Long-term and post-acute care organizations have not received the same support as other care settings for creating interoperable patient data tools, putting home health and hospice providers at a disadvantage, according to new research by the Department of Health and Human Services.

Electronic health records (EHRs) are used by the vast majority of long-term and post-acute care (LTPAC) providers. Within the home health and hospice industries, roughly 78% of providers have adopted an EHR, according to the study. And while their functionality is largely the same as those used in other care settings, EHRs used by home care and hospice providers fall short when it comes to their interoperability capabilities. 

A key reason for this, HHS found, is that LTPAC organizations have not been incentivized to use interoperable technology in the same way as other healthcare providers.

“Due to thin operating margins, lack of adequate financial incentives has made it difficult to fund and implement interoperable HIT systems,” HHS said in its December report. “Organizations need a system or market reason to exchange data. Without the proper financial and policy incentives, it will be difficult to make organic progress toward interoperability.”

Meanwhile, other care settings have been able to benefit from government programs that encourage use of interoperable health data tools. Hospitals, for example, were selected to participate in Promoting Interoperability Programs, which offered financial incentives for implementing interoperable HIT.

And since hospitals and other acute care settings received this head start, many LTPAC providers have not been able to lay the groundwork to create interoperable HIT systems.

“Providers and vendors do not have a clear understanding of what data reporting and interoperability requirements will be in the future,” the report noted. “LTPAC organizations and vendors are left to do what they think is best, with limited guidance resulting in the lack of standardized and codified data to support interoperability,” the report said. 

LTPAC organizations have long petitioned lawmakers for help with creating interoperable patient data tools. And while hospitals were successful in earning this support, home health and hospice providers have not been able to do the same, HHS said in its report.

Still, the “next big step” in nationwide health data interoperability may be yet to come. The Trusted Exchange Framework and Common Agreement (TEFCA) has been slated for launch in the first quarter of 2024, and will create interoperable functionality among five EHR systems. LTPAC stakeholders have expressed hopes that TEFCA might benefit, rather than overlook, home health and hospice providers.

A new virtual reality platform helps simulate conversations between a terminally ill patient, a doctor and the patients’ family. 

The platform, developed by Jolly Good US Inc., is designed to be a training module for nurses and caregivers who hope to go into palliative care, the company said.

The need for high-quality hospice and palliative care is an ongoing concern in senior living communities and nursing homes. It is also more cost-effective to have policies that cover hospice for nursing home residents living with dementia, McKnight’s recently reported.

VR’s potential as a training environment for caregivers is starting to gain popularity, and healthcare workers have responded positively to existing tech, recent studies show. 

Jolly Good’s VR training system is the first of its kind geared toward palliative care, the company said.

The platform is designed to bridge the communication gap between hospice patients and caregivers, addressing a key factor influencing the disparity between the 90% of terminally ill older adults who express a desire to spend their final days at home or with family and the actual 30% who achieve this goal, according to Jolly Good’s data.

Recognizing the specialized concerns of palliative care, Jolly Good’s VR training offers a cost-effective and widely applicable tool for training workers, said Kei Ouchi, MD, associate professor of emergency medicine at Harvard Medical School. Jolly Good’s VR will be deployed at Harvard affiliate Brigham and Women’s Hospital.

“The VR technology allows learners to repeatedly high-stress, clinical situation from physician’s perspective regardless of location or time,” Ouchi said in a statement. “We expect that creating this dissemination strategy for evidence-based, palliative care communication skills will ultimately improve the quality of end-of-life care in the United States.”

Technology such as artificial intelligence, deployed for end-of-life purposes, still needs to allow for a personal or “warm” patient-caregiver relationship to be effective, one recent study asserts. 

For many new treatments and technology aimed at end-of-life care — for instance, an artificial intelligence-enabled analysis that determines life expectancy or survival likelihood — studies that validate their use often are based on small, or biased, data samples, and older adults should be made aware of these limitations when facing decisions about adopting such services.

This was one of several key findings in a new review of “ethical, equity and societal considerations” of digital health tools aimed at palliative or end-of-life care.

“The majority of digital health tools for palliative care are still prototypes tested on a few participants, rather than refined products evaluated through an adequately-powered randomized controlled trial,” the report authors wrote. “Transparency about the evidence base is vital.” 

