Journal of Social Work in End-of-Life & Palliative Care

ISSN: 1552-4256 (Print) 1552-4264 (Online) Journal homepage: http://www.tandfonline.com/loi/wswe20

Palliative Care in Your Nursing Home: Program

Development and Innovation in Transitional Care

Jennifer Giuffrida LCSW, ACHP-SW

To cite this article: Jennifer Giuffrida LCSW, ACHP-SW (2015) Palliative Care in Your Nursing
Home: Program Development and Innovation in Transitional Care, Journal of Social Work in
End-of-Life & Palliative Care, 11:2, 167-177, DOI: 10.1080/15524256.2015.1074143

To link to this article: http://dx.doi.org/10.1080/15524256.2015.1074143

Published online: 18 Sep 2015.

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 Journal of Social Work in End-of-Life & Palliative Care, 11:167–177, 2015
Copyright # Taylor & Francis Group, LLC
ISSN: 1552-4256 print=1552-4264 online
DOI: 10.1080/15524256.2015.1074143

Palliative Care in Your Nursing Home:

Program Development and Innovation
in Transitional Care
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JENNIFER GIUFFRIDA, LCSW, ACHP-SW

Director of Social Work, Schervier Nursing Care Center, Bronx, New York, USA

Each year in the United States, 31% of elders who die do so in

hospitals, accounting for over half a million deaths often involving
expensive and unnecessary treatments (Zhao & Encinosa, 2010).
Re-hospitalizations of frail elders with end-stage illnesses are a
concern for the hospitals that have discharged them and for the
facilities in which they live. In 2011, Schervier Nursing Care
Center, a 364-bed skilled nursing and rehabilitation facility in
the Bronx, NY, looked at its re-hospitalization rates. It was discov-
ered that a large percentage of the residents being sent to the
hospital were from the long-term and subacute populations with
end-stage diseases that were no longer responding to treatment.
This article describes the development of two innovative programs
whose goals were to increase the number of residents receiving pal-
liative care, increase the number of completed advance directives,
reduce re-hospitalizations, and increase hospital referrals to the
nursing home for palliative care. The key components of both
programs and their outcomes are described. The development
and implementation of these programs were the author’s capstone
project for the Zelda Foster Social Work Leadership Fellowship in
Palliative and End-of-Life Care.

KEYWORDS advance directives, end-of-life, long-term care,

nursing home, palliative care, program development,
re-hospitalization rates, transitions coach

Received 30 December 2014; accepted 15 July 2015.

Address correspondence to Jennifer Giuffrida, LCSW, ACHP-SW, Schervier Nursing
Care Center, Social Work, 2975 Independence Avenue, Bronx, NY 10463, USA. E-mail:
huntjennie@aol.com

167
 168 J. Giuffrida

INTRODUCTION

Nursing home residents, their family members, and the staff caring for them
are gaining increased awareness that comfort care is desired more than
aggressive treatment (Bern-Klug, 2010). A comprehensive palliative care
program within a nursing facility can improve satisfaction for all involved,
especially when the plan of care is designed with the resident’s intent and
best interest in mind (Bern-Klug & Simons, 2011).
With such a large number of elders making the nursing home their
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home (Zhao & Encinosa, 2010), instilling a focus on person-centered care

is key to honoring wishes and implementing an effective plan. Person-
centered care begins with the nursing home staff talking to the residents
and their family members about what matters most to them. In regards to
palliative and end-of-life care, the development of a strong plan of care
to honor their wishes is paramount. Clinical social workers have compre-
hensive assessment skills and are a good choice amongst nursing home
employees to engage the resident and family members in conversation
surrounding palliative and end-of life care. The social worker, with the
endorsement of the interdisciplinary team, is invaluable in providing care
for the resident when there is an increase in needs associated with end-of-
life planning.
In 2011, Schervier Nursing Care Center, a 364-bed skilled nursing and
rehabilitation facility in the Bronx, NY, wanted an effective palliative care
program, but knew this meant they would need to change the manner in
which goals of care were established. Schervier, as with many nursing
homes, had a strong rehabilitative and restorative focus. In discussions with
front-line clinical staff, it was evident that formulating a plan of care beyond
that focus proved difficult. One Certified Nursing Assistant, when asked what
she thought about palliative care, admitted that she felt like she was ‘‘giving
up’’ on the resident. Another nurse admitted that changing to a palliative care
philosophy for a resident that she had been tending to for over 4 years
proved especially difficult. It became evident, based on staff concerns, that
a series of processes was needed to establish staff’s increased comfort in
providing palliative care to the residents. To further enhance its palliative
care efforts, an innovative transitions program that assisted patients’ transfers
from acute care to the nursing home setting was also developed. This article
presents both programs.

