State Regulations and Hospice Utilization in Assisted Living During the Last Month of Life

Emmanuelle Belanger, Joan M. Teno, Xiao (Joyce) Wang, Nicole Rosendaal, Pedro L. Gozalo, David Dosa, Kali S. Thomas

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died in 2018 and resided in an RC/AL community with ≥25 beds at least 1 day during the last month of life. Setting/Participants: 23,285 decedents who spent time in 6274 RC/AL communities with 146 state license classifications. Methods: Descriptive statistics about hospice use; logistic regression models to test the association between regulations supportive of hospice care or registered nurse (RN) staffing requirements and the odds of hospice use in RC/AL in the last month of life. Results: More than half (56.4%) of the study cohort received hospice care in RC/AL at some point during the last 30 days of life, including 5.7% who received more intensive continuous home care (CHC). A larger proportion of decedents who resided in RC/ALs with supportive hospice policies received hospice (57.3% vs 52.6%), with this difference driven by more CHC hospice programs. This association remained significant after controlling for sociodemographic characteristics, comorbidities, time spent in RC/AL, and Hospital Referral Region fixed effects. Decedents in RC/ALs with explicit RN staffing requirements had significantly less CHC use (2.0% vs 6.8%). Conclusions and Implications: A large proportion of RC/AL decedents received hospice care in RC/AL regardless of differing regulations. Those in licensed settings with explicitly supportive hospice regulations were significantly more likely to receive hospice care in RC/AL during the last month of life, especially CHC level of hospice care. Regulatory change in states that do not yet explicitly allow hospice care in RC/AL may potentially increase hospice utilization in this setting, although the implications for quality of care remain unclear.

Original languageEnglish (US)
Pages (from-to)1383-1388.e1
JournalJournal of the American Medical Directors Association
Issue number8
StatePublished - Aug 2022
Externally publishedYes


  • Hospice
  • assisted living
  • policy
  • residential care

ASJC Scopus subject areas

  • Nursing(all)
  • Health Policy
  • Geriatrics and Gerontology


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