Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

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ABSTRACT Burdensome transitions – increases in intensity of care at the end of life (EOL) – are not necessarily desired by patients or their advocates. Patients with Alzheimer’s disease and its related Dementias (AD/ADRD) frequently require the agency of their proxies (whether family or other decision makers) to ensure that their wishes are met. Prior work has shown that existence of an advanced directive or other forms of advanced care planning is associated with lower rates of burdensome transitions at EOL in a national nursing home (NH) population. Use of POLST has been associated with lower ICU use among patients with dementia at EOL. NH quality – as measured by the CMS Five Star Rating in NH Compare – is associated with greater completion of POLST among long term NH patients, most of who screen for significant cognitive impairment. Patients with AD/ADRD represent a challenging, but appropriate population for POLST implementation to reduce burdensome transitions at the end of life. The goal of POLST is to codify patient’s wishes in a single document that captures the physician’s specific orders for care intensity. The goal is for medical providers to follow these orders. Patients with AD/ADRD are highly dependent on others to complete and maintain POLSTs that reflect their wishes. In preliminary work, we have shown that NH quality is associated with POLST completion. It is less clear if NH quality impacts how POLST is completed within NH among patients with AD/ADRD. Do lower quality NHs complete POLSTs that reflect patient wishes and / or the best judgement of their proxies? Or, are lower quality NHs defaulting to higher intensity care when POLSTs are completed, resulting in patients with AD/ADRD undergoing more burdensome transitions and receiving higher intensity care at the end of life? In this administrative supplement, we will investigate the impact of NH quality on care preferences and care delivery for individuals with AD/ADRD with significant cognitive impairment at the end life in California (2011 to 2018) in order to specifically address the following specific aims: 1. Determine the impact of overall and constituent characteristics of NH quality on POLST completion and patient preferences among LTC patients with AD/ADRD at the end-of-life. 2. Determine the impact of NH quality on burdensome transitions at the end-of-life among LTC patients with AD/ADRD at the end-of-life accounting for POLST completion. This supplement will specifically address how NH quality influences the completion and recording of patient preferences in one type of ACP instrument – the POLST – and how NH quality and POLST interact to influence intensification of care at EOL for patients with AD/ADRD.