LITERATURE REVIEW

Despite palliative care gaining increased recognition in the last decade, much
of the literature looks at palliative and end-of-life care in the home-hospice
or acute care setting. Very little has been written about palliative care services
 Palliative Care in Your Nursing Home 169

in the nursing home setting. Pain and symptom management are strong
components of palliative care but a study reports that the nursing home
population still does not receive adequate pain management or symptom
relief (Russell, Madsen, Flesner, & Rantz, 2010). Similarly, within the last
several years there appears to be greater acuity among nursing home
residents as a larger percentage of residents need assistance with activities
of daily living—such as bathing, dressing, toileting, transferring, or eating
(Bern-Klug & Simons, 2011). In the absence of solid end-of-life planning,
nursing home residents who are close to death endure painful, intrusive
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medical procedures that add little to their lives in regards to quality or quan-
tity (Bern-Klug, 2010). Instead, residents continue to receive aggressive medi-
cal treatment focusing on curative efforts which result in more interventions
and discomfort, thus decreasing quality of life (Rantz et al., 2012). Palliative
care, with its focus on relief of suffering and attention to quality of life, repre-
sents a philosophy that must be integrated across the spectrum of illness and
the life span of the nursing home resident (Allegre, 2010). This is an impor-
tant care model that is needed in light of projections that there will be
increasingly larger numbers of elders making their home the nursing home
(Yoder, 2012).
Coping with a chronic or terminal illness can be difficult enough
without having to worry about complex symptom management. Medicare
beneficiaries in the nursing home can use their hospice benefit to assist
them and their families with issues at the end of life. However, Medicare
regulations require a physician to certify that a patient has a life expectancy
of 6 months or less in order to be eligible for hospice benefits. Many
physicians are reluctant to certify a 6-month prognosis when there is
significant uncertainty, as exists with residents diagnosed with dementia
(Coll, 2010). The majority of older residents occupying nursing home beds
in the United States have some form of dementia and cognitive impairment
(Jones, Moss, & Harris-Kojetin, 2011) and a physician’s determination
of life expectancy can be difficult for the dementia patient (Mitchell
et al., 2010).
Since palliative care does not require a 6-month prognosis, there is no
reason why residents of a nursing home cannot access the services that a
palliative care program provides, not only at the very end of their lives,
but at the time their progressive illness is diagnosed or when they are initially
admitted to a nursing home. Patients, family members, and the interdisciplin-
ary team are beginning to recognize that patients, including those with
dementia, may be more comfortable and may receive more comprehensive
and satisfying care when palliative care measures are pursued (Connor,
Pyenson, Fitch, Spence, & Iwasaki, 2007).
Palliative care offers relief from symptom distress and psychosocial dis-
turbances at any point during a serious illness. In the nursing home setting, a
strong palliative care program includes discussion of advance directives,
 170 J. Giuffrida

proper pain assessment and control, psychosocial support, attention to

hygiene, symptom control, spiritual support, recreational activities, and
bereavement services (Johnson, 2005). Having access to a functional palli-
ative care program allows nursing home residents to have quality of life
and to have their symptoms managed in their home.