Researchers  ultimately made 10 recommendations for deploying digital tools, highlighted by the need to make sure patients feel that a personal or human element is involved. 

This echoes concerns about new tech in senior living communities overall, such as AI and robotics, where both caregivers and the residents themselves are concerned about removing social or in-person interactions, either with caregivers or among residents.

“With the world’s aging population and the associated rising prevalence of cancer and other life-limiting conditions, the need for proper, pragmatic and personalized care toward the end of life is increasing,” the study report noted. “The ‘high-touch’ and ‘warm’ nature of palliative care entails establishing an empathic relationship with patients and considering them as unique individuals.”

Practical concerns about tech aimed at older adults also exist, such as how easy a tool such as a smartphone is to use, the researchers warned. 

Overall, the report touches on several common concerns that have emerged over the past few years about new digital technologies, including privacy protection and lack of access to digital tools in rural or underserved populations.

ProMedica confirmed the transaction.

“The completion of this transaction is a major step forward that will enable ProMedica to focus more time, energy and resources on its core health system operations,” ProMedica Associate Vice President of  Strategic Communications Tausha Moore told the McKnight’s Business Daily. “The proceeds from this transaction will enable ProMedica to pay off some debt and help support the organization’s long-term financial stability goals.”

Most of ProMedica’s hospice locations will rebrand to the Heartland Hospice brand by the end of 2023, and home health locations will rebrand to Heartland Home Health in early 2024. ProMedica’s palliative care business will operate under Gentiva’s Empatia Palliative Care brand.

As McKnight’s previously reported, ProMedica has been streamlining its senior living and care properties. The company retains just two skilled nursing facilities among its varied holdings. One that it wholly owns is in Florida and another it jointly operates is in Ohio. Combined, the two locations have 213 beds.

ProMedica previously told McKnight’s that it “continues to take strategic action to strengthen our financial position and build greater stability and sustainability throughout the organization.”

Gentiva CEO David Causby, in a statement, called the company’s purchase of the ProMedica home health and hospice business “a significant milestone” that “will benefit the patients and families in our care.”

He added the company is  “enthusiastic about welcoming the talented caregivers at ProMedica into the Gentiva family.”

“As a combined company, we plan to increase the number of caregivers and provide greater access to our care offering to more patients in the communities we serve,” Causby said.

For the second time this year, the Drug Enforcement Administration is extending telehealth prescription options as the agency continues to weigh how and when clinicians can provide drugs virtually.

The flexible rules, which have been in place since the COVID-19 pandemic, were set to expire this year, but numerous organizations and leaders within the long-term care sector have advocated that they be made permanent. 

The DEA received 38,000 public comments over the summer on the issue and held a two-day listening session last month.

Although the DEA is concerned with access to opioids or other controlled substances, many advocates for the telehealth flexibilities argue that, for many older adults, access to pain relieving medication via telehealth is vital, particularly for those in either palliative or hospice care. 

The original rule to limit teleprescribing would place a heavy burden on pharmacies, said Chad Worz, PharmD, CEO for the American Society of Consultant Pharmacists. 

“We appreciate that the DEA is taking the time to hear stakeholders and get the final rule right,” Worz told McKnight’s on Tuesday. “The rulemaking failed to envision how telemedicine technologies are currently used in long-term care facilities. We hope that DEA will take our comments into consideration when drafting the final rule to ensure that patients have access to needed specialists and medications.”

The DEA’s newest extension is now set to run through 2024. Beyond that, DEA officials have suggested the agency could allow for a special registration period for certain telemedicine prescriptions. 

“We continue to carefully consider the input received and are working to promulgate a final set of telemedicine regulations, giving patients and medical practitioners time to plan for, and adapt to, the new rules once issued,” DEA spokespersons said in a statement last week. 

AMDA–The Society for Post-Acute and Long-Term Care Medicine is pleased that the federal government is taking more seriously the need to relax restrictions on prescribing medication via telehealth, a spokeswoman said. 

Regulation around telemedicine, particularly as it relates to eldercare and end-of-life, should be guided by the principle of medical necessity, said Dallas Nelson, CMD, and chair of AMDA’s telehealth subcommittee. 

