Chartbook on Healthy Living

Goals of Supportive and Palliative Care

• Disease cannot always be cured, and functional impairment cannot always be reversed.
• For patients with long-term health conditions, managing symptoms and preventing complications are important goals.
• Supportive and palliative care:
  • Cuts across many medical conditions.
  • Is delivered by many health care providers.
  • Focuses on enhancing patient comfort and quality of life and preventing and relieving symptoms and complications.

Measures of Supportive and Palliative Care

• Relief of Suffering:
  • Improvement in shortness of breath among home health care patients.
  • Nursing home residents with moderate to severe pain.
  • Nursing home residents who lose too much weight.
• Help With Emotional and Spiritual Needs:
  • Worsening depression or anxiety in nursing home residents.
• High-Quality Palliative Care:
  • Home health care patients with hospital admission.
  • Home health care patients with urgent, unplanned medical care.
  • Nursing home residents receiving antipsychotic medication.

Relief of Suffering

• Home health care patients with shortness of breath.
• Nursing home residents with moderate to severe pain.
• Nursing home residents who lost too much weight.

Shortness of Breath Among Home Health Care Patients

• Shortness of breath is uncomfortable.
• Many patients with heart or lung problems experience difficulty breathing and may tire easily or be unable to perform daily activities.
• Doctors and home health staff should monitor shortness of breath and may give advice, therapy, medication, or oxygen to help lessen this symptom.

Home Health Care Patients With Less Shortness of Breath

Adult home health care patients whose episodes of shortness of breath decreased, by age and race/ethnicity, 2010-2012

Left Chart:

2010 Achievable Benchmark: 70.7%.

Right Chart:

2010 Achievable Benchmark: 70.7%.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2010-2012.
Denominator: Adult nonmaternity patients completing an episode of skilled home health care.
Note: White and Black are non-Hispanic. Hispanic includes all races. Starting January 1, 2010, the patient assessment instrument for home health agencies was changed to OASIS-C.

• Importance: Shortness of breath interferes with activity and is an important health status indicator. It affects quality of life, ability to engage in a wide variety of activities, and patients' ability to care for themselves.
• Overall Rate: In 2012, 64.2% of home health care patients had less shortness of breath.
• Groups With Disparities:
  • In all years, Hispanics were less likely than Whites to show improvement in shortness of breath.
• Achievable Benchmark:
  • The 2010 top 5 State achievable benchmark was 70.7%. The top 5 States that contributed to the achievable benchmark are District of Columbia, Hawaii, Maryland, New Jersey, and South Carolina.
  • No group has achieved the benchmark.
  • Data are insufficient to determine time to benchmark.

Moderate to Severe Pain Among Nursing Home Residents

• Pain management is a particularly important clinical concern for older adults residing in nursing homes.
• Poorly managed pain can decrease resident quality of life, reduce mobility and functional status, and increase loneliness and depression (Abrahamson, et al., 2015).

Long-Stay Nursing Home Residents With Pain

Long-stay nursing home residents who have moderate to severe pain, by race and age, 2012

Left Chart:

2011 Achievable Benchmark: 7.1%.

Right Chart:

2011 Achievable Benchmark: 7.1%.

Key: AI/AN: American Indian or Alaska Native; API: Asian or Pacific Islander.
Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2011. Data are from the third quarter of the calendar year.
Denominator: All long-stay residents in Medicare- or Medicaid-certified nursing home facilities.
Note: For this measure, lower rates are better.

• Importance: Failure to identify the presence of pain or to assess its severity and functional impact can leave a potentially treatable symptom unrecognized and therefore unlikely to be addressed.
• Overall Rate: In 2012, 10.9% of nursing home residents had moderate to severe pain.
• Groups With Disparities:
  • In 2012, Blacks, Asians, Native Hawaiian s and Other Pacific Islanders (NHOPIs), and multiple-race residents were less likely than Whites to have moderate to severe pain.
  • American Indians and Alaska Natives (AI/ANs) were more likely than Whites to have moderate to severe pain.
  • Residents ages 0-64, 65-74, and 75-84 were more likely than residents age 85 and over to have moderate to severe pain.
• Achievable Benchmark:
  • The 2011 top 5 State achievable benchmark was 7.1%. The top 5 States that contributed to the achievable benchmark are District of Columbia, Hawaii, Maryland, New Jersey, and New York.
  • In 2012, only Asians had achieved the benchmark.
  • Data are insufficient to determine time to benchmark.

Weight Loss Among Nursing Home Residents

• Unintentional weight loss is a common problem among nursing home residents.
• Weight loss is associated with adverse, costly clinical outcomes, including increased hospitalization, morbidity, and mortality.
• The Minimum Data Set defines clinically significant weight loss for nursing home residents:
  • Weight loss ≥5% within a 30-day period or 10% within a 180-day period.

