Be Prepared: C A L I FOR N I A Reducing Nursing Home Transfers Near End of Life H EALTH C ARE F OU NDATION Executive Summary who thought that their dying loved one was Few nursing homes have developed a process not always treated with respect. There were no for helping residents understand and document statistically significant changes in process measures, their end-of-life wishes nor established adequate such as written advance directives and use of Do procedures to care for residents when they are Not Hospitalize and Do Not Resuscitate orders, Issue Brief dying. As a result, nursing home residents too although there was a mild trend toward increased often are hospitalized during the last weeks and use of hospice services after the intervention. months of life, resulting in unnecessary suffering and the potential for increased health care costs. The project identified a number of factors that inhibited further advances in participating nursing A recent regional project addressed inappropriate homes, including: the disruptive effect of the state nursing home-to-hospital transfers toward the survey process; financial incentives to transfer end of life through improved advance care residents to acute care facilities and disincentives planning, including the use of Physician Orders to care for them in place; lack of knowledge, skills, for Life-Sustaining Treatment (POLST). The and time of nursing home staff in the provision PREPARED project, a collaboration between of advance care planning and pain and symptom acute care and skilled nursing facilities, sought to management; and insufficient nursing home reduce avoidable hospitalizations and demonstrate administrative and physician support. a business case for this model. The intervention included hospital-supported clinician educators Several conditions were noted as contributing assigned to nursing homes to provide education, to significant improvements in certain facilities, role modeling, and coaching of key staff. Nursing including: sustained administrative support homes were divided into three groups or cohorts and leadership; facility advance care planning of six facilities, with each facility receiving six champions; involved physicians; focus on quality months of direct intervention from their assigned improvement; and opportunities for resident and team member. An outside evaluator audited the family education. success of the project. Regarding the fiscal impact for hospitals and The PREPARED project showed a statistically health systems interested in sponsoring a significant increase in the nursing home as the PREPARED-like model, the project report site of death for terminal patients and reduced describes three ways that they can benefit from hospitalizations from 9.6 per month per facility to preventing nursing home transfers: (1) by avoiding 8.9. There was an increase of 6 percentage points the increased cost of caring for patients in the in family members’ overall rating of their dying acute care hospital; (2) by avoiding the losses loved one’s quality of care and a 13 percentage commonly incurred for inpatient deaths; and point decrease in the number of family members (3) by avoiding readmissions that may expose sites M arch 2011 to penalties once provisions of the Patient Protection and nursing homes. Among those noted were low execution Accountable Care Act are implemented. The report also of advance directives, lack of clarity regarding resident identifies the environmental variables most helpful for a end-of-life preferences, inadequate staffing levels, poor particular hospital achieving revenue-neutral or improved staff education and training in end-of-life issues, fear of performance. litigation and regulatory citation, and avoiding attention and stigma from a death in the facility.2 The PREPARED project was shown to be a credible model for collaborative efforts between hospitals and This issue brief describes a regional project to address nursing homes. Improving nursing home advance care inappropriate nursing home-to-hospital transfers toward planning processes, with particular emphasis on the use the end of life through improved advance care planning. of POLST, can improve the quality of care delivered to The project, called PREPARED (Preparing Residents for frail, elderly residents. Furthermore, a program such as End-of-Life Plans and Respecting End-of-Life Decisions), PREPARED can convey operational and fiscal benefits to provides important lessons for communities interested in sponsoring hospitals, with return on investment expected ensuring that nursing home residents receive the care they to increase as a result of reforms at the state and national want in the most appropriate setting. The business case levels. for hospitals investing in a PREPARED-like program is also examined. Introduction American culture avoids discussions about death and Background dying, and nursing homes are no different. Most seriously In 2003, in response to a Sacramento area hospital’s ill or frail individuals who reside in nursing homes receive concerns about the number of nursing home transfers to little guidance in making plans for their end-of-life care. its facility, a pilot project was conducted to try and reduce Few facilities have developed a thorough process to talk inappropriate transfers.3 The project was constructed as with residents and their families about end-of-life wishes a collaboration between acute care facilities and nursing or have put in place adequate procedures to care for homes. residents when they are dying. For eight hours per week, a hospital-funded nurse As a result, even when contrary to