The DEA may re-evaluate its rules on prescribing controlled substances via telehealth appointments, following a deluge of 38,000 public comments on the initial rulemaking that would have tightened telehealth prescriptions for controlled substances, particularly those used frequently in long-term care facilities.

The DEA posted notice on its website last Friday that it is willing to consider a special registration process for certain controlled medications that would allow telemedicine prescribing without an in-person medical evaluation.

“I think it would be inappropriate, given the uniqueness of environments and patients we are serving, many with a high need for controlled substances at end of life, to not be able to offer that,” AMDA’s Nelson said. “Doctor distribution is growing shorter all the time, and by allowing access to things like behavioral health via telemedicine, we are extending a short workforce.” 

In April, another long-term care-related industry organization, LeadingAge, sent a letter to the DEA asking it to consider some key exemptions for nursing home, hospice and palliative care patients so their access to controlled medications would not be disrupted or require in-person medical appointments. 

“We do not believe prescribing controlled medications using telehealth for hospice patients or residents in long-term care is a high-risk situation that requires the guardrails outlined in DEA’s proposed rule,” wrote Katy Barnett, LeadingAge’s director of home care and hospice operations and policy. 

The new rules prohibited people from receiving 30-day prescriptions for more Schedule II narcotics without at least an initial in-person medical visit.

The agency announced on May 9, just two days before the COVID-19 public health emergency expired, that it would extend flexibilities for controlled substance prescriptions until Nov. 11. 

The DEA’s listening sessions will take place at its headquarters in Arlington, VA, on Sept. 12 and Sept. 13. Members of the public must register to attend in-person by Aug. 21. The agency will allow a limited number of 10-minute presentations by the public. 

More specific direct care worker training requirements in assisted living communities may help decrease the number of end-of-life care transitions, and more explicit staffing regulations may increase those transitions, according to a new study.

Researchers from the University of Rochester published a study in JAMDA, the Journal of the Society for Post-Acute and Long Term Care Medicine examining the frequency and categories of end-of-life care transitions among former Medicare beneficiaries living in assisted living communities. 

The study is reported to be the first to tie end-of-life care transition variations to state regulations on staffing and training. 

Overall, the researchers saw end-of-life care transitions among 35% of participants in the last 30 days of life and among 17% in the last seven days of life, although significant variations were seen across states. Frequency of care transitions in the last seven days of life was associated with state regulations on licensed direct care worker staffing and training.

State requirements on staff training led to few end-of-life care transitions. But the investigators also found that states with greater regulatory specificity on staffing requirements experienced a higher frequency of transitions during residents’ last seven days of life.

“On one hand, when ALCs have licensed staff or even simply more direct care worker staff, they have greater opportunity to identify increasing care needs of residents whose health status declines, thus precipitating care transitions to higher care settings,” they concluded. “On the other hand, when direct care workers are required to have more training, they may be better equipped to identify residents with higher care needs earlier and arrange for the care to be provided within the ALC, thus preventing potentially avoidable transitions.”

The study also noted that participants with end-of-life transitions in the last seven days of life tended to be younger, less likely to be enrolled in Medicare Advantage plans or hospice, and more likely to be dually eligible for Medicare and Medicaid. Those individuals also tended to live in assisted living communities with higher populations of residents who had mental health issues or cognitive issues, including Alzheimer’s disease and related dementias.

One surprising finding, they said, was the relatively high number of transfers to inpatient hospice programs occurring within both the last seven and 30 days of life. According to the study, more than 80% of assisted living community residents who died at home were enrolled in hospice. Researchers noted that this fact makes the frequent transfer of those individuals to inpatient hospice both “surprising and concerning.”

Time to revisit requirements?

The authors noted several implications of their findings, suggesting that minimum staffing requirements in assisted living settings — similar to those proposed by President Biden for nursing homes — may be needed to achieve better performance at the end of life. 

The study also highlights the importance of assisted living staffing and training in end-of-life quality of care, they said. Although assisted living communities usually do not have medical staff on site, the proper training of direct care workers may help in identifying residents’ needs and improving end-of-life care quality, they said.

“Because ALCs are largely regulated by states, state government officials and lawmakers may want to revisit their ALC staffing licensing and training regulations to set more specific requirements in these domains for quality improvement,” the authors wrote.