PALLIATIVE CARE PROGRAM DEVELOPMENT

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The mission statement of Bon Secours Health System, of which Schervier

Nursing Care Center is a member, is to bring compassion to health care
and to be Good Help to Those in Need1, especially those who are poor
and dying. It is unusual to find a mission statement in health care that men-
tions the dying. Nevertheless, we recognized that we needed to be able to
hold Schervier true to its mission statement. The staff was uncertain of the
meaning of palliative care. The concept of providing palliative care to the
residents was included in the goals of the nursing home, but the philosophy
was not adopted by all staff members. Only 5% of the residents were con-
sidered palliative care patients, and without a palliative care champion, the
palliative care committee met infrequently.
With the support of Administration and the impetus of the Zelda Foster
Leadership Fellowship, several initial steps were taken to lay the groundwork
for a facility-wide palliative care program:

. Established regular meetings of the Palliative Care Committee, with new

committee chair;
. Reviewed and revised policies and procedures regarding palliative
care;
. Established each discipline’s role in providing palliative care versus stan-
dard care (nursing, medicine, social work, dietary, recreation, pastoral
care, rehabilitation, volunteers);
. Educated staff about goals of care discussion (through in-services, captur-
ing each shift);
. Educated residents and families about the palliative care philosophy;
. Began presenting palliative care concepts and philosophy at new
employee orientation;
. Listed all residents on palliative care on daily census report;
. Included discussions of palliative care in daily morning report on
residents whose health was declining (weight loss, pneumonia, repeat
hospitalizations);
. Funeral planning and burial guide developed by the Social Work
Department;
. Set annual performance goals with palliative care measures;
. Unit tracking of advance directives by Social Work Department.
 Palliative Care in Your Nursing Home 171

Once those steps were completed and the Palliative Care Program
began to take shape, several components were developed:

. Palliative Care Order Sheet to help guide Clinical Staff interventions

allowing staff to take a fresh look at a resident, and build a new plan of
care (vs. editing an existing plan of care);
. Identification of direct palliative care admissions on admit sheet;
. Care plan meetings occur within 48 hours of admission with resident and
family, as opposed to the 10-day time frame postadmission as stated in the
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regulations;
. Daily visits by pastoral care staff;
. Private room whenever possible;
. Flexibility in meeting family ‘‘special requests’’;
. Accommodations for family members to stay overnight;
. Postdeath condolence card from all unit staff;
. Sharing of resident wake=Shiva and funeral arrangements with staff, with
at least one staff member attending;
. Biannual memorial service to provide support to grieving family members.

Systemic changes outside of the care teams were made—including

looking at processes in the admissions department for possible palliative care
referrals, partnering more closely with community hospice programs to
provide respite and acute care hospice services, and providing both formal
and informal educational sessions for the clinical staff and leadership. All
of these changes created a culture of palliative care in everyday practice.

OUTCOMES OF THE PALLIATIVE CARE PROGRAM

In the year following the implementation of the comprehensive palliative

care program, these outcomes were achieved:

. The number of residents on palliative care increased from 5 to 25%

. Re-hospitalization rates decreased from 17.4 to 15.2%
. Residents with health care proxies increased from 65 to 69%
. Residents with DNR orders increased from 64 to 73%
. Residents with feeding tubes declined from 24 to 14.

GOING FORWARD

Due to the program’s success and the staff’s adoption of the palliative care
philosophy, it is anticipated that the data will continue to improve as the pro-
gram evolves and increasing numbers of residents are placed on the program.
In terms of Advance Directives, the facility plans to adopt the Medical Orders
 172 J. Giuffrida

for Life-Sustaining Treatment (MOLST). Honoring patient preferences is

a critical element in providing quality palliative care. To date, advance
directives are established as separate orders on separate documents, like
the resuscitation orders, and the health care proxy. MOLST is a document
designed to improve the quality of care patients receive by translating patient
goals for care and preferences into medical orders (Bomba, Morrissey, &
Leven, 2011). MOLST is based on communication between the patient, his
or her health care agent or other designated surrogate decision maker, and
health care professionals that ensures shared, informed medical decision
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making.

