Home Health Appears Not to Help Terminally Ill Die at Home

Though 86% of Americans would prefer to spend their final days in their own homes, that’s a more realistic goal in some U.S. states than others. And just because someone elects to use home health or hospice services doesn’t mean they’ll spend any more of their final days at home, according to a study recently published in The New England Journal of Medicine (NEJM).

For the study, Press Ganey Chief Medical Officer Thomas Lee and his co-authors analyzed the number of days Medicare beneficiaries who died in 2012 and 2013 spent at home during the last six months of their lives. The researchers created a map that reveals the mean number of days spent at home by these Medicare beneficiaries by hospital referral region, or regional health care markets as defined on the basis of historical hospital-usage patterns.

Americans are more likely to spend their final days at home if they live in Montana, Kansas or North Dakota, but not if they live in Louisiana, Tennessee or most major U.S. cities.

The researchers calculated “days at home” as 180 days, minus the number of inpatient days in a skilled nursing facility, an acute care facility, an inpatient rehabilitation facility or an inpatient hospice unit.

The amount of time dying patients in the United States spend at home varies widely by geographic region, and in some cases, even within single states, the study revealed. In Miami and Los Angeles, for instance, dying patients spent an average of just 120 days at home. In Rochester, Minnesota, and Great Falls, Montana, dying patients spent an average of 142 days at home.

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Dying patients in Modesto, California, meanwhile, spent an average of 136 days at home, despite the relatively low number of days dying patients spent at home in Los Angeles.

Opting to use more home health or hospice services won’t necessarily keep terminally ill patients in their own homes, the study indicated.

“One might expect that greater use of home health and hospice services would correlate with more days at home, but as the graph shows, the opposite is true,” the researchers wrote in NEJM.

Specifically, in regions where patients had more days on which they received hospice services, home health services or both, they spent fewer total days at home, the researchers found.

In Munster, Indiana, patients in their last six months of life spent an average of only 123.88 days at home, despite receiving an average of 17.63 days of home health and/or hospice services. In nearby Chicago, patients in their last six months of life similarly spent an average of 122.24 days at home, even though they received an average of 17.31 days of home health and or/hospice services.

Meanwhile, in Cedar Rapids, Iowa, patients in their last six months of life received an average of only 5.2 days of home health and/or hospice services, but spent an average of 140.04 days at home. Similarly, in Sioux Falls, South Dakota, patients in their last six months of life received an average of only 3.96 days of home health and/or hospice services, but spent an average of 142.08 days at home.

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All the while, there are many patients who would prefer to not be at home when they are sick and dying, the researchers noted in NEJM. Perhaps staying at home would result in less-than-complete relief of their pain and discomfort, for instance.

There may be geographic, cultural, socioeconomic or other non-clincial factors driving patients’ preferences for spending their final days at home, the researchers acknowledge, adding that additional analysis could potentially show that home hospice care is effective at increasing the number of days patients spend at home when studied within a narrower time frame, such as in the last 30 days of life.

“Furthermore, alternative types of payment contracts for health care providers may affect the number of days patients spend at home, so the effect of new payment incentives should be monitored,” the researchers concluded. “Ultimately, eliciting patients’ preferences and organizing care to accommodate individual patients’ goals is what matters most.”

Written by Mary Kate Nelson