Impact of Organizational Factors on Hospice Use among Nursing Home Decedents

Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, only a small proportion of residents receive hospice care before death. This study examines the relationship between NHs' propensity for hospice referral and residents' hospice use. Furthermore, we examine the extent to which individual, organizational and market characteristics explain variation in hospice use.

Medicare Hospice, Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases are linked with survey responses about their organization's hospice referrals provided by directors of nursing (DON) in 296 New York NHs. The study sample includes 8,420 residents who died in these NHs during 2007.

An individual-level multivariate model is estimated. Independent variables are introduced into the model sequentially. Individual risk factors are included first, followed by NH hospice referral propensity and facility characteristics. Fixed effects, accounting for NH market region, are then added.

Overall, 15.75% of sample decedents used hospice care. After controlling for individual risk factors, NHs' propensity for hospice referral is a significant predictor of hospice use (p=0.024). Adding hospice referral propensity, facility characteristics and market region to the model significantly reduces unexplained variance in hospice use (pseudo-R square increases from 0.04 to 0.12).

Our study confirms that the receipt of hospice care does not only depend on individual risk factors but also on NH practice patterns and facility characteristic. Potential interventions designed to effect greater use of hospice may need to focus on the organizational structure and facility-level care processes.