Rehabbed to Death Reframed: In Response to “Rehabbed to Death: Breaking the Cycle”

In this issue of the Journal of the American Geriatrics Society, an invited Special Article by Flint and colleagues expands on their editorial “Rehabbed to Death,” which appeared in the New England Journal of Medicine (NEJM) earlier this year. We agree with the underlying premise of these articles. There are many older adults likeMrs P, portrayed in theNEJM article, who cycle between hospitals and “rehab facilities” during the last year or two of their lives. Their care is often fragmented, uncomfortable, and distressing for the individual and family, futile, and expensive. The cycle is perpetuated, in part, by perverse financial incentives in the way Medicare pays for the care of patients like Mrs P. At the same time, many gaps exist in helping older adults at the end of their lives and their families establish rational and person-centered goals, as well as for many, a lack of services available to meet these goals in the most appropriate setting. We agree with the authors that health policy should incentivize comprehensive geriatric services that are available throughout all care settings, including increased support for home-based personal and caregiver needs. The authors suggest that rehab facilities should be renamed to “after-hospital transition in care.” The decision about where to receive post–acute care is complex and involves weighing several person-centered factors. Most older patients would prefer to go home directly from the hospital, but this is not feasible or safe for many due to the home environment, lack of family members or friends who can provide necessary support, and/or lack of adequate financial resources to pay for in-home care that is not covered by Medicare or supplemental insurance. The Medicare skilled home health benefit can assist patients in going home when additional support is available for assistance with basic and instrumental activities of daily living. Thus, nursing homes (ie, what the authors refer to as rehab facilities) play an essential role for many older patients who cannot go home immediately after a hospitalization. In this editorial, we use the general term “nursing home,” which is also labeled as nursing facilities and skilled nursing facilities (SNFs), as most of these settings have some or all of their beds licensed for skilled care. Although providing transitional care services from the hospital and back to other living settings is a large component of what nursing homes do, their role in today’s healthcare system is much broader. Mrs P, who is on a downward trajectory and cycling between the hospital and the nursing home, represents only one of several types of older adults cared for in this setting. Nursing homes care for a heterogeneous group of older adults, which is why the care is complex, the quality of care challenging to measure, and the optimal strategies to fund the care illusive. Older adults being “rehabbed to death” is only one, albeit important, part of the picture. Thus, we think the concept of rehabbed to death needs to be reframed. Reframing rehabbed to death involves putting Mrs P into context of the other types of individuals who are cared for in nursing homes. Figure 1 depicts six types of individuals currently cared for in the nursing home setting. Individuals may transition between these types over time. There are two basic types—one that is in the facility for relatively short periods of time and because of their clinical needs they are most appropriately referred to as “patients.” The second are individuals who live in the nursing home with no plan for discharge back to another setting—these individuals are most appropriately referred to as “residents.” Mrs P would fit into the “terminally ill” type of patient on the far left side of the figure. Additional case scenarios illustrate the other types of patients and residents: