Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses’ assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide “the power of the visual” permitting virtual assessment for the off-site physician, validation of nursing assessment, “real time” assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.

By 2030, it is projected that 40% of all US deaths will occur in nursing homes (NHs). 1 Despite an estimated $136 billion spent each year, NH care has been associated with poor symptom control, low family satisfaction, and burdensome and unnecessary care transitions in the final months of life. [1][2][3] Little is known about this vulnerable population's specific palliative care (PC) needs. As part of a PC quality initiative, we sought to identify which NH residents were eligible for PC services, describe their characteristics, and better understand resident and family perceptions regarding symptoms and quality of life.Methods | Between January and May 2015, all 228 residents in 3 northern California NHs were screened for PC eligibility via staff interview and medical record review using the INTER-ACT (version 3.0; MED-PASS) tool, Identifying Residents Who May Be Eligible for Hospice or Palliative Care/Comfort Order. 4 Research assistants abstracted medical record and Minimum Data Set (MDS) data for all PC-eligible residents (n = 157). A convenience sample of PC-eligible cognitively intact residents (n = 17) and their families (n = 28) were administered the Quality of Life at the End of Life (QUAL-E) instrument and completed semistructured interviews. Only the QUAL-E findings are presented herein. The University of California, San Francisco, institutional review board deemed this to be quality improvement activity and did not require review.

The goal of providing the highest quality care for residents is the focus of the nursing home community. However, escalating service demands and limited resources constitute significant challenges to achieving this goal. This report summarizes the findings of an effort to assess the need for palliative care services in nursing homes and to identify successful models of palliative care service delivery in these settings.