ASPPH logo


Member Research & Reports

Member Research & Reports

Yale: Multiple Care Transitions Identified in End-of-Life Care for Hospice Patients

Although hospice is embraced for the quality care for people nearing the end of life, a new study led by the Yale School of Public Health finds that many patients experience multiple transitions (being move from one facility to another), disrupting their routines and placing them at heightened risk for medical errors.

Shiyi Wang
[Photo: Dr. Shiyi Wang]

Researchers found that that 10.2 percent of patients experienced at least one health care transition after their hospice enrollment. And in some states, the proportion with at least one transition exceeded 20 percent. A total of 6.6 percent of hospice patients had between two to 19 care transitions, 53.4 percent of which were transitions to a hospital.

The study, published February 17 in the Journal of the American Geriatrics Society, is one of the first to examine the number and types of transitions that hospice patients experience before death.

“A notable proportion of hospice users experience at least one transition in care,” said lead author Dr. Shiyi Wang, an assistant professor in the department of chronic disease epidemiology and a faculty member in the Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale School of Medicine. “This matters because such transitions may place hospice users at risk of discontinuity of care and medical errors, while also increasing the level of stress for their caregivers and family members.”

Dr. Wang and colleagues identified Medicare beneficiaries who were enrolled in hospice and examined transition trajectories after hospice enrollment, national variation in transitions and factors associated with transitions. Transitions in care are defined as transferring from and to a hospital, skilled nursing facility, homes health agency, hospice, or home (Home means that patients were not hospitalized, or did not receive services from skilled nursing facility, home health agency, or hospice).

The study found that people who were younger, non-white, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition. The transitions varied widely from state to state, ranging from 6.9 percent in Idaho to 20.6 percent in Florida.

“The provider- and state-level variation in the proportion of hospice users who had care transitions suggests that provider and market factors and not solely individual and family preferences may influence transitions,” said Dr. Wang. “Care transitions after hospice enrollment might be used as a quality indicator for hospice care.”

Dr. Elizabeth Bradley, senior author of this study and Brady-Johnson Professor of Grand Strategy, and Health Policy and Management at Yale School of Public Health, said that multiple transitions indicated care at the end of life is fragmented, which can be difficult for both patient and family.

“Future studies that identify care transitions that deviate from individual preferences and examine the effect of such transitions in care at the end of life on costs are needed,” Dr. Bradley said.

Other study authors include Dr. Melissa D. Aldridge, Dr. Cary P. Gross, Dr. Maureen Canavan, Dr. Emily Cherlin, and Ms. Rosemary Johnson-Hurzeler. The study was supported by grants from the National Cancer Institute, the John D. Thompson Foundation and the National Institute of Nursing Research.