Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC Demonstration Project

Abstract

Objectives To characterize pretransfer on‐site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long‐stay residents transferred for behavioral concerns. Design This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns. Setting NHs in central Indiana were utilized (N = 19). Participants This study included long‐stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers). Measurements The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on‐site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses. Results Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia‐related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses. Conclusion Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns.

Describing Transfers Originating Out-of-Facility for Nursing Home Residents

“…9,27,28 Symptoms at the time of the transfer may play a more important role in identifying avoidable transfers, and there is some evidence that certain symptoms, such as behavioral concerns, may correlate with avoidability of a transfer. 29 Although it is unclear whether this will extrapolate to community transfers, the aim of this analysis was to identify symptoms as modifiable risk factors of potentially avoidable community transfers.…”

Review article: Roles of activities of daily living and frailty assessments for residents of residential aged care services in emergency department transfers: A scoping review

“…At the conclusion of the analysis, no role in decision making about treatment in the ED was reported in relation to frailty or to ADL assessment in 25 of the 34 studies, although the studies referred to ED transfer from RACS 14–20,23–25,27–34,36–40,44,47 . These studies will therefore not be discussed further.…”

“…Thirty-four references were selected after assessment for eligibility by the inclusion criteria as shown in Figure 1, half of which were from North America. 16,20,21,[23][24][25][26][30][31][32]36,[38][39][40][41]43,47 The majority of the patients in the study populations were female, with mean ages over 80 years. The study methods were varied (Table 1) with 20 being prospective.…”

“…The study methods were varied (Table 1) with 20 being prospective. [16][17][18][19][21][22][23][25][26][27][28][29][30]33,34,39,41,42,46,47 A retrospective method was employed in nine 14,15,20,24,35,38,40,43,45 and one had both prospective and retrospective components. 32 Cross sectional methodology was executed in four instances.…”

“…An ADL assessment was referred to in 31 papers (Table 1). The minimum data set (MDS) 18,19,24,26,27,31,32,[36][37][38] was used in 10 studies, whereas the Katz scale 15,16,22,23,30,34,35 was found in seven and the Barthel index 17,28,33,[44][45][46] in six, as well as the Practical Routine Elder Variants Indicate Early Warning for Emergency Department (PREVIEW-ED) tool, 21 the ability for ADL 40 and the Groupes Iso-Ressources (GIRS) 29 in one project each. While ADL function was referred to as part of clinical assessment, a scale was not used in five publications.…”