HOLLYWOOD, FLA. — Identifying nursing home residents with the greatest risk of dying, and offering them help with their advance planning, can improve the quality of care at the end of life, Dr. Cari R. Levy said at the annual symposium of the American Medical Directors Association.
Dr. Levy and her colleagues at the University of Colorado, Denver, compared end-of-life quality of care at a Denver nursing home before and after the implementation of an advance planning initiative. After implementation of the program, residents were less likely to die in the hospital and more likely to receive palliative care and hospice services. In addition, more residents had advance directives in place.
The researchers implemented the Making Advance Planning a Priority or MAPP program. The goal of the program is to encourage collaboration between nursing home staff with palliative care specialists to provide end-of-life planning to those residents who are at greatest risk of death.
To determine their risk of death, nursing home residents were assessed using the Flacker Mortality instrument, which assigns a score that translates into the chances of dying in the next year. For example, a Flacker mortality score of 0–2 means a 7% chance of dying, while a score of 11 or greater equals an 86% chance of dying in the next year.
The researchers targeted those residents with a score of 7 or greater, meaning they had a 50% chance of dying in the next year. “This person has a 50–50 chance of dying in the next year, so it's probably a good idea to get the advance planning in order,” Dr. Levy said.
After the residents were identified as high risk, the researchers informed the attending physicians of their mortality scores and helped them to obtain a palliative care or hospice consult if that was in line with the goals of the residents and their families.
The researchers performed a retrospective chart review of 96 patients who died in the year before intervention and 101 patients who died in the year after.
After the intervention, residents were less likely to die in the hospital. Before the implementation of the MAPP program, 48.2% of residents died in the hospital, versus 8.9% after the program. This was a statistically significant result. Palliative care referrals also increased with the program. Referrals rose from 7.4% before intervention to 31.1% post intervention. This also was a statistically significant finding.
All patients who died after the MAPP initiative was implemented had an advance directive in place, Dr. Levy said. Before the intervention, about 12% of residents died without having an advance directive.
In an effort to determine if the program would be applicable at other facilities, the researchers performed the same retrospective chart review at seven other community nursing homes in the Denver area but did not implement the MAPP program.
Across the seven nursing homes, the researchers found similar overall referral patterns among the 253 residents who had died in those facilities in the last year.
About 53% of residents had been referred to hospice before death, 8% were referred to a palliative care program, and 88% had do-not-resuscitate orders in place. About 10% of residents did not have an advance directive, Dr. Levy said.
