BACKGROUND/RATIONALE:
Hospice utilization in Veterans Affairs (VA) nursing homes, called Community Living Centers (CLCs), is inconsistent. The annual mortality rate among the CLC population is 39%. As the number of veterans with end-of-life (EOL) care needs in CLCs increases, it is imperative to understand end-of-life care practices in CLCs and identify CLC residents with limited life expectancy so that veterans can receive hospice services if prognosis is six months or less and when goals of care are focused on comfort rather than cure.

OBJECTIVE(S):
1) Describe characteristics of veterans living in a CLC prior to death, 2) determine factors that predict site of death (hospital vs. CLC) among veterans living in a CLC, and 3) develop a tool to identify CLC residents at risk for death.

METHODS:
The Vital Statistics File was used to identify veterans with a date of death in FY2005. Minimum Data Set (MDS) data were extracted for all decedents and site of death was identified using the Extended Care Main File. Two group comparisons were performed followed by multivariate regression analysis to determine factors predictive of hospital as a site of death. The Hospice Eligibility Prediction (HELP) tool was developed using MDS data to provide a reliable method for identifying the CLC population eligible for hospice care (<6month life expectancy). Site visits were performed at five CLCs to gain an in-depth understanding of how hospice programs in CLCs identify veterans at risk of death and provide end-of-life care.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Hospice use among CLC decedents exceeds hospice usage reported in community-based nursing homes. Prevalence of severe pain is high and many lack documented care goals. Absence of documented care goals is associated with a higher likelihood of hospital death and repeated hospitalizations but hospice is associated with improved EOL care practices. These results highlight areas for improvement in EOL care of veterans in CLCs. Improved identification of hospice-eligible CLC residents may increase appropriate hospice utilization in CLCs as has been observed in community-based nursing homes.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Levy C, Bemski J, Kutner JS. Are hospices establishing pre-hospice/palliative care programs? Journal of palliative medicine. 2008 Apr 1; 11(3):413-4. [view]
2. Radcliff TA, Levy CR. Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents. Journal of hospital medicine. 2010 Feb 1; 5(2):E3-E10. [view]
3. Levy C, Morris M, Kramer A. Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation. Journal of palliative medicine. 2008 Mar 1; 11(2):217-25. [view]
4. Levy. Partnering nursing homes and palliative care specialists. Long-Term Care Interface. 2007 Nov 1; 8(6):26-31. [view]
5. Levy C, Palat SI, Kramer AM. Physician practice patterns in nursing homes. Journal of The American Medical Directors Association. 2007 Nov 1; 8(9):558-67. [view]

Journal Other

1. Wilson B, Kutner JS, Levy C. Do health insurance plans perpetuate ambiguity about palliative care? Journal of palliative medicine. 2008 Nov 1; 11(9):1182. [view]

Book Chapters

1. Levy CR, Kutner J, Holroyd-Leduc J, Reddy M. A Good Death: Appropriate End-of-life Care. In: Holroyd-Leduc J, Reddy M, editors. Evidence-Based Geriatric Medicine: A Practical Guide. United Kingdom: Wiley-Blackwell Publishing; 2012. Chapter 14. 175-186 p. [view]

Center Products

1. Levy C. Podcast: Implementing a Nursing Home Palliative Care Program. 2007 Oct 1. [view]

Conference Presentations

1. Levy C. Acute myocardial infarction in nursing home residents: Adherence to treatment guidelines reduces mortality but why is adherence so low? Poster session presented at: American Medical Directors Association Annual Symposium; 2008 Mar 1; Salt Lake City, UT. [view]
2. Levy C. Advance Care Planning: The most important intervention in long-term care. Paper presented at: Colorado Health Care Association Spring Conference; 2008 May 1; Avon, CO. [view]
3. Levy CR. Assessing Best Practices in Anemia of Chronic Kidney Disease Through Video Views and Real Talk. Paper presented at: Gerontological Advanced Practice Nurses Association Annual Conference; 2009 Oct 1; Savannah, GA. [view]
4. Levy CR. Assessing Hospice Eligibility Among Veterans in Nursing Homes. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2010 Feb 25; San Francisco, CA. [view]
5. Levy C. Drilling Down on Pain and Diabetes in Long-term Care. Paper presented at: Colorado Health Care Association Spring Conference; 2008 May 1; Avon, CO. [view]
6. Levy CR. Family, Patient, Support Network and Health Care Provider Use of the Internet in End-of-Life Care. Presented at: International Workgroup on Death, Dying and Bereavement Biennial Seminar; 2008 Oct 1; Provincetown, MD. [view]
7. Levy C. Implementing a Nursing Home Palliative Care Program. Paper presented at: American Medical Directors Association Annual Symposium; 2007 Mar 1; Hollywood, FL. [view]
8. Levy C. Implementing a Nursing Home Palliative Care Program. Paper presented at: American Academy of Hospice and Palliative Medicine Annual Assembly; 2007 Feb 1; Salt Lake City, UT. [view]
9. Levy C. Implementing a Palliative Care Program in Long-term Care. Paper presented at: Wisconsin Association of Homes and Services for the Aging Spring Conference; 2008 May 1; Pewaukee, WI. [view]
10. Levy C. Long Term Care Physician Inquiries Network. Paper presented at: American Medical Directors Association Annual Symposium; 2007 Mar 1; Hollywood, FL. [view]
11. Levy C. Symposium on Translating Research into Practice: End of Life Care in Nursing Homes. Paper presented at: American Medical Directors Association Annual Symposium; 2007 Mar 1; Hollywood, FL. [view]
12. Levy C. The Long-term Care Continuum. Paper presented at: American Medical Directors Association Annual Symposium; 2008 Mar 1; Salt Lake City, UT. [view]
13. Levy C. The Perfect Storm: Dementia, Depression and Delirium in Long-term Care. Managing behaviors in cognitively impaired elders. Paper presented at: North Dakota Healthcare Association Quality Care Annual Series; 2008 Aug 1; Bismarck, ND. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Prevention
Keywords: End-of-life
MeSH Terms: none