The Care Continuum for Hospitalized Medicare Beneficiaries Near Death

Background: Rising use of postacute care (PAC) facilities over the past 2 decades has contributed to increased transitions of care in the last year of life (1, 2). Medicare PAC facility benefits cover rehabilitation from acute illness in skillednursing facilities, inpatient rehabilitation facilities, or longterm acute care hospitals. Amid pressure to reduce length of stay, hospitals often use PAC facilities as a stopgap and send elderly patients near the end of life to facilities designed more for rehabilitation than palliative care. The role of PAC facilities as a discharge destination for patients in the last days or weeks of life has been underappreciated, particularly because the alternative choice of hospice care may improve their quality of life (3). Objective: To assess the use of PAC facilities, overall and by hospice use, as well as hospital readmissions from these facilities in patients near death. Methods and Findings: We studied Medicare fee-forservice beneficiaries who died between 2006 and 2011 using the beneficiary summary files, data from the Medicare Provider Analysis and Review, and hospice base claims. We described use of PAC facilities and acute hospitals overall and by hospice status, dichotomized as any versus no hospice claims in the last year of life. Among 8 216 193 Medicare beneficiaries who died, 23.3% received care in a PAC facility in the last 90 days of life. Further, 16.1% received care in a PAC facility in the last 14 days of life and 9.9% received care in in a PAC facility on the day of or day before death. Among patients using a PAC facility within the last 30 and 90 days of life, 50.1% and 60.4%, respectively, returned to an acute hospital before death; most of these readmissions were transferred directly from PAC facilities (Table 1). Among all Medicare beneficiaries who died during the study period, 39.0% used hospice services in the last year of life. Those who did not had higher use of acute care hospitals and PAC facilities in the days and weeks before death (Table 2). Discussion: Patients who used PAC facilities in the last month of life were frequently readmitted to an acute care hospital before death, and patients who did not use hospice services had higher use of acute care hospitals and PAC facilities before death. Given the lack of palliative care expertise in PAC facilities and the key contribution of such facilities to Medicare spending growth (4), these transitions may lead to lower-quality end-of-life care for patients and increased cost to the health system.