A recently published study has discovered that nursing home residents are spending more time receiving high-intensity therapy and rehabilitation treatment at the end of their life. The therapies are unnecessary and potentially harmful to patients but reap significant financial benefits for for-profit nursing home facilities, the study published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA) concluded.
Researchers collected data from more than 600 nursing home facilities in New York and 55,691 long-stay decedent residents. The researchers focused on residents who received very high to “ultrahigh” (a term coined by Medicare for rehabilitation exceeding 12 hours per week) rehabilitation services during the last 30 days of their life. The treatments included physical, occupational and speech therapies, which garnered the biggest payouts from insurers.
According to Bloomberg, Medicare provides hefty reimbursements to nursing homes with patients facing the most complex and time-intensive rehabilitation. Nursing homes that made a profit were more than two times as likely to use high-intensity therapy to ultrahigh intensity therapy when compared with non-profit nursing homes, said Helena Temkin-Greener, professor at the University of Rochester Medical Center Department of Public Health Sciences, who led the study.
“This suggests there are substantial differences in both practice and policy with regard to the use of rehabilitation therapy across nursing homes,” said Temkin-Greener. “We also found that residents in chain facilities had a significantly higher probability of receiving low-to-medium therapy at the end of life.”
During the study period, rehabilitative therapy use in the last month of life increased by 20 percent, ultrahigh therapy by 65 percent. Therapy use varied substantially across nursing homes, ranging from none to 45 percent of all decedent residents. Nursing homes with more physical therapists on staff were significantly more likely to provide levels of high-intensity therapy and ultrahigh intensity therapy to their long-stay decedent residents.
This newfound research prompted Temkin-Greener to ask, “If ultrahigh therapy is good for patients at the end of life, why are only for-profits using it?”
Research shows that rehabilitation-based techniques in therapy benefit beneficial patients when used properly, Temkin-Greener said, but with those approaching death, alternative end-of-life care, such as hospice or palliative care, would be more productive. Ultrahigh therapy may also be accelerating the resident’s decline and distracting nursing home staff from acting on more suitable care methods for end-of-life.
When nearing the end of life, residents may experience a decline in overall health status, which may be amplified following a hospitalization. In some cases, therapy may be an appropriate intervention to address such changes. In some instances, this is productive. If a patient has declined swallowing function, it may be reasonable intervention to implement the use of adaptive equipment to facilitate self-feeding. However, the precise “dose” of therapy needed to accomplish these goals may be at low or intermediate intensity rather than high or ultrahigh.
“Staff need to carefully consider at what level therapy may be helpful to residents as they approach the end of life versus when the burden of such an intervention outweighs any perceived benefits and may actually contribute to suffering prior to death,” said Temkin-Greener. “It is important to identify the threshold at which therapy interventions are unlikely to enhance quality of life or reverse the natural course of decline associated with terminal illness.”
The number of patients living in nursing homes has seen a decline in recent years, but many still experience abuse and neglect. An estimated one in five beds in a skilled-nursing home goes unused; today, occupancy is at roughly 85 percent, a five percent decrease since 2008, according to recent data from National Investment Center for Seniors Housing and Care. Starting Oct. 1, 2019, Centers for Medicare and Medicaid Services will begin a new ‘Patient-Driven Payment Model.’ The model will determine condition-based payments that are specific to a patient’s health needs, rather than assessing the care based on high-intensity therapy treatments.
“Our findings suggest that financial considerations may contribute to, if not directly drive, the receipt of end of life rehabilitation therapy,” said Temkin-Greener. “It is worth noting that among decedents receiving therapy in the last month of life, 60 percent were hospitalized within prior 2 months, compared with 24 percent among those who did not receive therapy prior to death.”