Hospice and palliative care in nursing homes: challenges and opportunities for enhanced access.

The use of hospice care in nursing homes (NHs) has grown exponentially, but an increasing concern is the lack of access to resident and family-centered palliative care when residents do not elect hospice, and in time periods prior to election. This concern is amplified by the high magnitude of palliative care needs present for NH residents (and their families) when the NH will be their final residence; and, it is amplified because of short hospice stays, half of which are 22 days or less. This manuscript describes the use of the Medicare hospice care in NHs and discusses the policy, staff and physician barriers to timely hospice referral. It also describes the challenges NHs face in expanding residents' access to palliative care. Opportunities and approaches for increasing palliative care expertise and practice in NHs are presented.