Nursing Home Residents Who Lost Too Much Weight

Long-stay nursing home residents who lost too much weight, by age and race/ethnicity, 2011-2012

Left Chart:

2011 Achievable Benchmark: 7.4 %.

Right Chart:

2011 Achievable Benchmark: 7.4 %.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2011-2012.
Note: White and Black are non-Hispanic. Hispanic includes all races.

• Importance: Nursing home residents with weight loss are at higher risk for functional decline, hip fracture, and death. Weight loss also may lead to muscle wasting, infections, and increased risk of pressure ulcers. Detecting and preventing weight loss is central to ensure appropriate nutritional intake.
• Overall Rate: The percentage of long-stay nursing home residents who lost too much weight changed slightly from 9.1% in 2011 to 9.4% in 2012 (data not shown).
• Groups With Disparities:
  • In 2012, the percentage of nursing home residents who lost too much weight was lower for Black and Hispanic residents compared with White residents. Nearly 10% of White nursing home residents lost too much weight compared with 8.1% of Black residents and 7.0% of Hispanic residents.
• Achievable Benchmark:
  • The 2011 top 6 State achievable benchmark was 7.4%. The top 6 States that contributed to the achievable benchmark are California, District of Columbia, Maryland, Massachusetts, New York, and Texas.
  • In 2011 and 2012, only nursing home residents ages 0-64 and Hispanics achieved the benchmark.
  • Data are insufficient to determine time to benchmark for other groups.

Help With Emotional and Spiritual Needs

Depression or Anxiety Among Nursing Home Residents

• Nursing home residents have higher rates of depression compared with community-dwelling peers:
  • Related to higher rates of physical illness, pain, comorbidity, disability, cognitive problems, and nutritional deficits (Choi, et al., 2008).
• Depression may:
  • Cause significant suffering.
  • Reduce quality of life.
  • Worsen physical symptoms such as pain.
  • Impair one's ability to find meaning in life.
  • Shorten survival in some illnesses.
  • Interfere with relationships.
  • Cause distress to family and friends (Widera & Block, 2012).

Nursing Home Residents Who Are More Depressed or Anxious

Long-stay nursing home residents who are more depressed or anxious, by chronic conditions, overall and stratified by race/ethnicity, 2012

Left Chart (number of chronic conditions):

• Total - 7.8%.
• 0 Conditions - 5.2%.
• 1 Condition - 6.4%.
• 2-3 Conditions - 7.4%.
• 4+ Conditions - 9.1%.

2011 Achievable Benchmark: 3.7%.

Right Chart:

2011 Achievable Benchmark: 3.7%.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2012.
Note: White and Black are non-Hispanic. Hispanic includes all races. For this measure, lower rates are better

• Importance: Depression is a very expensive, complicating, and treatable condition for nursing facility residents.
• Overall Rate: In 2012, 7.8% of long-stay nursing home residents had increased depression or anxiety.
• Groups With Disparities:
  • Residents with 0, 1, and 2-3 chronic conditions were less likely than residents with 4 or more chronic conditions to be more depressed or anxious.
  • Regardless of chronic conditions, Black and Hispanic residents were less likely than White residents to be more depressed or anxious.
• Achievable Benchmark:
  • The 2011 top 5 State achievable benchmark was 3.7%. The top 5 States that contributed to the achievable benchmark are Alabama, California, District of Columbia, Mississippi, and Nevada.
  • In 2012, no group had achieved the benchmark.
  • Data are insufficient to determine time to benchmark.

High-Quality Palliative Care

• Home health care patients who were admitted to the hospital.
• Home health care patients who needed urgent, unplanned medical care.
• Antipsychotic medication use.

Hospitalization and Unplanned Care as a Measure of Home Health Care

• The goals of home health care are to restore, maintain, or slow the decline of well-being and functional capacity, and to assist patients to remain in the community by avoiding hospitalization or admission to long-term care facilities.
• The Centers for Medicate & Medicaid Services considers acute care hospitalizations and emergency department use during home health care to be one of the key quality measures for care given to homebound Medicare beneficiaries.
• Hospitalization leads to increased cost for payers, leaves older adults at risk for adverse events such as medical errors, reduces quality of life for patients and their caregivers through psychological distress, and exposes already compromised patients to further decline and reduced functional status.

Home Health Care Patients Who Were Admitted to the Hospital

Home health care patients who were admitted to the hospital, by age, 2010-2012, and by race, stratified by age, 2012

Left Chart:

2010 Achievable Benchmark: 17.7%.

Right Chart:

2010 Achievable Benchmark: 17.7%.

Key: AI/AN: American Indian or Alaska Native; NHOPI: Native Hawaiian or Other Pacific Islander.
Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2012.
Note: For this measure, lower rates are better.

