Rehab and Death: Improving End-Of-Life Care for Medicare Skilled Nursing Facility Beneficiaries.

Hospitalized older adults with serious illness may be discharged to a skilled nursing facility (SNF) with the hope of improving strength to live independently and receive further disease-directed treatment, or because it is one of the few insurance-covered options for care that provides room and board coverage. For those that do not improve, discharge to a SNF can begin a cycle of costly care transitions between hospital, home with home health care, SNFs, and long-term care facilities, leading to fragmented care and missed opportunities for discussions about preferences for care, illness understanding, and to address distressing symptoms. It can also lead to dying in the emergency room and other locations that are not consistent with patient wishes. In this article, we describe key policies that contribute to high-cost, low-value care near the end of life for older adults using the Medicare SNF benefit. With this foundation, we propose next steps to understand the scope of the problem better and offer solutions to improve care, including increasing palliative care delivery in SNFs and changes to the Medicare SNF benefit to improve hospice access and utilization for beneficiaries who currently experience multiple care transitions near the end of life.