Literature Review

When Medicare sent patients home sooner, Mary Naylor built the safety net Penn LDI - Leonard Davis Institute of Health Economics; by Liz Seegert; 11/17/25 When Medicare’s diagnosis-related group (DRG) payment system took effect in October 1983, hospitals adapted quickly, discharging patients faster to manage fixed reimbursement rates. Heart failure patients who once stayed eight to 10 days were going home in three to four days. But LDI Senior Fellow Mary Naylor, then a fellow with what was then known as the U.S. Senate Committee on Aging and Finance, realized no one had thought about what happened after discharge. She saw how these shifts created new risks for older adults, as hospitals lacked the infrastructure to support care continuity. ...

[Hospice] Christmas drive ongoing for local nursing homes McAlester News-Capital, Stigler, OK; by Remus Martin; 11/11/25 San Bois Hospice [in southeast Oklahoma] is hosting a Christmas drive for local nursing homes lasting until Dec. 10. Stacey Harvey, marketing employee with San Bois Hospice, started the drive eight years ago with the organization. ... She said children are always remembered during Christmas time, but the elderly tend to be forgotten. They want to make sure people in the nursing home are not forgotten and receive gifts.

‘Best and worst of times’ as skilled nursing providers face more uncertainty McKnights Long-Term Care News, Boston, MA; by Kimberly Marselas; 11/3/25 In a year in which uncertainty and inaction have been common themes, LeadingAge executives acknowledged ... that aging services providers are increasingly split into haves and have-nots.  “We have all been navigating a great deal of uncertainty, and yet many organizations have had their best years, ... President and CEO Katie Smith Sloan told a standing room-only crowd. “Others are hanging by a thread, dependent on Medicaid, struggling on staffing, particularly in rural communities with old physical plants, and boards that are stuck on preserving the status quo. It is truly the best and worst of times.”

Living with dementia report emphasizes that even those with advanced disease have stories to share JAMA Medical News; by Rita Rubin, MA; 10/31/25 As the average age of the US population has risen, so has the number of people living with Alzheimer disease and related dementias. And yet, dementia is still a highly stigmatized condition, a new collection of essays published by the Hastings Center for Bioethics points out. Clinicians, caregivers, and loved ones could improve the lives of the more than 7 million people in the US who are living with dementia if they only recognized that such individuals still have their own stories to tell, even when they can’t express themselves the same way they did before their symptoms appeared. 

CMS’s Special Focus Facility Program for Nursing Homes has not yielded lasting improvementsOIG press release; 10/29/25This report evaluated the effectiveness of the Centers for Medicare & Medicaid Services’ (CMS) Special Focus Facility (SFF) program, the agency’s flagship effort to address quality problems at the nation’s poorest-performing nursing homes. OIG found nearly two-thirds of facilities that graduated from the SFF program between 2013 and 2022 later exhibited recurring quality issues. Among nursing homes that received a serious deficiency in the three years after graduating, 38% put residents at risk of serious injury, harm, impairment or death. For program improvement, OIG recommended that CMS use more nonfinancial remedies, assess enforcement effectiveness—especially for staffing deficiencies—and incorporate ownership data.Publisher's note: It's interesting to see what works - and what doesn't work - from the CMS / OIG perspective.

Engaging community health workers in Advance Care Planning  Hospice News; by Jim Parker; 10/24/25 Three organizations have developed an advance care planning training program in Illinois for community health workers that could potentially be adapted for other states. The seeds for the project were planted when the Illinois Public Health Association (IPHA) was awarded a grant by the Health Resources & Services Administration (HRSA). IPHA proceeded to engage the Illinois Hospice & Palliative Care Organization (IL-HPCO) and the HAP Foundation as subject matter experts to help develop the curriculum, as well as the education company Hospice Media, which filmed and designed the modules and workbooks.

Three tried-and-true strategies AHCA Gold Quality Award winners use to land and keep staff McKnights Long-Term Care News, Las Vegas, NV; by Kimberly Marselas; 10/22/25 Leaders of three of the nation’s best-performing nursing homes shared ... outside-the-box recruitment and retention strategies that have made robust staffing the linchpin of their respective quality-improvement journeys. ... Here, McKnight’s Long-Term Care News shares a few of the role model practices Peters and her two 2025 Gold National Quality Award peers rely on to create staff loyalty, even in highly competitive markets.

Study: Nearly two-thirds of nursing home residents were exposed to med combos linked to potential drug-drug interactions McKnights Long-Term Care News; by Foster Stubbs; 10/17/25 About 62% of nursing home residents experienced one or more drug-drug interactions (DDI) between 2018 and 2020, according to an October study published in the Journal of the American Geriatrics Society. Researchers examined 485,251 Medicare fee-for-service beneficiaries 66 years or older living in nursing homes with observable Medicare Part D prescription drug data. Data were drawn from Medicare claims linked to Minimum Data Set 3.0 clinical assessments. 

