Objectives: To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with improved EOL outcomes.
Design: Retrospective cohort study using Medicare claims data from 2018-2019. Sensitivity analyses used logistic regression models to assess robustness.
Setting and participants: National, population-based study of Medicare decedents residing in licensed AL communities across the United States. The main analytic sample included 42,466 AL residents who received hospice and died during enrollment. A separate sample of 61,851 was used to assess live discharges. Participants were identified by linking 9-digit ZIP codes of 10,452 licensed ALs to Medicare enrollment files. Individuals younger than 55 years, not enrolled in hospice, or enrolled in Medicare Advantage were excluded.
Methods: Key exposures included the frequency of hospice staff visits (clinical vs nonclinical) and the presence of state AL regulations related to staffing and medication delegation. Outcomes included EOL transitions within the last 7 days of life, POD in AL vs other settings, and live discharges from hospice.
Results: More frequent clinical staff visits were associated with lower rates of EOL transitions [-12 percentage points (pp)], reduced live discharges (-4 pp), and increased likelihood of dying in place (+4 pp; all P < .001). Nonclinical visits showed modest but consistent associations with improved outcomes. State regulations requiring on-site staffing and permitting medication delegation were associated with fewer transitions and higher rates of in-place death.
Conclusions and implications: Hospice staffing intensity, especially clinical visits, appears to be associated with EOL outcomes for AL residents. AL state regulations are also associated with hospice quality. These findings underscore the role of both organizational practices and regulatory policy in shaping hospice experiences in AL settings.
