Institutional Special Needs Plans and End-of-Life Outcomes for Nursing Home Residents With Dementia

Importance: Nursing home residents with dementia are often unnecessarily hospitalized at the end of life. Institutional Special Needs Plans (I-SNPs) are a type of Medicare Advantage plan for long-term nursing home residents that use advanced practice clinicians to manage care. Studies have demonstrated the effectiveness of the original and largest I-SNP operated by UnitedHealthcare (UHC), but there has been minimal evaluation of non-UHC I-SNPs, which have driven recent growth, nor specific focus on end-of-life outcomes. Objective: To examine the association of I-SNP enrollment with end-of-life outcomes for nursing home residents with dementia, separately for UHC and non-UHC I-SNPs. Design, Setting, and Participants: This retrospective cohort study used 2010 to 2022 Medicare data on 1.4 million long-stay nursing home residents with dementia who died between 2013 and 2022. Facility-level and patient-level selection bias were addressed with cross-temporal propensity score matching and difference-in-differences models. Both the direct effects of I-SNP enrollment, as well as the indirect (ie, spillover) effects on nonenrollees residing in nursing homes offering I-SNPs were assessed. Variation in these relationships by I-SNP maturity was also examined. Data were analyzed from November 2024 to April 2026. Exposure: Four I-SNP exposure categories: UHC I-SNP enrollment and spillover; non-UHC I-SNP enrollment and spillover. Main Outcomes and Measures: Hospitalization and hospice use in the last month of life. Results: The study cohort included 1 415 265 long-stay nursing home residents with dementia who died between 2013 and 2022. The unadjusted hospitalization rate in the last 30 days of life was 27.7%. UHC I-SNP enrollment was associated with a 9.0-percentage point (pp) reduction in hospitalization (95% CI, -10.3 pp to -7.7 pp) while non-UHC I-SNP enrollment was associated with a 5.9-pp reduction (95% CI, -8.4 pp to -3.5 pp). The spillover effect on nonenrollees in nursing homes offering a UHC I-SNP was a 1.7-pp (95% CI, -2.4 pp to -1.1 pp) decline in hospitalizations; the spillover effect in non-UHC nursing homes was not statistically significant. Similar trends appeared with hospitalization in the last 3 days of life, intensive care unit admission, and mechanical ventilation, but there was no association with hospice use. The reduction in hospitalizations increased in the 3 years after nursing home I-SNP adoption, then plateaued. Conclusions and Relevance: In this retrospective cohort study, I-SNP enrollment was associated with significantly fewer hospitalizations for nursing home residents with dementia at the end of life, with effect sizes larger for UHC vs non-UHC I-SNPs. Plan maturity and volume are likely important factors impacting success.