their wishes, nursing consultant mentored staff in one nursing home in home residents too often are hospitalized during the last advance care planning, goals of care discussions, and weeks and months of life.1 When residents are transferred education and consultation on pain and symptom to an emergency department without guidance about management. The hospital also contracted four hours their goals of care, they may receive treatment that is per week with a palliative care physician to support the more burdensome than beneficial, resulting in patient project. Within six months of implementation, hospital suffering and family distress. Furthermore, these transfers transfers from that nursing home decreased 56 percent may contribute to increased health care costs with no and patient/family satisfaction measures improved. The improvement in patient outcomes. pilot was expanded in 2004 to a second nursing home, with similar results. Improving nursing home practices and procedures pertaining to end-of-life care is not a small challenge. A Based on these promising results, in 2007 the California 2008 study by the California HealthCare Foundation HealthCare Foundation funded the Coalition for identified barriers to good end-of-life care in California Compassionate Care of California (CCCC) to test the 2  |  California HealthCare Foundation replicability of the model.4 Through a collaboration members and their hospital system leaders throughout the of three hospital systems and 18 nursing homes in project. the Sacramento area, the PREPARED project’s goal was to ensure that nursing home residents receive the Nursing homes were divided into three sequential groups most appropriate end-of-life care by reducing avoidable or cohorts of six facilities, with each facility receiving six hospitalizations and enhancing palliative care in nursing months of direct intervention from their assigned team homes.5, 6 Key project objectives were to increase advance member. Education was provided to the administrator, directive use, improve staff skills in facilitating advance nursing director, and clinical staff during the six-month care planning, and establish a community end-of-life care period and follow-up support was offered through the standard for area nursing homes. Additionally, the project remainder of the project. Team members developed action aimed to demonstrate the business case for this model to plans tailored to their assigned nursing home and visited facilitate its sustainability and spread. the facility weekly to provide education and support. Process and Intervention CHCF contracted with Brown University to The three Sacramento area hospital systems provided independently evaluate the project.7 PREPARED team four to eight hours per week of clinician educators members conducted chart extractions to gather data for (RN or MSW) with expertise in end-of-life care for the outside evaluators, who also made site visits with work in designated nursing homes. With input from participating nursing home and hospital systems. hospital management, nursing home partners were recruited, focusing on facilities that had a high volume of discharges, had existing relationships with project team Elements of the PREPARED Intervention members, were in close proximity to the hospitals, and/ • Establish a memo of understanding with nursing or were particularly interested in participating. An initial home admin/director of nursing. kick-off meeting for the project was held to garner a • Provide advance care planning (ACP) education to broad base of support; 50 representatives from hospital nursing home staff; introduce POLST. systems, nursing homes, and state survey and ombudsman • Help develop improved ACP process for residents. departments attended. • Provide role modeling and coaching of nursing home staff to improve their ACP facilitation skills. • Offer family education forums. Since nursing home involvement was voluntary, several • Encourage physician support and participation. actions supported their participation: requiring a signed • Identify nursing home champions to ensure memorandum of understanding with nursing home sustainability. leaders; sending an informational letter to the nursing home medical director and all other physicians who had patients at the facility; introducing assigned team members to facility leaders and staff; and identifying POLST Plays an Important Role champions within nursing homes who could serve as POLST (Physician Orders for Life-Sustaining Treatment) project “cheerleaders.” Project leaders and team members is a physician order that gives patients more control met bi weekly to review implementation efforts, discuss over their end-of-life care. Produced on a distinctive challenges, and adapt the intervention as necessary. bright pink form and signed by both the physician and Informal communication occurred between team patient, POLST specifies the types of medical treatment that a patient wishes to receive towards the end of Be Prepared: Reducing Nursing Home Transfers Near End of Life  |  3 life. It encourages communication between providers ◾◾ Increased utilization of hospice services. and patients, enables patients to make more informed decisions, and clearly communicates these decisions to The PREPARED project showed a statistically significant providers. As a result, POLST can prevent unwanted increase in the nursing home as the site of death for or medically ineffective treatment, reduce patient and terminal patients (from an average of 5.2 deaths per family suffering, and help ensure that patients’ wishes are facility per month to 6.0), indicating that