Results Summary
What was the research about?
Nearly one in three Americans lives in a nursing home at the end of their life. Prior studies have shown that when residents are dying, the care nursing homes give may not always match what the residents want. For example, many nursing home residents don’t get enough help with pain. Also, nursing homes may send patients to the hospital for treatment when they would prefer to stay where they are.
In this study, the research team wanted to learn if giving nursing homes support to set up and train palliative care teams would improve care quality for dying residents. Palliative care aims to prevent and treat suffering. The palliative care teams included nursing home staff such as doctors, nurses, and social workers. These teams worked with experts for several months to learn how to care for patients using a palliative approach.
The research team compared two groups of nursing homes: those that had the team training and those that didn’t. The team looked at
- Residents’ pain and depression symptoms in the last 90 days of life
- How often residents went to the hospital in the last 90 days of life
- Whether residents died in the hospital or nursing home
What were the results?
There was no difference in these three areas between nursing homes that had and didn’t have team training. But of the 14 nursing homes that had the training, 6 had palliative care teams that worked together well, based on staff interviews. The other 8 homes didn’t have consistently working teams.
The research team compared the six nursing homes with working palliative care teams and the eight other nursing homes. In nursing homes with working palliative care teams, fewer residents who died did so in the hospital. Residents of nursing homes with working teams had fewer symptoms of depression in the last 90 days of life than residents of nursing homes without working teams. Residents’ pain severity and the number of hospital admissions in the last 90 days of life were about the same at nursing homes with and without working palliative care teams.
Who was in the study?
The study used Medicare data for 5,830 deceased residents from 25 nursing homes in New York. These residents were at least 65 years old. More than 90 percent of residents were white, and 65 percent were women.
What did the research team do?
The research team assigned 14 nursing homes by chance to receive staff training in palliative care and 11 nursing homes to not receive training. The team helped set up and train the palliative care teams. After training, a palliative care nurse practitioner worked with nursing home staff for two months to guide patient care. The nurse practitioner then consulted with nursing home staff as needed for another 8 to 10 months.
The research team looked at Medicare records for the location of residents’ deaths and their hospital admissions, pain, and depression in the last 90 days of life.
Patient advocates, palliative care experts, and nursing home managers helped the research team design the study.
What were the limits of the study?
Some nursing homes were better able to support the new palliative care teams than other nursing homes. Results may have been different if all nursing homes were able to form and maintain working palliative care teams.
Future research could look at ways to create palliative care teams that work well in more nursing homes.
How can people use the results?
Palliative care may help improve end-of-life care for nursing home residents. But nursing homes may need more or different types of support to provide this type of care.
Professional Abstract
Objective
To assess the impact of palliative care team training for nursing home staff on care processes and resident outcomes, such as location of death, hospitalization frequency, and pain and depression in the last 90 days of life
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 25 nursing homes in New York State; Medicare data from 5,830 residents ages 65 and over within 90 days of death |
| Interventions/ Comparators |
|
| Outcomes |
Primary: nursing home resident place of death; number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms within 90 days of death Secondary: communication/coordination, team effectiveness, organizational readiness for palliative care |
| Timeframe | Up to 90-day follow-up for primary outcomes |
This randomized controlled trial compared outcomes among residents of nursing homes that received team building and training in palliative care with residents of nursing homes that did not receive such training. In 14 of 25 nursing homes, researchers assisted in establishing palliative care teams made up of each nursing home’s staff and provided training in palliative and end-of-life care to these teams. Following training, palliative care teams went on patient rounds with a palliative care nurse practitioner for two months. The nurse practitioner was available to consult with teams during the subsequent 8 to 10 months. The other 11 nursing homes continued with care as usual without palliative care support from the research team.
Using vital status data and data from the Minimum Data Set collected for all Medicare- and Medicaid-certified nursing homes, researchers assessed resident outcomes before and after the palliative care training period. Researchers reviewed data for 5,830 decedents from the 25 participating nursing homes. The sample comprised decedents whose last 90 days of life occurred prior to the beginning of the intervention and those whose last 90 days of life occurred once nursing homes implemented palliative care teams. These decedents were at least 65 years old and were Medicare eligible. More than 90% of residents were white, and 65% were women. Researchers also interviewed and surveyed nursing home staff about how the palliative care teams worked and what the nursing home administrators did to support the teams.
To control for selection bias, researchers also compared outcomes between residents of the 25 nursing homes enrolled in the study and 119,486 residents from 609 other nursing homes in New York State.
Patient advocates, palliative care experts, and nursing home directors gave feedback on the study design, development of training materials, and implementation of the training.
Results
Nursing homes in the study that did not have palliative training did not differ on any of the primary study outcomes when compared with the nursing homes that had palliative care training. However, of the 14 nursing homes that received training, 6 facilities reported developing sustainable working palliative care teams that shared a sense of mission, shared the ability to influence care, and received support from facility administrators. At the other eight facilities, staff reported that the palliative care teams did not function consistently.
The research team compared outcomes for nursing homes that had working teams with those that had training but did not form consistently working teams. Compared with decedent residents at nursing homes that had not formed working teams, decedent residents at nursing homes with consistently working teams showed
- Reductions in in-hospital deaths (average odds ratio [OR]=0.4; p<0.001)
- Fewer depressive symptoms (OR=0.191, p<0.01)
When compared with residents at nursing homes without consistently working teams, decedent residents at nursing homes with working palliative care teams showed no statistically significant differences in pain severity or hospitalizations.
During the study period, nursing homes that were not in the study (clean control) showed reductions in residents’ pain severity and depressive symptoms.
Limitations
Some nursing homes were better able to build and maintain palliative care teams than others. At baseline, it was not possible to differentiate homes that may have been better prepared to work with the skills acquired during the intervention.
Conclusions and Relevance
This study suggests that palliative care teams may benefit nursing home residents by helping to reduce depressive symptoms and in-hospital deaths. However, not all nursing homes that received research team support developed palliative care teams.
Future Research Needs
Future research could evaluate the facility-based factors that affect the sustainability of palliative care teams in nursing homes.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
The following are strengths and limitations noted in peer review, and the researchers’ responses:
- The reviewers applauded the researchers for providing a clear presentation not only of the research but also of their difficulties in implementing the palliative care intervention in nursing homes and in collecting data from staff.
- The reviewers requested clarification regarding the nature of this study, which the report described as testing efficacy (i.e., whether the intervention works when compared with no intervention). The researchers revised the report to indicate that the study looked at the intervention’s effectiveness (i.e., how well the intervention works in a real-world context).
- The reviewers asked the researchers to provide results from tests of the study’s main hypotheses in the final report’s abstract. The researchers responded that the report did provide results for the first hypothesis, but they were unable to test the second and third hypotheses because of problems collecting data.
- The final report emphasized the results of a sensitivity analysis showing that nursing home teams that were more functional, or working, had better implementation of the intervention than teams that were less functional, or nonworking. The reviewers noted that while the idea for this analysis came from preplanned in-depth interviews with nursing home staff, the analysis comparing working and nonworking nursing home teams was not preplanned and therefore should not be presented as key findings. The researchers responded that the report clearly presents these findings as sensitivity analyses and not as main findings.
- The reviewers asked the researchers to soften the conclusion that the intervention was effective, pointing out that the prespecified analysis across all nursing home teams, the main result, did not show the intervention to be effective. The researchers declined to revise their conclusions to downplay the importance of the analysis of working versus nonworking teams’ outcomes. The final report retains a focus on this post-hoc result, which reviewers described as hypothesis generating and not a confirmation of the intervention’s effectiveness.