Market and Provider Effects on Hospice in Nursing Homes

描述（由申请人提供）：尽管临终关怀在疗养院（NH）及其好处的快速增长，NH居民构成了一个弱势群体，面临着超越社区人员所经历的临终关怀的准入障碍。研究表明，临终关怀登记与居民接受疼痛评估和管理的可能性更大，并且在生命结束时住院的可能性更小。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，而且在实践中，并非所有NH都有这样的合同。此外，低医疗补助报销的国家卫生服务可能会产生负面影响，他们决定提供临终关怀。在这个拟议的项目中，我们使用国家数据来检查的过程中，医疗保险临终关怀福利成为绝症NH居民。我们利用关联的医疗保险索赔、疗养院和临终关怀提供者数据以及最小数据集（MDS）临床信息。我们将描述和特点，在地方，州和国家层面的渗透医疗临终关怀在疗养院。使用多层次建模技术，我们将研究设施，市场（包括供应商和人口）和国家的特点对临终关怀在疗养院的渗透的影响。使用详细的临终关怀提供者的数据，我们将评估临终关怀的收入和转诊来源的影响，在北卡罗来纳州和南卡罗来纳州的疗养院临终关怀的渗透，调整设施，市场和国家的特点。最后，我们将开发一个理解的非市场因素与临终关怀渗透在养老院时，观察到的做法是不一致的渗透，我们的多层次模型预测。我们将确定美国四个主要地理区域（即，西部、中西部、南部和东北部），当存在对这种提供的低预测（“假阴性”）时，确定在疗养院中不提供护理的临终关怀提供者，并且当存在对这种提供的高预测（“假阳性”）时，确定临终关怀提供者。我们将进行个案研究的一个“假阳性”和一个“假阴性”临终关怀提供者在四个地理区域进行实地考察和采访临终关怀和疗养院的工作人员（和他们的地理附近的疗养院）。

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).