more patients at honored. the end of life were cared for in the nursing home setting than previously. In addition, the overall hospitalizations The pilot project used the POLST form as its primary decreased from 9.6 per month per facility to 8.9.8 While communication tool; the PREPARED team introduced it not statistically significant taken as a whole, by the third in 2007 as an option for participating nursing homes. In cohort of nursing homes the decrease in hospitalizations 2009, California law required all health care professionals did reach statistical significance.9 and providers, including hospitals, nursing homes and first responders, to honor POLST orders. Taken together, these findings suggest that deaths shifted from hospitals to nursing homes. This is important Findings because the nursing home may be the better location to The PREPARED product data were assessed in the receive care from staff who know and respect the person’s aggregate, with each cohort of six facilities analyzed psychological, emotional, and spiritual needs. together. Evaluators compared data collected prior to the intervention from 15 to 20 patient charts per facility Regarding family perceptions of care for their dying loved with data collected after the intervention. In addition, one, there was an increase of 6 percentage points in family they conducted interviews prior to the intervention with members’ overall rating of quality of care as excellent. 103 family members of persons who died in the nursing Also, the number of family members who thought that home and 86 interviews with family members following their dying loved one was not always treated with respect the intervention. decreased by 13 percentage points. Nevertheless, these improvements were not statistically significant. To assess the impact of the project, evaluators analyzed outcome measures, including: Finally, there were no statistically significant changes in process measures such as written advance directives ◾◾ Reduction in hospitalization rates; and use of Do Not Hospitalize (DNH) and Do Not ◾◾ Increase in nursing home as site of death; Resuscitate (DNR) orders. However, there was a mild trend toward increased use of hospice services after the ◾◾ Improved perceptions of quality of care by decedent intervention. family members; and ◾◾ Medical care consistent with advance directives and Discussion residents’ wishes. While there was evidence of improvement in several key metrics, the results did not show the overall degree Process measures were also analyzed, including: of impact demonstrated in the pilot project. An environmental scan conducted by the project evaluators ◾◾ Rate of written advance directives; indicated that the Sacramento area may be ahead of other ◾◾ Orders to limit hospitalization; and parts of the state in terms of end-of-life planning, which 4  |  California HealthCare Foundation may have lessened the project’s impact. Data show that “bed-hold” rate for three days to ensure there is space DNR and DNH rates in the Sacramento area are well available when the resident is discharged. When the above state and national averages, and the intensity of person returns to the nursing home, the facility receives care is less; both are trends that occurred over the years a higher per diem rate due to the acute care stay. These prior to the intervention.10, 11 Therefore it is plausible to financial implications reduce the motivation to care for suggest that other areas in California might have a greater the resident in the nursing home. effect in terms of reduced hospitalizations from this intervention than did the Sacramento region. Lack of ACP knowledge. Many nursing home staff have very limited knowledge of end-of-life issues, minimal The decrease in hospitalizations by the third nursing time for attending trainings or developing new skills, and home cohort suggests a maturation of the project. This cultural backgrounds that can inhibit accepted processes correlates with continued improvement and modification for end-of-life care. Some nursing homes provide little of the intervention based on team members’ experience advance care planning (ACP) beyond brief conversations and needs of the nursing homes. Also, the advent of upon admission by a non-health care professional. And POLST legislation on January 1, 2009, requiring all there often is a lack of understanding about ACP, such as health care professionals and providers to recognize and the distinction between an advance health care directive follow POLST orders, led to an increase in POLST and an intensity of care form. adoption from the first cohort to the third. An “All Facilities Letter” from the California Department of Lack of administrative and physician support. A lack Public Health also brought needed attention to this issue of administrative and physician support significantly by introducing POLST to California nursing homes and reduced the level of participation from some nursing notifying them of the law’s provisions. homes. One facility dropped out of the intervention when upper-level management withheld its backing. Some Factors that Inhibited Change nursing homes were reluctant to invest additional staff The project team pointed to several circumstances that time to ACP and POLST education without enthusiastic inhibited change, including the following. support of the POLST form and process from their physicians. Work disruption. Facility surveys conducted by California’s Department of Health Services result in Lack of symptom management knowledge. The project considerable work disruption. All elective activities, was constrained by its inability