Nursing Home Residents with End-Stage Dementia and Medicare SNF Care: How Is Hospice Enrollment Associated with Site of Death?

Objective: To identify how hospice enrollment is associated with site of death for nursing home (NH) residents with end-stage dementia who receive Medicare skilled nursing facility (SNF) care near the end of life.

Methods: In the 50 U.S. states and the District of Columbia we merged resident assessment data (MDS) with Medicare claims and denominator data to identify hospice enrollment and hospital use for year 2006 NH decedents having end-stage dementia and receiving Medicare SNF care in the last 90 days of life (N= 19,271). We conducted multivariate logistic regression with a generalized estimating equation and clustered on NHs (N=8,454) to examine the association between hospice enrollment and a hospital death, controlling for individual and NH-level variables.

Results: Thirty-three percent of residents with end-stage dementia and SNF care enrolled in hospice. One percent of decedents with hospice had a hospital death, compared to 17% of nonhospice decedents. Hospice enrollment was associated with a 94% lower likelihood of dying in a hospital (AOR 0.06; 95% CI 0.046, 0.076). Controlling for hospice enrollment, residents with a recognized six-month prognosis (per the MDS) and with do not resuscitate and/or do not hospitalize orders had a significantly lower likelihood of a hospital death. Nonwhite and Hispanic residents had a significantly greater likelihood of a hospital death as did those residents in for-profit NHs.

Implications: End-stage dementia residents who enroll in hospice have a greater likelihood of dying in place and this lower hospital use at the end-of-life may result in dollar savings for Medicare.