PERS PE C T IV E
Firearm Safety
Rehabbed to Death
as Health Care’s Highway
Rehabbed to Death
Lynn A. Flint, M.D., Daniel J. David, R.N., Ph.D., and Alexander K. Smith, M.D., M.P.H.​​
M s. P. was an 87-year-old
woman with moderate de-
mentia who lived alone in an
apartment before being admitted
to the hospital with pneumonia.
During her hospitalization, she
became deconditioned and could
no longer walk without assis-
tance. Friends and family were
unable to provide the amount of
help she needed to live safely at
home, so she was transitioned to
a nursing home for post-acute
care, paid for by Medicare. She
then developed diarrhea, however,
and was readmitted to the hospi-
tal with a Clostridium difficile in-
fection. She was transferred back
to the nursing home for more
rehabilitation, only to develop de-
lirium, which led to a fall and a
readmission. Shortly after Ms. P.’s
third transfer to the nursing home,
the 100 days of skilled nursing
facility–based post-acute care cov-
ered by Medicare ended. She con-
tinued to need help with activities
of daily living. Returning home
was not an option, since her fi-
nancial and social supports were
limited. Ultimately, Ms. P. paid
out of pocket for long-term care
in the same facility until she ex-
hausted her small savings and
qualified for Medicaid, which then
covered the cost of her nursing
home care. She was hospitalized
repeatedly until she died, a year
after her initial hospitalization,
never having returned home.
Older adults often use post-
acute care services, particularly
near the end of life. After an ill-
ness necessitating hospitalization,
Medicare Part A covers a limited
duration of post-acute care ser-
408
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vices, including skilled nursing
services and rehabilitation either
at home or in a skilled nursing
facility, inpatient rehabilitation
facility, or long-term acute care
hospital. In 2013, a total of 23%
of hospitalized Medicare benefi-
ciaries were discharged to a post-
acute care facility, 87% of them
to a skilled nursing facility.1 Post-
acute care in skilled nursing fa-
cilities is meant to be short term,
a bridge to home, and many bene-
ficiaries are successfully dis-
charged home from there. For a
substantial minority, however, the
post-acute stay is the gateway into
a cycle between the hospital and
the nursing home that spans the
final months of life.2 Of Medi-
care beneficiaries who died be-
tween 2006 and 2011, one in
eight had cycled from hospital to
skilled nursing facility to hospi-
tal during the last year of life.3
We have seen this cycle in prac-
tice. At discharge, these patients
are often told they have to go to
“rehab” (as post-acute care facili-
ties are called on the wards) to
“get stronger before going home.”
When a seriously ill patient with
poor rehabilitation potential is dis-
charged to a post-acute care facil-
ity, an unspoken conversation en-
sues. Inpatient providers think,
“I know this person is declining.
But if she can’t go home, where
will we send her besides a post-
acute care facility?” The post-acute
care providers think, “This person
is clearly declining. Why did they
send her here without talking
about goals of care?” Patients and
families think, “How did we end
up in a nursing home? Aren’t
n engl j med 380;5 nejm.org January 31, 2019
The New England Journal of Medicine
rehabbed to death
there any other options?” Often,
no one mentions the possibility
of death or discusses the goals of
care. In treating discharge to a
post-acute care facility as a routine
event, we are missing an oppor-
tunity to improve care for seri-
ously ill older adults.
Certain policies of the Centers
for Medicare and Medicaid Ser-
vices (CMS) perpetuate this cycle,
and we have several recommen-
dations for changing them. First,
CMS policies could ensure that
financing meets the functional
needs of older adults with serious
illness. Although the majority of
older adults face functional dis-
ability in the last 2 years of life,
the Medicare home health bene-
fit does not provide continuous
assistance with activities of daily
living (e.g., bathing, dressing, and
using the bathroom).4 Medicaid,
the dominant payer for long-term
care in nursing homes, also covers
home- and community-based long-
term services and supports, includ-
ing assistance with daily needs,
but coverage of such services varies
by state. Ms. P. might have avoid-
ed the post-acute care facility en-
tirely if the Medicare home health
benefit or the Medicaid long-term
services benefit had been expand-
ed to include greater support for
activities of daily living. Medicaid
has taken steps toward increas-
ing support for home services.
Under the Affordable Care Act, a
pilot grant program offered incen-
tives to states to rebalance Med-
icaid funding away from nursing
home care to increase long-term
services and supports in the home
and community by improving ac-
PE R S PE C T IV E Rehabbed to Death

