Integrating Palliative Care into Nursing Homes

For these individuals, the delivery of coordinated, person-centered services at the end of life is a central component in the array of supportive and therapeutic services they receive. Although growing numbers of nursing home residents are accessing Medicare’s hospice benefit before death, substantial barriers continue to impede the meaningful integration of palliative and hospice care into the long-term services and supports that most nursing home residents receive. These barriers range from the orientation of nursing homes — and the regulatory standards that govern them — toward rehabilitative care, to the fragmented approach of Medicare and Medicaid in financing acute, post-acute, palliative, and supportive services.

Palliative care is not just for people at the end of life; rather, it can be integrated throughout the continuum of illness to address physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.” Hospice is a type of palliative care that focuses on the final months of life, whereas palliative care is provided at all stages of serious illness, regardless of the patient’s prognosis or treatment choices. Key features of palliative care are: open communication about future illness trajectories, which allows for patient and family-centered discussions of treatment options and goals of care; documentation of these goals, often through completion of advance directives or a Physician’s Orders for Life-Sustaining Treatments (POLST) form; holistic assessment and interventions to minimize physical, psychosocial, and spiritual suffering; support of activities to bring life closure; and bereavement services for families.

Currently, most formal palliative care programs operate in clinic and hospital settings, where there is evidence that these programs enhance the quality of care, increase patient and family satisfaction, and decrease health care costs. The failure of palliative care to take hold in nursing homes stems from several factors:  regulations that favor rehabilitation over palliative care; inadequate staff knowledge and skill in palliative care; financial disincentives (e.g., higher reimbursement for skilled nursing care and invasive therapies); misconceptions about palliative care; and lack of reimbursement for specialized palliative care.

There are 3 models for delivering palliative care in nursing homes:

• Hospice agency/nursing home partnerships.
• Externally based palliative care.
• Facility-based palliative care.