to provide adequate including quality improvement efforts, are generally education and consultation on pain and symptom put on hold for the duration of the survey, which can management. Although this more intense level of activity extend for many weeks. Several of the study facilities were contributed to the success of the pilot due to support involved in surveys during the intervention and their from a contracted physician, it was not possible to active participation was curtailed as a result. replicate fully that part of the intervention with the time and resources allocated. Misaligned incentives. There can be financial incentives for nursing homes to transfer residents to acute care Limited time. Finally, team members had a limited facilities, and disincentives for caring for residents in number of hours to spend in each facility and lacked place. When a nursing home resident is transferred to a enough flexibility in their work schedules to leverage hospital, Medi-Cal continues paying the nursing home all mentoring and educational opportunities. Coupled Be Prepared: Reducing Nursing Home Transfers Near End of Life  |  5 with a relatively short intervention period of six months unit secretary, as the person responsible for many process per facility and a fast turn-around time period for the issues, became a cheerleader for proper storage and evaluation, these time constraints may have prevented retrieval of advance directives and POLST forms. more positive change. Involved physicians. Discussing patient goals of care Factors that Supported Change and documenting end-of-life wishes is best served While the evaluation did not measure change or analyze with engaged physicians. Those nursing homes with outcomes in individual nursing homes, there were active physician champions saw an increased focus on facilities that made significant changes in their ACP effective ACP and use of POLST, which set the tone and processes as a result of the project. Corporate leadership expectations for other staff. in several nursing homes instituted new policies and procedures and replaced their intensity of care forms Quality improvement focus. Nearly all the nursing with POLST. Some of those facilities now have nearly homes eventually adopted POLST in their facilities. Most all their residents with completed POLST forms and facilities that embraced this tool early did so because of systems in place to make sure POLST is stored and its potential to advance end-of-life care that was resident- retrieved appropriately. Other facilities are instituting directed and person-centered. communication tools introduced by team members during the intervention. Opportunities for resident and family education. While not all nursing homes conducted educational Those nursing homes that were most likely to integrate forums for residents and family members, those that did improved ACP strategies demonstrated the following. discovered that they generated a level of excitement that carried over into richer ACP conversations with staff. Sustained administrative support and leadership. The top-down culture of most nursing homes requires In addition to efforts to improve nursing home ACP that management be on board for any intervention expertise and capacity, the project sought to determine to be successful. Strong administrative involvement the business case for hospital systems to invest in similar helped ensure broad awareness of and participation interventions in order to reduce preventable transfers in PREPARED. One nursing home’s director of staff from nursing homes. development required staff to attend educational programs; another facility’s administrator and director of Hospitals Benefit from Avoiding nursing set an example for licensed staff by attending all Preventable Transfers educational programs provided by their team member. Hospitals and health systems can benefit from preventing Additionally, low turnover among key staff helped sustain nursing home transfers: (1) by avoiding the increased initial efforts. cost of caring for patients in the acute care setting; (2) by avoiding the losses commonly incurred for Facility champions. These supporters varied among inpatient deaths; and (3) by avoiding readmissions nursing homes (administrators, physicians, staff that may expose sites to penalties once provisions of development officers, nurses, social services designees), the Patient Protection and Affordable Care Act (PPACA) but those facilities with leaders who were passionate about are implemented. improving ACP and committed to the project were more likely to make positive change. In one nursing home, the 6  |  California HealthCare Foundation Lower Per-Patient Costs revenues less total costs) for cases transferred from nursing The clearest benefit from avoided nursing home transfers homes that ended in death. If the hospital loses money on occurs in integrated health systems, such as Kaiser such cases and if a sizable number of the transfers come Permanente, where the system is at risk for all health from four to six specific nursing homes, a program like care costs for enrolled patients, regardless of care setting. PREPARED that targets staff at those sites has a high Rather than securing compensation for each admission, probability of paying for itself. hospitals in integrated systems receive no additional revenue when patients are transferred from nursing For integrated systems, where margin and revenues are homes. To the contrary, their costs increase due to the less pertinent factors in assessing the business case for higher expense of acute care versus nursing home days possible interventions, the