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One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

The length of stay data were striking:

  • the median length of stay in a nursing home before death was 5 months
  • the average length of stay was longer at 14 months due to a small number of study participants who had very long lengths of stay
  • 65% died within 1 year of nursing home admission
  • 53% died within 6 months of nursing home admission

The authors also found that length of stay varied based on a number of demographic, social, and clinical factors. For instance:

  • men died sooner after admission than women (men had a median length of stay of around 3 months versus 8 for women)
  • married nursing home residents died sooner after admission than unmarried participants (an average of 4 months sooner)
  • nursing home residents in the highest quartile of net worth died six months sooner than those in the lowest quartile.

I had a chance to talk with the lead author, Anne Kelly, about the implications of these findings. Kelly told me “that even though this study doesn’t address why certain demographic and social factors lead to a shorter length of stay, it does look like people with greater social support at home have shorter lengths of stay when admitted to a nursing home.”  Kelly also explains that the findings of this study reinforce the idea that advance care planning needs to occur upon admission to a nursing home. In her words: “it’s best to begin those discussions early on and readdress them frequently during their stay given that so many people are going to be there for only a brief time.”

I think these findings have broader implications for our community as well. For one thing, I think it should make us re-evaluate our priorities when thinking about where we put our clinical efforts. For instance, most palliative care consultations occur within hospitals, although most patients will die outside of the hospital setting. With the recent NEJM study on the effectiveness of outpatient palliative care (see here to learn more), maybe we should think of more effective ways in partnering with nursing home providers to manage the end-of-life needs of these patients.  Sounds like fresh territory for a geriatrics and palliative care collaboration (hmmm, I wonder what we should call such an endeavor???)

by: Eric Widera

This Post Has 14 Comments

  1. SF Weekly's Blog also commented on this article at -

    Their take home – "If you're going to put Grandma or Grandpa in a nursing home — don't put off making a visit."

  2. End of life/Advanced Planning is part of every admission in the SNF and certainly part of every admission discuss I have with patients. As a former hospice nurse, now a GNP working in the SNF environment I am a strong advocate for good EOL care for my patients. I think the bigger issue is the problem with reimbursement issues for EOL care in this environment. Certainly those residents who are "custodial" residents can receive hospice services without being penalized, but skilled patients are penalized by switching from skilled to hospice services. The problem with that is that while I can ensure my patient is comfortable, symptoms are managed, I cannot access the wonderful services of the interdisciplinary team (social worker, chaplain, volunteers, etc.) and cannot access bereavement services for the family members.

  3. Queen Bee, I completely agree with the issue you raise. In my training I worked in a SNF and this issue of patients on the skilled benefit who were hospice appropriate came up ALL THE TIME. Like once a week (in a busy SNF). These pateints faced the choice of staying on the SNF benefit and having symptoms managed by facility staff but none of the other services hospice provides (social work, chaplain, volunteer) or switching to hospice and paying for room and board out of pocket (usually ~$300/day). Not suprisingly, most chose to stay on the SNF benefit. We need more palliative care options in SNF (more hospice like services) and changes to the hospice/SNF benefits to allow these patients access to hospice without penalty.

  4. Eric, great post. I have been collaborating for the past year with an MSW brought in specifically to push Pall Care consultation in the post-acute SNF setting. We looked at 2 months of post-acute discharges in the spring and found we were successfully targeting the right group (longer LOS in post-acute, less likely to return home, more likely to have had an Adv Dir in their chart already), and we certainly succeeded in getting more POLSTs complete and into the EMR, but unfortunately we can't be sure about clinical outcomes (didn't have the analytical support to cull the KP databanks). So even though it's a smaller group than the entire custodial population, I would suggest that frail elders transitioning through post-acute care are ripe for the PallCare conversation, given the trajectory. (And I agree, the hospital is no longer the ideal place for this. The LOS at KP is so short, it's a wonder the patients and families even remember how their ailments were treated…) -marc (rothman)

  5. This is a great article. Thank you for the clear and concise infomation. This will help us advise our clients for end of life planning.

  6. A nursing home is a place where sick or old people, requiring attention and medical care, can stay. Thanks for the information.

  7. According to the 2004 National Nursing Home Survey, nursing home residents who did not receive end-of-life (EOL) care had a mean length of time from admission of 837 days (median of 462 days), while residents who received EOL care had a mean length of time from admission of 761 days (median of 479 days).

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  8. Most of us plan to live in nursing homes during old age. You've come up with interesting statistics.

  9. Thanks for sharing some of the real statistics instead of spending last time at nursing home old age homes are also a good options now a days where you can have a lot of new pals around

  10. Very interesting post from a financial point of view. Long-term care insurance companies always make sure to talk about average stays in nursing homes, but fail to provide additional detail as to a broader range statistics such as the distribution provided in the graph. Thanks for this very enlightening information

  11. If 53% go in only having 6 months to live should all these people be counted as dying from Covid19 if they were going to die anyway? If so we are artifically raising the Covid19 death count.

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