cess, including for “pre-Medicaid”
patients like Ms. P. Participation
decreased, however, after the pro-
gram ended in 2015.
Second, Medicare could pay for
nursing-home–level care and hos-
pice for persons with functional
disability nearing the end of life.
Under current regulations, a Med­
icare-covered short stay in a post-
acute care facility must be aimed
at improvement. If one’s health
is not expected to improve, the
only option beyond paying out of
pocket for room, board, and as-
sistance is to “spend down” one’s
savings to qualify for Medicaid.
To address this problem, Hus-
kamp et al. have proposed a new
Medicare Part A benefit for end-
of-life care in nursing facilities,
which would cover both hospice
and custodial care.5 The Veterans
Administration provides an exem-
Compare website, where facilities
with higher readmission rates re-
ceive lower ratings.
Policy change takes time. To
begin addressing this problem,
practicing clinicians can improve
communication with patients and
caregivers. Discharge communi-
cation can go beyond “you need
to go to rehab to get stronger.”
Clinicians can ask permission to
share their estimate of the pa-
tient’s prognosis for functional
recovery, acknowledging the un-
certainty of that estimate while us-
ing the best available prognostic
tools to guide discussion. Clini-
cians can then inquire about pa-
tients’ goals in view of the prog-
nostic information and provide
recommendations for discharge
based on those goals.
Ideally, a hospital clinician
would have discussed Ms. P.’s
could help in complex circum-
stances.
Discharge to a post-acute care
facility is a pivotal life event for
many older adults. Rather than
treating it as mundane, we can
embrace the opportunity to ad-
dress crucial issues related to
quality of life and goals of care.
Existing policy is disease-focused
and ignores the critical needs
stemming from disability near
the end of life. But policy change
won’t work if we don’t improve
communication at key transition
points — and improved commu-
nication will have limited effect if
we don’t address policy’s failure
to support daily assistance needs
of dying older adults. We will
therefore need to make progress
on the two fronts simultaneously.
Disclosure forms provided by the authors
are available at NEJM.org.

plar: veterans nearing the end of
life are eligible for hospice care
in a nursing home without incur-
ring out-of-pocket costs.
Finally, policy could continue
to move toward removing incen-
goals and whether and how they
could be met in various settings.
The details of these discussions
could be documented in the med-
ical record and communicated ex-
plicitly to clinicians at the post-
From the Division of Geriatrics, Department
of Medicine (D.J.D., A.K.S.), and School of
Nursing, Department of Community Health
Systems (D.J.D), University of California,
San Francisco, and the San Francisco Veter-
ans Affairs Medical Center (D.J.D., A.K.S.)
— both in San Francisco.

tives for nursing homes to hospi-
talize long-stay residents covered
by Medicaid. Currently, nursing
homes have particular incentives
to hospitalize residents who are
eligible for both Medicare and
Medicaid, because these patients
can return to the nursing home
on the higher-paying Medicare
post-acute care benefit before
transitioning back to long-term
care with lower Medicaid day
rates. Higher Medicaid day rates
for long-term care might reduce
the churn of long-stay residents
between hospital and nursing
home near the end of life. One
recent step forward is the public
reporting of 30-day readmission
rates on the CMS Nursing Home
acute care facility, enabling them
to continue the conversation more
effectively. We recognize that these
types of conversations are more
complicated and time consuming
than typical discharge commu-
nications. But hospitalists, dis-
charge-planning nurses, and so-
cial workers can be trained in
communication about serious ill-
ness. Advance care planning
codes, introduced in 2016, can
be used to bill for the extra time
spent. Investigation of the effects
the new codes have had on the
quantity and quality of advance
care planning conversations could
guide future policy adjustments.
And specialized geriatrics and
palliative care consultation teams
1. Tian W. Statistical Brief #205:​an all-
payer view of hospital discharge to post-
acute care, 2013. Healthcare Cost and Uti-
lization Project (HCUP). Rockville, MD:​
Agency for Healthcare Research and Quality,
2016 (https://www​.hcup​-­us​.ahrq​.gov/​reports/​
statbriefs/​sb205​-­Hospital​-­Discharge​-­Postacute
​-­Care​.jsp).
2. Wang SY, Aldridge MD, Gross CP, Cana-
van M, Cherlin E, Bradley E. End-of-life care
transition patterns of Medicare beneficiaries.
J Am Geriatr Soc 2017;​65:​1406-13.
3. Lage DE, Caudry DJ, Ackerly DC, Keat-
ing NL, Grabowski DC. The care continuum
for hospitalized Medicare beneficiaries near
death. Ann Intern Med 2018;​168:​748-50.
4. Smith AK, Walter LC, Miao Y, Boscardin
WJ, Covinsky KE. Disability during the last
two years of life. JAMA Intern Med 2013;​173:​
1506-13.
5. Huskamp HA, Stevenson DG, Chernew
ME, Newhouse JP. A new Medicare end-of-
life benefit for nursing home residents.
Health Aff (Millwood) 2010;​29:​130-5.
DOI: 10.1056/NEJMp1809354
Copyright © 2019 Massachusetts Medical Society.
Rehabbed to Death

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