PALLIATIVE CARE TRANSITIONS PROGRAM

Recent research has highlighted the revolving door between nursing homes
and hospitals across the country (Berkowitz, Schreiber, & Paasche-Orlow,
2012). One of the major reasons cited for readmissions to the hospital is poor
communication and fragmented care. From a systems perspective, a safe
transition from the hospital to the community or a nursing home requires
care that centers on the patient and transcends organizational boundaries
(Jencks, Williams, & Coleman, 2009). Individuals with chronic and complex
care needs are particularly vulnerable to experiencing poor quality of care
and problems of care fragmentation during transitions between settings—
e.g., hospital to nursing home (Coleman & Broult, 2003). Coleman and Broult
also note that all too often, health care settings act individually, without
knowledge of the services provided, problems addressed, preferences
expressed, or medications prescribed in the previous care setting.
Following the implementation of the palliative care program, Schervier
developed a unique, 1-year pilot program entitled ‘‘Transitional Care Program
for Palliative Care Patients.’’ For patients on palliative care, transitional care
services are critically important. Many of these patients are placed on palli-
ative care without having a good understanding of their diagnosis and what
palliative care means. Many arrive at the receiving nursing home without clear
and accurate documentation, including medications and advance directives,
thus leaving them vulnerable for unwanted and unnecessary resuscitation
codes, treatments, and re-hospitalizations. Families, too, often lack the knowl-
edge and understanding necessary to assist their loved ones during this
difficult time.
Transfer to the hospital can be a traumatic experience for patients and
their families. They often become disoriented, are surrounded by unfamiliar
faces, are frequently subjected to tests and procedures that are unnecessary
and burdensome, and often return to the nursing home in worse condition
then when they left (with pressure ulcers, infections). Rather than sending
a resident back to the hospital, comfort care and symptom management
 Palliative Care in Your Nursing Home 173

should be provided in the nursing home by caring, familiar staff in the

residents’ own environment.
Schervier felt strongly that a Transitional Care Program would reduce
readmissions to the hospital while faithfully honoring and respecting the resi-
dent’s wishes and values. This would be accomplished by hiring a full-time
Palliative Care Transition Coach, a clinical social worker, who would focus
on the hospitalized patient’s needs prior to, during, and immediately follow-
ing transition to the nursing home, thereby expanding the purview of the tra-
ditional team. The Transition Coach would work together with the resident
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and his=her family to maximize the involvement of interdisciplinary expert-

ise, ensuring that critical issues are addressed, appropriate professionals
are involved, treatment goals are understood, and the care plan is executed
correctly.
The key concept in the success of this program is in the word
‘‘transition.’’ All of the people involved (patient, family, hospital=nursing
home staff) must be conscious of their language and replace the word
‘‘discharge’’ with the word ‘‘transition.’’ Discharge implies a termination, or
a hand-off to the next provider. Transition implies a continuation of care
but in a different setting. This is particularly important with patients transi-
tioning to palliative care in the nursing home.

PROGRAM GOALS

The main goal of the program is to improve communication among palliative

care patients, families, and the interdisciplinary team regarding each patient’s
wishes and values, especially with regard to hospitalization. This is facilitated
by the Transition Coach. If the patient or family does not want hospitaliza-
tion, then a Do Not Hospitalize Order is obtained from the attending phys-
ician. All documentation upon admission to the nursing home is verified
as accurate and complete—including advance directives, diagnoses, and
current medications. This information is obtained by the Transition Coach
prior to the patient’s transition from the hospital and verifies its accuracy
and completeness when the patient is admitted to the nursing home.
Another goal of the program is to improve patient quality of care and to
ensure that each resident’s wishes and values are respected in accord with
their advance directives and that no unnecessary and unwanted treatments
and procedures are performed. This would include such things as feeding
tubes, I.V. fluids, blood work, and resuscitation.
The staff is sensitized to each patient’s social, psychological, cultural and
spiritual needs, and wishes including level of family involvement, visits from
clergy, food preferences, activity preferences (e.g., music, pet therapy,
movies), and degree of emotional support. The Transition Coach meets with
the resident’s receiving clinical team prior to arrival and informs them of the
 174 J. Giuffrida

resident’s needs and wishes. The Transition Coach then follows up with the
resident and=or family within 1-week post-admission to ensure that needs
and wishes are being addressed.
The program empowers families=health care proxies to take an active
role in their loved one’s care and to make them feel that they are a valued
member of the team. This includes keeping them informed about changes
in the resident’s condition, responding to their questions in a timely manner,
and inviting their participation at care plan and family meetings.
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OUTCOMES FROM THE TRANSITIONAL CARE PROGRAM