benefits of avoided inpatient or more costly out-of-network hospital per diem charges deaths can be appreciated as fewer inpatient days. By when beds are full at the acute care site. avoiding preventable transfers the health system is able to keep more acute care beds available and reduce the Looking forward, the PPACA includes incentives for likelihood of needing to use out-of-network beds. physicians to join forces in accountable care organizations (ACOs) which, like today’s integrated health systems, will Fewer Readmissions have a patient-centered revenue structure. Since these Preventing nursing home transfers also can help organizations are intended to accept risk for the total cost reduce 30-day readmissions to acute care hospitals. of care received by a population of patients, ACOs will The PPACA includes provisions that will change the be positioned to better coordinate patient care and reduce way the Centers for Medicare and Medicaid Services unnecessary hospital admissions. If ACOs provide high (CMS) compensates hospitals for these readmissions. quality care and reduce costs to the health care system, Beginning in FY 2013, CMS will penalize hospitals that they retain a portion of the savings. have excessive readmission rates for patients with three common conditions: heart failure, acute myocardial Fewer Inpatient Deaths infarction (AMI), and pneumonia. In FY 2015, the list Hospitals typically lose money on most inpatient deaths, of monitored conditions will expand to include patients which tend to have lengths of stay and costs that are three with several other conditions often found in nursing times greater than those of the overall hospital population. home patients. Additionally, as the primary payer for the vast majority of patients who die in acute care facilities, Medicare uses a The fiscal impact of these changes to reimbursement fixed reimbursement system that is typically insufficient could be significant and serve as powerful motivators to cover hospitalization costs. Therefore, with every to prevent avoidable readmissions. Starting in FY 2013, avoided inpatient death, the hospital can expect to avoid CMS is empowered to withhold up to 1 percent of a net loss. total Medicare payments when individual hospitals exceed the expected number of readmissions for any of While there will be tremendous variation in costs and the monitored conditions. The penalty cap increases to revenues for terminal admissions across cases and sites, 2 percent of payments in FY 2014, and up to 3 percent a hospital should be able to recoup its investment in in FY 2015 and thereafter. a program like PREPARED. Hospitals can measure the degree to which they would benefit from avoiding inpatient deaths by evaluating their net margin (net Be Prepared: Reducing Nursing Home Transfers Near End of Life  |  7 An intervention like PREPARED could be one tool for Weighing “The Stick” The formula for determining Medicare penalties is hospitals to use to prevent avoidable readmissions. Since based on the number of patients with the applicable nursing home residents have multiple chronic conditions condition, the base payment CMS made for those like the cardiovascular and lung diseases that are targeted patients, and the percentage of readmissions that were for monitoring and are at risk for multiple acute care above the expected rate. For example, if a hospital sees 100 patients with pneumonia, and on average is stays in the last months of life, the PREPARED approach compensated $5,000 for each case, and the number of could help protect hospitals from excessive readmission readmissions was 25 percent higher than expected, then rates and the accompanying financial penalties. the penalty for these cases would be: 100 3 $5,000 3 0.25 5 $125,000. Factors that Support Hospital Success For the purpose of this example, assume the hospital with PREPARED had the exact same incidence of excessive readmissions The likelihood of an intervention like PREPARED to for heart failure and AMI patients, meaning they face an excessive reimbursement penalty of $375,000. The achieve revenue-neutral or improved performance at portion of that $375,000 the hospital is at risk for would a particular hospital is enhanced when the following depend on the total amount of compensation the site environmental variables exist: received from CMS. If the hospital received $35 million in total payments from CMS in FY 2013, their penalty ◾◾ The health system/hospital is at risk for all patient would be capped at $350,000, or 1 percent of the health care costs, regardless of treatment setting. total revenues they received from CMS. However in FY 2014, when the cap moves to 2 percent of total ◾◾ A relatively small number of nursing homes (four CMS payments, that site would be subject to the to six) are responsible for a sizable proportion of entire $375,000 penalty, if there were no change in the incidence of readmissions. transfers to the acute care facility, in particular transfers that occur in the last year of life and end in death. ◾◾ The hospital has a history of experiencing negative The specter of reduced compensation for Medicare cases margins (losses) on inpatient deaths. has made efforts to avoid preventable readmissions an organizational priority for many health systems and ◾◾ The hospital has an active inpatient palliative care hospitals. These changes in readmission compensation program. In addition to ensuring the availability are putting community hospitals in a position similar to of skilled providers who could serve as educators, that of integrated systems, where risk for health care costs developing