Specialized nursing facility clinicians found to improve end-of-life care

Specialized nursing facility clinicians, or SNFists, may decrease the likelihood of nursing home residents experiencing stressful hospitalizations and improve the quality of life in their last days, according to researchers from Weill Cornell Medicine.

The paper, published in JAMA Network Open, examined how SNFists uniquely impacted the care of nursing home residents in their last 90 days, compared with those cared for by other clinicians. This large-scale study is the first of its kind.

"The literature has described certain features or outcomes that translate into what we think is poor quality at the end of life," said Dr. Arnab Ghosh, assistant professor of medicine at Weill Cornell Medicine and a hospitalist at NewYork-Presbyterian/Weill Cornell Medical Center.

"One example is transferring residents to the hospital and admitting them for conditions like pneumonia or UTIs (urinary tract infections) that may have been managed in the nursing home, or going from nursing home to hospital to another nursing home."

The physical act of transferring the residents to new environments increases their risk of delirium and discomfort, the researchers said. Transfers also interrupt communication and continuity of care, burdening patients and making them more uncomfortable.

The study defined SNFists as health care professionals (physicians, nurse practitioners, and physician assistants) who provided at least 80 percent of their patient visits in the nursing home setting. They noted this specialization gives SNFists deeper insight into the clinical conditions facing nursing home residents, which allows for better communication between the residents, their families, and other staff members.

The study of 2,091,954 nursing home residents aged 65 and older during a period from January 2012 to December 2019 found that SNFists managed about 46 percent of this group. The researchers determined that care from an SNFist decreased risk by up to 6 percent for hospitalizations due to any reason, including pneumonia, urinary tract infection, dehydration, or sepsis.

The need for SNFists will only grow as the U.S. population ages and more people develop dementia—two-thirds of all deaths related to Alzheimer's disease occur in nursing homes. Other professions may also need to step up.

"We need more research comparing the quality of care from different nursing home clinicians, including medical doctors, nurse practitioners, and physician assistants, but we clearly see fewer MDs working in nursing homes while NPs and PAs are increasing," said Dr. Hye-Young Jung, associate professor of Population Health Sciences at Weill Cornell Medicine.

The researchers suggest that medical schools and residency programs may need to offer more nursing home care experiences to increase the number of physicians in this field. They also emphasize the need for designating an official specialization, as with other areas of medicine like hospitalists, which would provide certification of the unique knowledge and skills needed in the nursing home setting.