The number of hospitals referring palliative care patients to this facility

increased with the Transition Coach visiting various hospitals, promoting
the program and enlisting support. The year prior to the Transition Coach
program, only eight acute care facilities referred patients to Schervier. That
number increased to 15 acute care facilities after 1 year of the Transition
Coach, as a result of outreach to neighboring facilities about the palliative
care initiatives offered at Schervier.
The admission goal for the Transition Coach was expected to be two
admissions per month with the total of 24 patients per annum. After 12
months, the Transition Coach admitted 33 patients from acute care facilities.
A palliative care transition checklist was formulated ensuring that all neces-
sary documentation and directives were gathered from the acute facility
and relayed accurately to the skilled nursing facility, ensuring that the facility
was thoroughly prepared to accept the patient from the hospital.
Additionally, the facility re-hospitalization rate decreased from 15.2 to
13.9%. The re-hospitalization rate for the 33 palliative care patients admitted
through the Transition Coach was 7.2%, well below the national benchmark
of 23% at that time (Centers for Medicare and Medicaid Services, 2013).
In-house residents on the palliative care program increased from 18 to
27%. Based on these outcomes, Schervier became recognized by acute care
referral sources as a premier provider of palliative care services and as a
model for other long-term care facilities to replicate.
There is also a fiscal incentive for facilities hoping to replicate this
program. Average reimbursement rates for all-inclusive daily rates for our
current residents are as follows: $288=day for Medicaid payers and approxi-
mately $375=day for Medicare=HMO payers for Level 1 services for those on
palliative care (that is, not anticipating a need for a high level of rehabilitation
services for these residents). Out of these rates, approximately $80=day go to
direct expenses, such as pharmacy and laboratory. If 50% of admissions
come from each category, then the facility receives extra net revenue of
approximately $251=day for each additional admission brought in specifi-
cally through the efforts of the palliative care transition coach.
 Palliative Care in Your Nursing Home 175

As the nature of long-term care is to provide services for individuals with

chronic illnesses in order to optimize their quality of life until their deaths, it is
possible that all organizations that provide long-term care to older adults
might adopt such an approach and program. This model could have far reach-
ing effects, not only locally, but also state-wide and nationally. It is a natural fit
with what organizations should be doing in the institutional care of frail
elders. The program has shown good outcome measures and demonstrated
financial viability. As nursing home administrators recognize the program’s
positive impact on patient care and patient referrals, there is a strong likeli-
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hood that they would consider adopting the program.

CONCLUSION

The ethical principles of social work practice as outlined by the Code of

Ethics of the National Association of Social Workers are Service, Social Jus-
tice, Dignity and Worth of the Person, Importance of Human Relationships,
Integrity, and Competence (NASW Code of Ethics, 2008). Advocating for the
adoption of a palliative care philosophy not only utilizes the social worker’s
skill set but fulfills the important ethical principles listed above. Social
workers in long-term care institutions can take a leadership role and work
with the interdisciplinary team and administration to implement palliative
care approaches and programs. Social workers are in a strong position within
the organization to understand the resident and family issues associated
with life-limiting illnesses and advocate for the formulation of a palliative
care program within their nursing home.
The Palliative Care Program at Schervier Nursing Care Center demon-
strates how other nursing facilities can consider the development of a quality
palliative care program. Nursing home residents have the right to make their
own choices, to be free from pain and discomfort, and to choose a death that
takes place in a familiar setting surrounded by those who care. That choice,
however, is only available when the staff educates the resident and family
member about their options. As health care providers in long-term care, there
is an ethical and professional obligation to provide residents with the best
possible quality of life. Only by ensuring that residents and their family mem-
bers are aware of palliative care, and putting a system in place to provide pal-
liative care, have nursing homes met their responsibilities to their residents.