• Importance: Acute care hospitalization is a national priority for Medicare recipients, based on evidence that 20% of all Medicare beneficiaries who were hospitalized had a return hospital stay within 30 days.
• Overall Rate: In 2012, 25.8% of home health care patients had to be admitted to the hospital.
• Groups With Disparities:
  • In 2012, Black patients age 65 and over were more likely than White patients to be admitted to the hospital.
  • Asians ages 0-85 were less likely than Whites to be admitted to the hospital.
• Achievable Benchmark:
  • The 2010 top 5 State achievable benchmark was 17.7%. The top 5 States that contributed to the achievable benchmark are Idaho, Montana, Oregon, South Dakota , and Utah.
  • Data are insufficient to determine time to benchmark.

Home Health Care Patients Who Needed Urgent, Unplanned Medical Care

Home health care patients who needed urgent, unplanned medical care, by age, 2010-2012, and by ethnicity, stratified by age, 2012

Left Chart:

2010 Achievable Benchmark:15.2%.

Right Chart:

2010 Achievable Benchmark:15.2%.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2012.
Note: White and Black are non-Hispanic. Hispanic includes all races. For this measure, lower rates are better.

• Importance: Identification of inappropriately high emergency department (ED) use and encouragement of agencies to implement interventions that reduce inappropriate ED use can help improve health and lower costs.
• Overall Rate: In 2012, 21.4% of home health patients needed urgent, unplanned medical care.
• Groups With Disparities:
  • For all age groups, Hispanic home health care patients were less likely than White patients to need urgent, unplanned care.
  • In 2012, Black home health care patients age 65 over were more likely than White patients to need urgent, unplanned medical care.
• Achievable Benchmark:
  • The 2010 top 5 State achievable benchmark was 15.2%. The top 5 States that contributed to the achievable benchmark are California, District of Columbia, Florida, South Dakota, and Utah.
  • Only Hispanic home health care patients ages 65-74 have achieved the benchmark.
  • Data are insufficient to determine time to benchmark.

Antipsychotic Medication Use Among Nursing Home Residents

• In the past, inappropriate prescribing of antipsychotics in nursing homes has primarily been considered a marker of suboptimal care.
• Recent studies have shown antipsychotic use is also a drug safety issue (Huybrechts, et al., 2012).
• Safety concerns with antipsychotic medication use in older adults include:
  • Cerebrovascular events.
  • Hyperprolactinemia.
  • Pneumonia.
  • Cardiovascular events.
  • Thromboembolism (Chiu, et al., 2015).

Nursing Home Residents Who Had Antipsychotic Medication

Long-stay nursing home residents who had antipsychotic medication, by sex, race, and chronic conditions, 2012

Key: CC = chronic conditions.
Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2012.
Note: For this measure, lower rates are better.

• Importance: Higher rates of morbidity and mortality have been identified when antipsychotic medication is used for treatment that is not for an indication approved by the Food and Drug Administration.
• Overall Rate: In 2012, 21.8% of long-stay nursing home residents received antipsychotic medication.
• Groups With Disparities:
  • In 2012, nursing home residents with 1 or more chronic conditions were more likely than residents with no chronic conditions to receive antipsychotic medications.
  • Black, Asian, NHOPI and multiple-race residents were less likely than White residents to receive antipsychotic medications.
• Achievable Benchmark:
  • The 2012 top 6 State achievable benchmark was 15.0%. The top 6 States that contributed to the achievable benchmark are Alaska, California, Hawaii, Michigan, New Jersey, and Wyoming.
  • No group has achieved the benchmark.
  • Data are insufficient to determine time to benchmark.

Nursing Home Residents Who Had Antipsychotic Medication, by State

Long-stay nursing home residents who had antipsychotic medication, by State, 2012

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2012.
Note: For this measure, lower rates are better.

• The percentage of residents who received antipsychotic medication in States in the highest and lowest quartiles follows:
  • Highest quartile, 24.5% and higher.
  • Lowest quartile, less than 17.3%.
• In 2012, 8 of 11 States in the quartile with the highest percentage of long-stay nursing home residents who received antipsychotic medication were located in the South.

References

Abrahamson K, DeCrane S, Mueller C, et al. Implementation of a nursing home quality improvement project to reduce resident pain: a qualitative case study. J Nurs Care Qual 2015 Jul-Sep;30(3):261-8. PMID: 25407787.

Chiu Y, Bero L, Hessol NA, et al. A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents. Health Policy 2015 Jun;119(6):802-813. Epub 2015 Feb 28. PMID: 25791166. http://www.sciencedirect.com/science/article/pii/S0168851015000652. Accessed June 17, 2015.

Choi NG, Ransom S, Wyllie RJ. Depression in older nursing home residents: the influence of nursing home environmental stressors, coping, and acceptance of group and individual therapy. Aging Ment Health 2008 Sep;12(5):536-47. PMID: 18855169.

Huybrechts KF, Gerhard, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: Population based cohort study. BMJ 2012 Feb 23;344:e977. PMID: 22362541. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285717/. Accessed June 17, 2015.

Widera EW, Block SD. Managing grief and depression at the end of life. Am Fam Physician 2012 Aug 1;86(3):259-64. PMID: 22962989. http://www.aafp.org/afp/2012/0801/p259.html. Accessed June 17, 2015.

Return to Contents