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.
