Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity

Abstract

Background Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Results Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions

“…We also restricted our analyses to the first SNF stay, which limits our ability to study differences in care provided by ACOs and Non-ACOs for the specific population of patients who require repeated transfers17 between nursing facilities and acute-care hospitals. Although we did account for important case-mix components that have been previously noted to be more common in patients requiring repeated transfers (eg, age, race), our claims-only based study was unable to capture other important characteristics (eg, code status, changes in goals of care, patient or family requests) that require qualitative methods to assess 17. Finally, ACO-attributed patients may select higher-quality SNFs, with more experienced nurse practitioners delivering care for reasons unrelated to their attribution status (eg, fewer comorbidities).…”

“…Our use of only the index SNF stay was motivated by concerns that patients with repeated SNF stays would be more likely to be complex in characteristics not well described in claims data. For example, although we did account for important case-mix components that have been previously noted 17 to be more common in patients requiring repeated transfers (eg, age, race), our claims-only based study was unable to capture other important characteristics (eg, code status, changes in goals of care, patient or family requests) that have required qualitative methods to assess.…”

“…Although we did account for important case-mix components that have been previously noted to be more common in patients requiring repeated transfers (eg, age, race), our claims-only based study was unable to capture other important characteristics (eg, code status, changes in goals of care, patient or family requests) that require qualitative methods to assess. 17 Finally, ACO-attributed patients may select higher-quality SNFs, with more experienced nurse practitioners delivering care for reasons unrelated to their attribution status (eg, fewer comorbidities). Our findings in our second analysis regarding improved outcomes for ACO-attributed patients may, therefore, not necessarily reflect gains from coordination efforts by ACOs.…”

Nursing Home Use of a Resident and Family Decision Guide to Reduce Hospital Readmissions: A Quality Improvement Project

“…Consistent with previous researchers, our study found that family insistence on transferring the resident to the hospital was an issue, 13 including repeat transfers that were potentially avoidable. 14 Because this Decision Guide originated from a person-centered research approach focused on resident and family perspectives 16 regarding their understanding and misunderstandings about resident transfers and nursing home care, it is unlike other clinically focused tools for staff use, such as the INTERACT Tools 11 and the newer Avoidable Transfer Tool developed to retrospectively identify factors influencing resident transfers and how to avoid them in the future. 27 Working with residents and family members is integral in reducing readmission rates.…”

“…12 Notably, of the 650 hospital transfers that were evaluated during this project, 111 (17%) were due to resident and family insistence, 13 a previously neglected factor contributing to these preventable readmissions that occur relatively frequently. 14 To address this heretofore neglected aspect of avoidable hospitalizations, we adopted a person-centered research approach 15,16 beginning with a series of 271 in-depth interviews with 96 nursing home residents, 75 families, and 100 staff and providers from 18 nursing homes in South Florida. Based upon the interview results, an interdisciplinary team created an evidence-based decision aid, Go to the Hospital or Stay Here?…”