Care transitions among Medicare beneficiaries at the end of life

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Mrs. K, age 72, is a widow who lives alone in a two-story home. She's recently been discharged after a 3-day hospitalization for worsening heart failure (HF). She's receiving home healthcare services for ongoing assessment of cardiopulmonary and functional status, for education about her medication and diet regimen, and for an evaluation of her home environment. This is her third hospitalization in the past 6 months and her second admission to home care.
During the home care admission visit, Mrs. K reports increasing fatigue and weakness over the past few weeks. She also says that she has to use her oxygen most of the time, not just when walking as in the past. Her son reports that she can no longer walk up the stairs and has been sleeping in therecliner since being discharged home. Mrs. K told the nurse that she no longer wants to go back and forth to the hospital and just wishes she could get “fixed up at home” instead.
In this case, the nurse is in an ideal position to further assess and implement a feasible and appropriate plan of care for this patient. Although each patient's situation differs, the nurse can use some key pieces of information to help minimize unnecessary care transitions for patients who may be nearing the end of life. This could improve the quality of patient care while helping to reduce costs.
This article incorporates findings from a national study that explored the care transitions of 110,218 Medicare beneficiaries during their last year of life.1 Using a retrospective cohort design, Medicare administrative data were used to examine and compare health service use in the last year of life among older adults with HF, chronic obstructive pulmonary disease (COPD), and lung cancer.2 Using a fictitious patient, Mrs. K, this article explores pertinent issues faced by older adults living with end-stage diseases and their many care transitions as they near the end of life. It highlights the nurse's vital role of improving these patients' transitions by incorporating evidence-based findings into practice, by using a framework to help clarify patients' goals of care, and by advocating for needed policy changes for this population.
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