Utilization of Hospice and Palliative Care Among Patients With Mental Illness: A Retrospective Cohort Study

Background: Individuals with mental illness (MI) experience premature mortality and health disparities, yet little is known about their access to hospice and palliative care. Objective: To examine hospice enrollment, timing, length of stay, and palliative care utilization among Medicare decedents with mental illnesses. Design: Retrospective cohort study using 100% Texas Medicare claims data (2016–2022). Participants: Texas Medicare beneficiaries aged ≥ 20 years who died between 2016 and 2022, with chronic life-limiting medical conditions identified 13–24 months prior to death (N = 288,566). Measurements: Outcomes included hospice enrollment, hospice length of stay, timing of first hospice enrollment, and palliative care receipt. Mental illnesses were identified using ICD-10 codes. Results: Among 288,566 decedents, 120,695 (41.8%) had at least one mental health diagnosis 13–24 months prior to death; the remaining 167,871 (58.2%) had no mental health diagnosis and constituted the comparison group. Compared with controls, beneficiaries with schizophrenia and related psychotic disorders (SRPDs) had longer hospice stays (median 43 vs. 16 days), higher adjusted hospice length of stay (adjusted coefficient 0.26 [95% CI, 0.21–0.31]), and a temporally heterogenous enrollment pattern: a lower likelihood of enrollment within 180 days of death (aHR, 0.88 [95% CI, 0.85–0.91]) but a higher likelihood of enrollment more than 300 days before death (aHR, 2.74 [95% CI, 2.37–3.17]). Neurocognitive conditions were the primary hospice diagnosis for 55.1% of patients with SRPDs versus 22.8% of controls. Despite longer hospice stay, patients with SRPDs had lower odds of receiving a palliative care consultation (aOR, 0.90 [95% CI, 0.85–0.96]). Conclusions: Mental illnesses were associated with complex hospice utilization patterns characterized by longer length-of-stay, higher likelihood of enrollment far from death, lower likelihood of enrollment within 180 days before death, and lower palliative care consultation use in some groups.