retirement Study (HRS) for 5163 US adults who died between January 1994 and December 2007 and were aged a mean 83 years at death.

A total of 30.5% of individuals had used the SNF benefit during the last 6 months of life, and death during SNF use was common; 9.2% of the entire study cohort died while enrolled in SNF. Notably, just 0.5% of all decedents had used the SNF and hospice benefit concurrently.

For individuals who were living in the community before the last 6 months of life, death in a nursing home was more common if the SNF benefit had been used during those last 6 months, at 42.5%, versus 5.3% for previous community-dwelling SNF nonusers.

After adjustment for demographic, social, and clinical factors, SNF was used significantly more by adults aged 85 years or older, those with at least a high school education, those who did not have cancer, those who resided in nursing homes, those who were expected to die, and those who had used home health services before the last 6 months of life, report the authors.

In an accompanying editorial, Peter Boling (Virginia Commonwealth University, Richmond) commented that the findings "indicate a need for additional attention to trajectories, goals of care, and payment policy in the context of long-term care."

He added that financial incentives for nursing home facilities and financial burdens on families are causing the SNF benefit to be used "too often" for patients in whom the expected outcome is death.

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