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OBJECTIVES We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN Cross‐sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. Setting Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS A total of 5168 residents with a median age of 82 years. MEASUREMENTS Data from 3946 MOQI‐adapted ACTs. RESULTS A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61‐3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38‐3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33‐3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17‐7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9‐25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46‐.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54‐.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68‐.93; P = .003). CONCLUSION Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953–1959, 2019

Background: Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse-led models of care focusing on improving in-house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals.Franziska Zúñiga and Raphaëlle-Ashley Guerbaai shared first authorship.

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs’ discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.