Rehabilitation Therapy for Nursing Home Residents at the End-of-Life

Published:October 01, 2018DOI:



      Ultrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents.


      An observational study covering a time period 2012-2016.

      Setting and participants

      New York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691).


      Data sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File.
      Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated.


      Overall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time.

      Conclusions and Relevance

      This is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents.


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        • Acumen L.
        Skilled Nursing Facilities Payment Models Research: Technical Report.
        2017 (Available at: Accessed August 31, 2018)
        • OIG
        Questionable Billing by Skilled Nursing Facilities. Office of Inspector General, Department of Health and Human Services.
        (Washington, DC)2010 (doi:OEI-02-09-00202. Available at: Accessed August 31, 2018)
        • OIG
        The Medicare Payment System for Skilled Nursing Facilities Needs to be Reevaluated.
        (Washington, DC)2015 (Available at: Accessed August 31, 2018.)
      1. OIG. Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements. Office of Inspector General. Department of Health and Human Services. Washington, DC; 2013. doi:OEI-02-09-00201. Available at: Accessed August 31, 2018.

        • Weaver C.
        • Mathews A.
        • McGinty T.
        How Medicare rewards copious nursing-home therapy. The Wall Street Journal.
        (Available at:) (Accessed August 15, 2018)
        • O'Brien S.R.
        • Zhang N.
        Association between therapy intensity and discharge outcomes in aged Medicare skilled nursing facilities admissions.
        Arch Phys Med Rehabil. 2018; 99: 107-115
        • Ouslander J.G.
        • Lamb G.
        • Perloe M.
        • et al.
        Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs.
        J Am Geriatr Soc. 2010; 58: 627-635
        • Temkin-Greener H.
        • Zheng N.T.
        • Xing J.
        • Mukamel D.B.
        Site of death among nursing home residents in the United States: Changing patterns, 2003-2007.
        J Am Med Dir Assoc. 2013; 14: 741-748
        • Xing J.
        • Mukamel D.B.
        • Temkin-Greener H.
        Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations.
        J Am Geriatr Soc. 2013; 61: 1900-1908
        • Gozalo P.
        • Teno J.M.
        • Mitchell S.L.
        • et al.
        End-of-life transitions among nursing home residents with cognitive issues.
        N Engl J Med. 2011; 365: 1212-1221
        • Miller S.C.
        • Lima J.C.
        • Looze J.
        • Mitchell S.L.
        Dying in U.S. nursing homes with advanced dementia: How does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?.
        J Palliat Med. 2012; 15: 43-50
        • Miller S.C.
        • Lima J.C.
        • Mitchell S.L.
        Influence of hospice on nursing home residents with advanced dementia who received medicare-skilled nursing facility care near the end of life.
        J Am Geriatr Soc. 2012; 60: 2035-2041
        • Aragon K.
        • Covinsky K.
        • Miao Y.
        • et al.
        Use of the Medicare posthospitalization skilled nursing benefit in the last 6 months of life.
        Arch Intern Med. 2012; 172: 1573
        • Norton S.A.
        • Ladwig S.
        • Caprio T.V.
        • et al.
        Staff experiences forming and sustaining palliative care teams in nursing homes.
        Gerontologist. 2018; 58: e218-e225
        • Hawes C.
        • Morris J.N.
        • Phillips C.D.
        • et al.
        Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS).
        Gerontologist. 1995; 35: 172-178
        • Mor V.
        • Angelelli J.
        • Jones R.
        • et al.
        Inter-rater reliability of nursing home quality indicators in the U.S.
        BMC Health Serv Res. 2003; 3: 20
        • Saliba D.
        • Jones M.
        • Streim J.
        • et al.
        Overview of significant changes in the minimum data set for nursing homes version 3.0.
        J Am Med Dir Assoc. 2012; 13: 595-601
        • RTI
        MDS 3.0 Quality Measures User's Manual.
        (Waltham, MA)2016
        • Centers for Medicare and Medicaid Services
        Long Term Care Facility Resident Assessment Instrument 3.0. User's Manual.
        (Available at: 2015)
        • Lepore M.
        • Leland N.
        Nursing homes that increased the proportion of medicare days achieved gains in quality: Outcomes for long-stay residents.
        Health Aff. 2015; 34: 2121-2128
        • Thomas K.
        • Dosa D.
        • Wysocki A.
        • Mor V.
        The Minimum Data Set 3.0 Cognitive Function Scale.
        Med Care. 2017; 55: e68-e72
        • Grabowski D.C.
        • Feng Z.
        • Intrator O.
        • Mor V.
        Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations.
        Health Serv Res. 2010; 45: 1963-1980
        • Cai S.
        • Mukamel D.B.
        • Veazie P.
        • et al.
        Hospitalizations in nursing homes: Does payer source matter? Evidence from New York State.
        Med Care Res Rev. 2011; 68: 559-578
        • Travis S.S.
        • Bernard M.
        • Dixon S.
        • et al.
        Obstacles to palliation and end-of-life care in a long-term care facility.
        Gerontologist. 2002; 42: 342-349