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

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.