Size of the financial incentives in Medicare’s Skilled Nursing Facility Value-Based Purchasing ProgramJAMA Network Open; Robert E. Burke, Franya Hutchins, Jonathan Heintz, Syama R. Patel, Scott Appel, Julie Norman, Atul Gupta, Liam Rose, Rachel M. Werner; 9/25The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program seeks to reduce all-cause 30-day readmissions from SNF for traditional Medicare beneficiaries recently discharged from the hospital. Under SNF VBP, most SNFs receive a financial bonus or penalty up to 2% of their total traditional Medicare revenues each year, on the basis of their performance on 30-day readmission rates compared with other SNFs, or their own improvement in readmission rates over time. In this cohort study, we found that the size of the financial incentives at the SNF level are relatively small in terms of dollars and as a proportion of net operating income, and that most SNFs experienced substantial variability from year to year in their incentive payments. These 2 factors may have contributed to the relative lack of effectiveness of the SNF VBP program. First, if the level of the penalty is not sufficient to hire additional staff, purchase equipment (such as an x-ray machine or laboratory testing), or invest in new care processes, then SNFs will not be able to improve their ability to manage changes in patient condition. 

With palliative care, earlier referrals mean fewer end-of-life emergency department visits ONS Voice; by Anne Snively, MBA, CAE; 10/15/25 Patients with cancer who are referred to palliative care within one month of death have a mean of 1.17 emergency department (ED) visits, compared to a mean of 0.13 visits for patients referred to palliative care 12 months or more before death—a 160% difference. The data are part of a new study published in JAMA Network Open in July 2025. ... Most of ED visits (47.0%) and EOL ED visits (81.4%) occurred within one month of the palliative care consultation, but the researchers found that both kinds of ED visits “gradually decreased as the time from consultation to death extended.” 

Alzheimer’s Association, Maine Chapter sees largest turnout for annual fundraiser walk WABI-5, Bangor, ME; by Grace Bradley; 10/11/25 For more than two decades, folks have hit the streets of Bangor to help raise money and awareness for Alzheimer’s. On Saturday, Maine’s chapter of the Alzheimer’s Association says they saw the largest crowd yet of about 400 people for their largest annual fundraiser. “We provide free care and support for families and community members walking through this disease, whether it’s Alzheimer’s or other forms of dementia. So what we do enables us to do everything for free. But we also take a portion of that money and put it towards research,” explains Kris Baker, Development Manager of Alzheimer’s Association Maine. Editor's Note: Do you support and partner with the Alzheimer's Association?

Conspiracy of verticals:  Rethinking healthcare models with Peter Benjamin Teleios collaborative Network (TCN); video/podcast hosted by Chris Comeaux with Peter Benjamin; 10/8/25 In this conversation, Peter Benjamin and Chris Comeaux discuss the impact of COVID-19 on mortality rates, particularly the concept of 'death pull forward' and its implications for Hospice Care. Peter highlights the significant role of assisted living facilities in Hospice days and explores macro trends in healthcare, emphasizing the shift from vertical to horizontal care models. The discussion also covers the evolution of Palliative Care, frail elderly practices, and institutional special needs plans (iSNPs), while stressing the importance of measuring quality of care, particularly in pain management. 

Communication surrounding treatment preferences for older adults with dementia during emergency medical services responseJournal of the American Geriatrics Society; by Lauren R. Pollack, Danae G. Dotolo, Anna L. Condella, Whitney A. Kiker, Jamie T. Nomitch, Elizabeth Dzeng, Nicholas J. Johnson, Thomas D. Rea, May J. Reed, Michael R. Sayre, Erin K. Kross; 9/25Emergency Medical Services (EMS) providers, capable of rapidly delivering life-prolonging interventions, are often first to respond to acute health concerns for older adults in the United States. Prior work has shown a preference among many people with dementia for comfort-focused care near end-of-life. EMS providers treating critically ill older adults with dementia face challenges that may hinder their ability to elicit treatment preferences, in particular when responding to calls from professional caregivers. Direct communication with surrogate decision-makers may facilitate goal-concordant care.Assistant Editor's note: Being an RN for over 40 years, I have seen many changes in health care, especially in what is expected now of patients/families. I remember the day when nurses were not permitted to share with the patient his/her own BP reading; instead, we were to tell patients to "ask the doctor". Back then the doctor controlled almost all aspects of the patient's care, as well as the sharing of information with the patient about his/her own medical condition. I am glad those days are gone. Now, patients are expected to engage in ongoing discussions regarding advance care planning, execute written advance directives, and are expected to share their care preferences with health providers and loved ones and/or caregivers. It would be an ideal world where health care providers were continuously aware of evolving patient preferences and could always deliver goal concordant care. I believe we need to keep working toward this goal, but I also understand that this expectation can add burden to patients who are already extremely burdened with the many difficult aspects of serious illness. I believe that, as health care providers, we need to appreciate that some people simply cannot or will not share their preferences; it is simply too scary, too foreign, too difficult to do so.