Hospice care in the nursing home: changes in visit volume from enrollment to discharge among longer-stay residents.

Our objective was to describe the pattern of visits made to longer-stay hospice patients in nursing homes with different diagnoses over the course of their hospice stay. This was a retrospective cohort study in which we used administrative data from a large hospice provider. Longer-stay was defined as hospice enrollment for 12-24 weeks. Residents were categorized by primary diagnosis (cancer, dementia, debility, and other). Three periods of care were isolated: the first week, the penultimate month to death/discharge, and the final week. Visit volume was measured by the number of visits per 100 resident-days. Visits by four provider types were examined: physicians, nurses, aides, and ancillary staff (social workers and chaplains). Visit volume rates were calculated for each time period and were stratified by diagnostic group and provider type. We found that nurses made the most visits and physicians the least. Except for aides, all providers had more activity in the first and final days. Aides' activity increased following the first 2 days and was stable through the remainder of the hospice stay. During the penultimate month, aides had the highest visit rates. Visit rates were similar for all diagnostic groups until the final week of care, when residents with cancer received more visits than others. These patterns of visit volume and configuration confirm that care is most expensive in the earliest and the latest days.