What Models Exist for Delivering Palliative Care and Hospice in Nursing Homes?

Nursing Homes

Nursing homes are complex environments where both medical and supportive care are provided. The number of vulnerable residents requiring complex care is growing rapidly. Long-term care residents often have multiple chronic conditions; short-term residents are often very ill, but expected to recover and go home. More than 45% of nursing home residents have dementia, and 32% have various other psychological disorders. Nearly two-thirds of residents are prescribed psychoactive medications, including antidepressants, anxiolytics, antipsychotics, sedatives, and hypnotics. Roughly 70% of residents are bedridden or chairfast. Many require extensive assistance by nursing staff with their activities of daily living, and one-third receive therapy services by physical, occupational, and speech therapists. About 20% of hospitalized Medicare beneficiaries are discharged to a nursing home. Despite the need for supportive and rehabilitative care, the nursing home industry has struggled with issues of workforce capacity and care quality.

For decades, activists, researchers, and policymakers have voiced concerns regarding the quality of care in nursing homes. To address these concerns, in 1987 the federal government implemented a stringent set of regulations with which all Medicare-certified nursing homes were required to comply. These regulations, intended to improve oversight of care quality, made the nursing home industry one of the most heavily regulated industries in the country. Since the implementation of these regulations, nursing homes have been mandated to undergo comprehensive annual inspections by state surveyors who assess the processes and outcomes of the nursing care provided. Failure to meet regulatory standards results in deficiency citations. Although care quality has arguably improved since these regulations were put into place, the regulations are also criticized for being burdensome and restrictive. Directors of nursing homes report that much of their time is spent addressing regulatory standards, rather than working with staff or caring for residents. Additionally, because of the pressure to focus on compliance, caregivers, particularly registered nurses, are often forced to spend a great deal of their time documenting care rather than directly providing it. Nursing home quality data, including an overall star rating and ratings on multiple clinical quality metrics, are also publicly reported by Medicare on the Nursing Home Compare website ( https://www.medicare.gov/care-compare/ ).

Certified nursing assistants provide the majority of direct, hands-on care in nursing homes. They are helping residents get dressed, feeding them, helping with toileting, and meeting other basic needs. Licensed practical nurses (LPNs) are typically the largest group of licensed caregivers and registered nurses (RNs) the smallest. Numerous studies have demonstrated that adequate staffing and greater RN presence are associated with improved quality of care. Nonetheless, staffing represents a major challenge for nursing homes. Turnover rates for all nursing staff members are staggeringly high, which complicates implementation of new programs and trainings. In 2019, LeadingAge reported that annual turnover among certified nursing assistants was 40.7%, LPNs was 26.3%, and RNs was 31%. Many facilities staff according to the minimum standards, which experts argue are too low.

Negative reports in the popular press have given nursing homes a poor reputation. Although legitimate deficiencies do exist, nursing homes today rarely resemble the stereotypes they have been assigned. Nursing staff typically care very deeply for their residents and form strong relationships with the residents and their family members. Additionally, although nursing home staff may have less formal education than their colleagues in acute care, nurses and nursing assistants are frequently eager to receive continuing education to support them in their practice. Financial, regulatory, and workforce-related challenges may distract from the primary stated mission of nursing homes to provide the best possible care to frail and older residents.

Given the growing numbers of residents who have unmet palliative care needs and spend time at the end of life in nursing homes each year, establishing strong palliative care programs within this setting is important for enhancing the quality of life these residents experience and the consistency and quality of care they receive. Many attributes of nursing homes make them ideal settings in which to deliver these services. Given the complexities surrounding care delivery in this setting, however, challenges exist that limit progress toward this goal.