Rebecca Anhang Price, PhD, from the RAND Corporation in Arlington, VA, and colleagues examined whether differences in profit status are associated with family caregivers’ reports of hospice care experiences using data from the Consumer Assessment of Healthcare Providers and Systems Hospice Survey for 653,208 caregiver respondents. A total of 906 not-for-profit hospices and 1,761 for-profit hospices were included, which had a mean of 25.7 and 13.8 years in operation, respectively.

The researchers found that for all measures, family caregivers reported worse care experiences at for-profit than not-for-profit hospices. After adjustment for hospice characteristics, significant differences in average hospice performance by profit status remained. For-profit hospice performance varied, with 31.1 and 21.9% of for-profit hospices scoring 3 or more points below and 3 or more points above the national average of performance, respectively. In contrast, among not-for-profit hospices, 12.5 and 33.7% scored 3 or more points below and 3 or more points above the average, respectively.

“In the hospice context, poor quality care has been associated with complicated family grief and poorer bereavement adjustment, so this quality gap, combined with the growing dominance of for-profit hospices, is of particular concern,” the authors write.

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Mazie Tsang, MD, from the University of California in San Francisco, and colleagues used data from the Health and Retirement Study (HRS), linked with Medicare claims (1998 to 2016), to identify 2,105 older adults (mean age, 76 years) in whom poor-prognosis cancers (cancers with a median survival of one year or less) were diagnosed. The prevalence of preexisting geriatric and palliative conditions was assessed.

The researchers found that after adjusting for gender, cancer type, and HRS survey time before the first Medicare claim for a poor-prognosis cancer, functional impairment and falls were highest among adults aged 85 years and older, while adults aged 65 to 74 years were less likely to have an advance directive. Women had a higher rate of pain and physical impairment in an adjusted analysis. Race and socioeconomic status predicted difficulty with mobility and instrumental activities of daily living, living alone, and advance directive completion.

“Older adults with poor prognosis cancers have an average life expectancy of less than one year. They represent an especially vulnerable group of patients,” Tsang said in a statement. “Based on our findings, all older adults with poor prognosis cancers should be assessed for preexisting conditions that are routinely managed by primary care practitioners, geriatricians and palliative care practitioners. Our findings are foundational to improving the holistic care of older adults with poor prognosis cancers.”

One author disclosed financial ties to the biotechnology industry.

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Residents living in states with supportive regulations around hospice and home healthcare were more likely to die in their assisted living “homes” rather than transition to skilled nursing care at end of life, according to the results of a new study.

An examination of varying state regulations of third-party services in assisted living communities — namely hospice, home health services and the use of private care aides — by Brown University researchers found that support for such services led to a larger number of residents dying in place rather than transitioning elsewhere at end of life.

The retrospective study involved 168,000 Medicare beneficiaries residing in more than 8,300 assisted living communities during the last 12 months of their lives, who died between 2017 and 2019.

Their results, published in JAMA Health Forum, found that regulations of assisted living residences — from admission criteria to staffing requirements — vary from state to state. Researchers said that states that allowed third-party services — including hospice, home health services and private care aides — may play an important role in meeting the growing care needs of residents who want to die in place.

According to the study, 13 states support all third-party services across all licenses. Many states supported some third-party services, or their regulations varied between license types of classifications. In addition, six stats were silent on all third-party regulations across assisted living licenses. 

Their results suggested that communities that support third-party services tended to retain a larger share of residents until death. A substantial variation was seen in the percentage of assisted living residents dying in place, from 18% in New York to 74% in Utah.

“With an increasing number of older adults calling assisted living ‘home’ and wishing to remain in place at the end of life, there is an increasing concern about the level of oversight needed to protect a vulnerable population of terminally ill residents,” the authors wrote.

The authors noted that despite evidence that older adults may prefer to avoid nursing home admission close to death, dying in an assisted living community does not guarantee high-quality end-of-life care — an area the authors said needs more study. 

The investigators concluded that more research also is necessary to identify factors affecting place of death and quality of end-of-life care for assisted living residents. Supportive regulations for services that are important in meeting the increasing care needs of individuals approaching death, they added, may be a good place to start.

Researchers from Oregon Health & Sciences University and the US Department of Veterans Affairs Medical Center in Providence, RI, contributed to the study.