REFERENCES

Allegre, A. (2010). Anticipating and managing common medical challenges

encountered at the end of life. In M. Bern-Klug (Ed.), Transforming palliative
care in nursing homes: The social work role (pp 107–139). New York, NY:
Columbia University Press.
 176 J. Giuffrida

Berkowitz, R. E., Schreiber, R., & Paasche-Orlow, M. K. (2012). Team improvement

and patient safety conferences: Culture change and slowing the revolving
door between skilled nursing facility and the hospital. Journal of Nursing Care
Quality, 27(3), 258–265.
Bern-Klug, M. (Ed.). (2010). Transforming palliative care in nursing homes: The
social work role. New York, NY: Columbia University Press.
Bern-Klug, M., & Simons, K. (2011). Palliative care in long-term care facilities
(pp. 103–114). New York, NY: Oxford Textbook of Palliative Social Work.
Bomba, P. A., Morrissey, M. B., & Leven, D. C. (2011). Key role of social work in
Downloaded by [Inter-American Development Bank (KNL/FHL)] at 06:48 13 November 2015

effective communication and conflict resolution process: Medical orders for

life-sustaining treatment (MOLST) program in New York and shared medical
decision making at end of life. Journal of Social Work in End-of-Life & Palliative
Care, 7(1), 56–82. doi: 10.1080=15524256.2011.548047
Centers for Medicare and Medicaid Services. (2013). Nursing home quality initiative:
Quality measures. Retrieved from http://www.cms.gov/Medicare/Quality-
InitiativesPatientAssessmentInstruments/NursingHomeQualityInits/NHQIQuality
Measures.html
Coleman, E. A., & Boult, C. (2003). Improving the quality of transitional care for
persons with complex care needs. Journal of American Geriatric Society, 51,
556–557. doi: 10.1046=j.1532-5415.2003.51186.x
Coll, P. (2010). Determination of life expectancy: Implications for the practice of
medicine. Annals of Long Term Care, 18(4), 21–24.
Connor, S. R., Pyenson, B., Fitch, K., Spence, C., & Iwasaki, K. (2007). Comparing
hospice and nonhospice patient survival among patients who die within
a three-year window. Journal of Pain and Symptom Management, 33(3),
238–246. doi: 10.1016=j.jpainsymman.2006.10.010
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among
patients in the Medicare fee-for-service program. New England Journal of
Medicine, 360(14), 1418–1428. doi: 10.1056=nejmsa0803563
Johnson, S. H. (2005). Making room for dying: End of life care in nursing homes.
Hastings Center Report, 35(6), S37–S41. doi: 10.1353=hcr.2005.0095
Jones, A. L., Moss, A. J., & Harris-Kojetin, L. D. (2011). Use of advance directives in
long-term care populations (NCHS Data Brief, No. 54). Hyattsville, MD: National
Center for Health Statistics.
Mitchell, S. L., Miller, S. C., Teno, J. M., Kiely, D. K., Davis, R. B., & Shaffer, M. L.
(2010). Prediction of 6-month survival of nursing home residents with
advanced dementia using ADEPT vs hospice eligibility guidelines. The Journal
of the American Medical Association, 304, 1929–1935. doi: 10.1001=jama.2010.
1572
National Association of Social Workers [NASW]. (2008). Code of ethics of the National
Association of Social Workers. Washington, DC. NASW Press.
Rantz, M. J., Zwygart-Stauffacher, M., Hicks, L., Mehr, D., Flesner, M., Petroski, G. F.,
. . . Scott-Cawiezell, J. (2012). Randomized multilevel intervention to improve
outcomes of residents in nursing homes in need of improvement. Journal of
the American Medical Directors Association, 13(1), 60–68. doi: 10.1016=
j.jamda.2011.06.012
 Palliative Care in Your Nursing Home 177

Russell, T., Madsen, R., Flesner, M. K., & Rantz, M. (2010). Pain management in
nursing homes: What do quality measures tell us? Journals of Gerontological
Nursing, 36(12), 49–56.
Yoder, S. (2012). The coming nursing home shortage. The Fiscal Times, pp. 83–84.
Zhao, Y., & Encinosa, W. (2010). The cost of end-of-life hospitalizations, 2007 (HCUP
Statistical Brief, 81). Rockville, MD: Agency for Healthcare Research and
Quality.
Downloaded by [Inter-American Development Bank (KNL/FHL)] at 06:48 13 November 2015