Racial/Ethnic Differences in Palliative Care Services and Potentially Avoidable Hospitalizations at End-of-Life in Nursing Homes Nationwide

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On any day, approximately 1.6 million Americans live in the nation’s nursing homes (NHs) and 90% of the residents are ≥ 65 years old. In the last two decades, there has been an increase in the proportion of racial/ethnic minority NH residents and a decrease in non-Latino White NH residents. Racial/ethnic minorities often reside in NHs situated in low-income communities that are poorly resourced and provide low quality of care. COVID-19 has highlighted the increased vulnerability of racial/ethnic minority NH residents. Prior to COVID-19, an estimated 25% of all deaths in the US occurred in NHs and approximately 44% of non-hospice NH residents experienced hospitalizations during the last 30 days of life. Racial/ethnic minority NH residents experience increased hospitalizations compared to non-Latino White NH residents. Many of these hospitalizations are potentially avoidable. Palliative care is essential in providing high quality end-of-life care by alleviating symptoms and providing support to patients and caregivers; yet, palliative care is suboptimal in many NHs. In preliminary work using 2017 data from the randomly sampled, national, stratified survey (n = 892) from the Study of Infection Management and Palliative Care at the End-of-Life (SIMP-EL; R01 NR013687; Stone PI and mentor), I found wide variation in NH palliative care services at the end-of-life. However, health disparities in NH palliative care services has not been studied. Furthermore, it is unknown how variations in NH palliative care services are associated with potentially avoidable hospitalizations at the end-of-life. Guided by the Gelberg-Andersen’s Behavioral Model for Vulnerable Populations, in the proposed study I will address these gaps by conducting a secondary, cross-sectional analysis using multiple data sources (i.e., the SIMP-EL survey; NH resident assessments from the Minimum Data Set 3.0; hospital claims data from the Medicare Provider and Analysis Review; NH facility characteristics from the Certification and Survey Provider Enhanced Reporting; and county level data from the Area Health Resources Files). Specifically, my aims are to: 1) Describe palliative care services provided in NHs across the nation and identify differences by population served (i.e., proportion of racial/ethnic minorities) and 2) Identify associations between palliative care services and potentially avoidable hospitalizations at the end-of-life by NH resident’s race/ethnicity. Aim 1 is a NH level analysis and Aim 2 is an individual resident level analysis. This research aligns with the National Institute of Nursing Research priority area of End-of-Life and Palliative Care Research to improve palliative care strategies for individuals and families with serious illness. To facilitate this research, the applicant will build her knowledge and skills in palliative care, quantitative research methods, and racial/ethnic health disparities. As a Latina pre- doctoral student with the dedicated mentorship of National Institutes of Health-funded interdisciplinary researchers, the resource-rich environment of Columbia University, and in response to PA-20-251, receipt of this fellowship will contribute to increasing the diversity of individuals conducting health-related research.