Stevenson David G, Bramson Jeffrey S
Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
J Pain Symptom Manage. 2009 Sep;38(3):440-51. doi: 10.1016/j.jpainsymman.2009.05.006.
The U.S. Medicare hospice benefit has expanded considerably into the nursing home (NH) setting in recent years. This literature review focuses on the provision of NH hospice, exploring its growth and the impact of such care on NH residents, cost and efficiency implications for NHs and government, and policy challenges and important areas for future research. Although hospice utilization is relatively modest among NH residents, its increased availability holds great promise. As an alternative to traditional NH care, hospice has been shown to provide high-quality end-of-life care and offer benefits, such as reduced hospitalizations and improved pain management. The provision of NH hospice also has been shown to have positive effects on nonhospice residents, suggesting indirect benefits on NH clinical practices. Importantly, the expansion of hospice in NHs brings challenges, on both clinical and policy dimensions. Research has shown that NH-hospice collaborations require effective communication around residents' changing care needs and that a range of barriers can impede the integration of hospice and NH care. Moreover, the changing case mix of hospice patients, including increased hospice use by individuals with conditions such as dementia, presents challenges to Medicare's hospice payment and eligibility policies. To date, there has been little research comparing hospice costs, service intensity, and quality of care across settings, reflecting the fact that few comparative data have been available to researchers. The Centers for Medicare & Medicaid Services have taken steps toward collecting these data, and further research is needed to shed light on what refinements, if any, are necessary for the Medicare hospice program.
近年来，美国医疗保险临终关怀福利已大幅扩展至养老院环境。本综述聚焦于养老院临终关怀服务，探讨其发展、对养老院居民的影响、对养老院及政府的成本和效率影响、政策挑战以及未来研究的重要领域。尽管养老院居民中临终关怀的利用率相对较低，但其可及性的提高具有巨大潜力。作为传统养老院护理的替代方案，临终关怀已被证明能提供高质量的临终护理并带来诸多益处，如减少住院次数和改善疼痛管理。养老院临终关怀服务的提供也已被证明对非临终关怀居民有积极影响，这表明对养老院临床实践有间接益处。重要的是，临终关怀在养老院的扩展在临床和政策层面都带来了挑战。研究表明，养老院与临终关怀机构的合作需要围绕居民不断变化的护理需求进行有效沟通，并且一系列障碍会阻碍临终关怀与养老院护理的整合。此外，临终关怀患者病例组合的变化，包括痴呆症等疾病患者临终关怀使用率的增加，给医疗保险的临终关怀支付和资格政策带来了挑战。迄今为止，很少有研究比较不同环境下的临终关怀成本、服务强度和护理质量，这反映出研究人员可获得的比较数据很少。医疗保险和医疗补助服务中心已采取措施收集这些数据，还需要进一步研究以阐明医疗保险临终关怀项目是否需要以及需要哪些改进。
