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Care for Advanced Dementia Patients

Study by HSL researchers finds managed care preferable over hospitalization

Susan Mitchell, M.D., M.P.H.'s picture
Care for Advanced Dementia Patients
Care for Advanced Dementia Patients

For nursing home residents with advanced dementia, managed care may mean equal or better outcomes

If a loved one of yours is a nursing home resident with advanced dementia, there’s a good chance that keeping him or her comfortable is your main goal--that’s the preference of more than 90% of family members in this situation. Yet many of these residents commonly experience stressful, aggressive interventions, like hospital transfers or tube-feeding, which don’t improve their quality of life or help them live longer.

A recent study I led shows that when these residents are covered by managed care insurance rather than Medicare, they have equal or even better outcomes with no significant difference in survival rates. In addition, the research suggests that the family members of managed-care residents with advanced dementia may be more satisfied with the overall care at the nursing home.

Reimbursement policies for nursing home care is one factor that leads to more aggressive care. Most nursing home residents with advanced dementia are eligible for both traditional Medicare, which pays for hospital care and physician services on a fee-for-service basis, and Medicaid, which pays nursing homes for daily room, board and nursing care.

Because nursing homes don’t receive more money to care for acutely ill long-term-care residents, they have an incentive to transfer these residents to the hospital and shift the cost of care short-tem from Medicaid to Medicare. In contrast, managed care programs combine Medicare and Medicaid costs for nursing home residents, which means that the financial incentive for hospitalizing these residents goes away.

The managed-care residents we studied received more primary-care visits, primarily from nurse practitioners; were more likely to have a do not hospitalize (DNH) order in place; and had fewer hospital transfers for acute illness than those with Medicare insurance.

What does this research mean for you? If your loved one is covered by Medicare, you may want to consider a managed care or nurse practitioner-based insurance plan instead.  Also, if you haven't already done so, talk to his or her physician about a "do not hospitalize" order, which would prohibit the nursing home from transferring your loved one to the hospital unless the transfer is needed for comfort.

Read more about this study and others on the Hebrew SeniorLife homepage.

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Senior Scientist, Institute for Aging Research

Dr. Mitchell is a Professor of Medicine at Harvard Medical School and senior scientist at Hebrew SeniorLife in Boston. She is a clinical epidemiologist and board certified geriatrician and internist in Canada and the United States. Dr. Mitchell's research interests focus on decision-making, health outcomes, and resource utilization for older people near the end-of-life, particularly those with dementia. She is the principal investigator on several large research projects funded by the National Institutes of Health to study the end-stages of dementia and has been a lead author on many...

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