En español | More older Americans on Medicare are spending their final days receiving care at home or in a community setting such as an assisted living facility — not in a hospital — according to a report published last week in the Journal of the American Medical Association (JAMA). This comes as good news for experts who have defined a "good death" as one outside an intensive care unit (ICU) and free from avoidable distress and suffering for patients, families and caregivers.
The study looked into 1,361,870 Medicare fee-for-service patients and 871,845 Medicare Advantage enrollees who died between 2000 and 2015 to better understand the level and quality of end-of-life care. What they found was that after an uptick in hospitalizations between 2000 and 2009, the numbers of ICU stays and “burdensome transitions” — a term that describes any time someone dies within three days of a hospital stay — began to stabilize and improve.
“I’ve always felt that site of death only tells you where someone was in the last minutes of their lives,” says the study's lead author, Joan Teno, M.D., a professor of medicine at Oregon Health & Science University. “But what’s really important is to note the places of care … prior to that dying episode.”
The findings show that Medicare-insured patients who died in acute care settings decreased from a high of 32.6 percent in 2000 to 19.8 percent in 2015, and “people were less likely to die three days after a hospitalization or another health care transition,” Teno says. “We also saw a very striking decrease in people who had three or more hospitalizations during the last 90 days of life. That went down from 11.5 percent in 2009 to 7.1 percent in 2015.”
Experts say the lower numbers of disruptive hospital stays coincide with the timing of the dramatic program and policy changes to the U.S. health care system after 2009, most notably the adoption of the Affordable Care Act (ACA) in 2010, which had as a goal improving end-of-life care, including the growth of hospice and palliative care services.
As part of the ACA, hospitals were required to look at their hospitalization and readmission procedures. A 30-day rehospitalization penalty was enacted, which made acute care centers more accountable for where they were discharging patients and the level of care those patients would receive. There was also was an overall transition “from paying for volume [of services] to paying for value,” Teno says.
To make further gains, Teno says it is critical that we educate consumers about their care and the dangers of both overtreatment and undertreatment, and that we have a system of accountability for both errors. “And it is very important that we have a very frank conversation with people at this stage of life who are seriously ill about what’s important to them at this phase of life, their understanding of their prognosis, the seriousness of the illness that they are dealing with … and their treatment options. If they have wishes to avoid hospitalization and try to remain at home, we need to design a system to allow this.”
For the over-50 population, Teno points out how assisted living facilities now account for a “good portion of our community deaths,” which is a marked shift. Those who are looking into such facilities should take this under consideration. Says Teno: “If I am going to choose an assisted living facility, and I am in my eighth or ninth decade of life, I’d probably want to be careful that the assisted living facility provides high-quality medical care that meets my needs and preferences, including care at the close of life.”