relationships with nursing home staff does not end at the time of hospital discharge. Ensuring would improve the efficacy of ACP begun in the that patient preferences are appreciated and adhered to inpatient setting. The hospital-based clinician in post-discharge settings takes on new importance when educators would share knowledge of palliative care readmissions put the hospital at risk for losses, or greater and ACP principles with nursing home staff, while losses, on Medicare cases. Revenues are still linked to learning what nursing home staff need from acute services, but those services would be offered at a loss, or a care sites to ensure continuation of ACP. greater loss, if the overall number of readmissions exceeds the expected level. Given that private payers commonly model reimbursement after CMS practices, it is highly likely that these changes will be mirrored in other plans as well. 8  |  California HealthCare Foundation Conclusion Endnotes The PREPARED project serves as a credible model for 1.A National Institute of Aging study found that 37 percent future collaborative efforts between hospital systems of nursing home resident hospitalizations are potentially and nursing homes. Improving nursing home staff avoidable. “Avoiding Unnecessary Hospitalizations For competence and confidence in managing advance care Nursing Home Residents,” ISSN: 1524 – 7929 Volume: planning issues, with particular emphasis on use of 15, February 01 2007. POLST as a tool for ensuring compliance with patient 2.California HealthCare Foundation Issue Brief, “Improving wishes, can improve the quality of care delivered to frail, End-of-Life Care in California’s Nursing Homes,” The elderly residents. The project brought about modest HSM Group, Ltd., September 2008. www.chcf.org changes in area nursing homes and laid the groundwork 3.Project conducted by Catherine McGregor, M.S.N., R.N.; for further advancements. The lessons learned and contact cate_mcgregor@att.net for details. progress to date should be instructive and encouraging to communities considering similar efforts. 4.The Coalition for Compassionate Care of California is a partnership of regional and statewide organizations Furthermore, a program such as PREPARED can dedicated to the advancement of palliative medicine and convey operational and fiscal benefits to sponsoring end-of-life care. www.coalitionccc.org hospitals, with return on investment expected to increase 5.Participating hospital systems included Catholic Healthcare as adjustments to CMS reimbursements take effect in West, Kaiser Permanente, and Sutter Health, with coming years. In particular, as hospitals assume increased University of California, Davis Health System providing risk for readmissions, interventions such as PREPARED some staff support during the last cohort. that ensure quality end-of-life care in the post-discharge 6.Participating nursing homes: Asbury Park Nursing and period should be a cost-effective and attractive option for Rehabilitation Center; Casa Coloma Health Care Center; hospitals. College Oaks Nursing and Rehabilitation Center; Eskaton Care Center Fair Oaks; Eskaton Care Center Greenhaven; Eskaton Care Center Manzanita; Eskaton Village, About the Authors Carmichael; Folsom Convalescent Hospital; Foothill Kathy Glasmire is associate director of the Center for Oaks Care Center; Gramercy Court, Horizon West – Healthcare Decisions. Kathleen Kerr is senior research analyst Carmichael (formerly Walnut Whitney Care Center); in the Department of Medicine, University of California, Horizon West – Lincoln (formerly Lincoln Manor); San Francisco. Horizon West Sacramento Center for Subacute Care (formerly Heritage Care Center); Horizon West - Sierra About the F o u n d at i o n Hills (formerly Sierra Hills Care Center); ManorCare The California HealthCare Foundation works as a catalyst to Health Services; Mission Carmichael Health Care Center; fulfill the promise of better health care for all Californians. Oak Ridge Healthcare Center; Sutter Oaks Nursing We support ideas and innovations that improve quality, Center – Midtown. increase efficiency, and lower the costs of care. For more information, visit us online at www.chcf.org. 7.Evaluation for internal use conducted by David Dosa, M.D., M.P.H.; Pedro Gozalo, Ph.D.; Joan M. Teno, M.D., M.S.; Center for Gerontology and Health Care Research, Warren Alpert School of Medicine of Brown University. July, 2010. Be Prepared: Reducing Nursing Home Transfers Near End of Life  |  9 8.A reduction of .73 per facility per month when adjusted for months with influenza activity. Brown University evaluation. 9.Change in hospitalizations per facility per month: Cohort 1, +2.63; cohort 2, -0.67; cohort 3, -4.51). Brown University evaluation. 1 0.DNH orders for cognitively impaired nursing home residents in Sacramento’s Hospital Referral Region (HRR#7) steadily increased from 2000 to 2004; by 2004 one in four persons with advanced dementia had a DNH order, a trend not seen in other California HHRs. Brown University evaluation. 1 1.Dartmouth Health Care Atlas data regarding care delivery during the last 2.5 years prior to death shows that between 2000 to 2003, the Sacramento health care region provided far fewer hospital days (9.85 days) to decedents during the last six months of life than the national (11.68 days) and state (11.75 days) averages. The Sacramento region provided more intensive care days per decedent (3.32 days) over the last six months of life then the national average (3.24) but significantly less then the California average (4.64). Brown University evaluation. 10  |  California HealthCare Foundation