Market and Provider Effects on Hospice in Nursing Homes

描述（由申请人提供）：尽管疗养院临终关怀（NHs）及其福利迅速增长，但NH居民构成了弱势群体，面临着社区人士所经历的临终关怀障碍。研究表明，接受临终关怀的住院患者接受疼痛评估和治疗的可能性更大，而在生命结束时住院治疗的可能性更小。然而，只有在NH与临终关怀提供者签订合同的情况下，NH居民才能参加医疗保险临终关怀，而实际上，并非所有的NHs都有这样的合同。此外，低医疗补助报销可能会对他们提供临终关怀的决定产生负面影响。在这个提议的项目中，我们使用国家数据来检查医疗保险临终关怀福利成为临终病人NH居民可用的过程。我们利用相关的医疗保险索赔，养老院和临终关怀提供者数据和最小数据集（MDS）临床信息。我们将描述和表征在地方，州和国家层面的医疗保险临终关怀在养老院的渗透。使用多层模型技术，我们将检验设施、市场（包括提供者和人口）和国家特征对疗养院临终关怀渗透的影响。使用详细的安宁疗护提供者数据，我们将评估安宁疗护收入和转诊来源对北卡罗来纳州和南卡罗来纳州疗养院安宁疗护渗透率的影响，并根据设施、市场和州的特点进行调整。最后，我们将进一步了解当观察到的实践与我们的多层模型预测的渗透不一致时，与养老院安宁疗护渗透相关的非市场因素。我们将识别在美国四个主要地理区域（即西部、中西部、南部和东北部）中，当提供临终关怀的预测较低（“假阴性”）时，在养老院提供临终关怀的临终关怀提供者；当提供临终关怀的预测较高（“假阳性”）时，识别不在疗养院提供临终关怀的临终关怀提供者。我们将在四个地理区域中，分别对一名“假阳性”和一名“假阴性”的安宁疗护提供者进行个案研究，方法是进行实地访问，并采访安宁疗护院和疗养院的工作人员（及其地理上邻近的疗养院）。

DESCRIPTION (Provided by Applicant): Despite the rapid growth of hospice in nursing homes (NHs) and its benefits, NH residents constitute a vulnerable population facing access barriers to hospice beyond those experienced by persons in the community. Research shows hospice enrollment is associated with a greater probability of residents having their pain assessed and managed and with a lesser probability of being hospitalized at the end-of-life. However, enrollment in Medicare hospice is only available to NH residents if a NH has a contract with a hospice provider, and in practice, not all NHs have such contracts. Furthermore, low Medicaid reimbursements to NHs may have a negative effect on their decision to offer hospice. In this proposed project we use national data to examine the process by which the Medicare hospice benefit becomes available to terminally ill NH residents. We take advantage of linked Medicare claims, nursing home and hospice provider data and Minimum Data Set (MDS) clinical information. We will describe and characterize at the local, state and national level the penetration of Medicare hospice in nursing homes. Using multilevel modeling techniques, we will examine the effect of facility, market (including providers and population), and state characteristics on the penetration of hospice in nursing homes. Using detailed hospice provider data, we will evaluate the effects of hospice revenue and referral sources on the penetration of hospice in nursing homes in North and South Carolina, adjusting for facility, market, and state characteristics. Finally, we will develop an understanding of the non-market factors associated with hospice penetration in nursing homes when the observed practice is discordant with the penetration as predicted by our multilevel model. We will identify hospice providers in each of the four major U.S. geographic regions (i.e., West, Midwest, South and Northeast) who are providing hospice care in nursing homes when there is a low prediction of such provision ("false negatives") and, identify hospice providers not providing care in nursing homes when there is a high prediction of such provision ("false positives"). We will conduct case studies of one "false positive" and one "false negative" hospice provider in each of the four geographic regions by conducting site visits and interviewing hospice and nursing home staff (and their geographic proximal nursing homes).