Appropriateness of the Decision to Transfer Nursing Facility Residents to the Hospital

Saliba, Debra; Kington, Raynard; Buchanan, Joan L.; Bell, Robert M.; Wang, Mingming; Lee, Martin L.; Herbst, M.; Lee, Daniel; Sur, Denise K.C.; Rubenstein, Lisa V.

doi:10.1111/j.1532-5415.2000.tb03906.x

Cited by 291 publications

(288 citation statements)

References 72 publications

(98 reference statements)

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“…42 Commentators have questioned the appropriateness of transitions of nursing home residents to hospital, particularly at the end of life. 43,44 Estimates of the proportion of emergency department attendances or admissions that were not in the patients' best interests are as high as 36-40%. In the UK, there is a perception that residents of nursing homes are still sent into acute hospitals to die, 45 and the probability of readmission to hospital within a short period of discharge is considerably higher for nursing home residents.…”

Section: Transitions For Care-home Residentsmentioning

confidence: 99%

Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study

Hanratty

Lowson

Grande

et al. 2014

Health Services and Delivery Research

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BackgroundThe end of life may be a time of high service utilisation for older adults. Transitions between care settings occur frequently, but may produce little improvement in symptom control or quality of life for patients. Ensuring that patients experience co-ordinated care, and moves occur because of individual needs rather than system imperatives, is crucial to patients’ well-being and to containing health-care costs.ObjectiveThe aim of this study was to understand the experiences, influences and consequences of transitions between settings for older adults at the end of life. Three conditions were the focus of study, chosen to represent differing disease trajectories.SettingEngland.ParticipantsThirty patients aged over 75 years, in their last year of life, diagnosed with heart failure, lung cancer and stroke; 118 caregivers of decedents aged 66–98 years, who had died with heart failure, lung cancer, stroke, chronic obstructive pulmonary disease or selected other cancers; and 43 providers and commissioners of services in primary care, hospital, hospice, social care and ambulance services.Design and methodsThis was a mixed-methods study, composed of four parts: (1) in-depth interviews with older adults; (2) qualitative interviews and structured questionnaire with bereaved carers of older adult decedents; (3) telephone interviews with care commissioners and providers using case scenarios derived from the interviews with carers; and (4) analysis of linked Hospital Episode Statistics (HES) and mortality data relating to hospital admissions for heart failure and lung cancer in England 2001–10.ResultsTransitions between care settings in the last year of life were a common component of end-of-life care across all the data sets that made up this study, and many moves were made shortly before death. Patients’ and carers’ experiences of transitions were of a disjointed system in which organisational processes were prioritised over individual needs. In many cases, the family carer was the co-ordinator and provider of care at home, excluded from participation in institutional care but lacking the information and support to extend their role with confidence. The general practitioner (GP) was a valued, central figure in end-of-life care across settings, though other disciplines were critical of GPs’ expertise and adherence to guidelines. Out-of-hours services and care homes were identified by many as contributors to unnecessary transitions. Good relationships and communication between professionals in different settings and sectors was recognised by families as one of the most important influences on transitions but this was rarely acknowledged by staff.ConclusionsDevelopment of a shared understanding of professional and carer roles in end-of-life transitions may be one of the most effective ways of improving patients’ experiences. Patients and carers manage many aspects of end-of-life care for themselves. Identifying ways to extend their skills and strengthen their voices, particularly in hospital settings, would be welcomed and may reduce unnecessary end-of-life transitions. Why the experiences of carers appear to have changed little, despite the implementation of a range of relevant policies, is an important question that has not been answered. Recommendations for future research include the relationship between policy interventions and the experiences of end-of-life carers; identification of ways to harmonise understanding of the carers’ role and strengthen their voice, particularly in hospital settings; identification of ways to reduce the influence of interprofessional tensions in end-of-life care; and development of interventions to enhance patients’ experiences across transitions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Transitions For Care-home Residentsmentioning

confidence: 99%

Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study

Hanratty

Lowson

Grande

et al. 2014

Health Services and Delivery Research

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“…Hospitals are generally not the preferred location for the site of death among the frail elderly, and in many cases hospitalizations are potentially avoidable. 21 Hospice enrollment is known to be associated with lower hospital use for dying NH residents 9 and previous research has shown that 33.5% of NH residents dying within 30 days of a SNF admission die in a hospital. 22 Unknown is how hospice use (and timing of referrals) may differ when SNF admission occurs near death and how hospice use subsequent to SNF may influence the probability of a terminal hospitalization.…”

mentioning

confidence: 99%

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Miller

Lima

Looze

et al. 2012

Journal of Palliative Medicine

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Background: Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. Methods: This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n = 99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital. Results: Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short ( £ 7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025). Conclusions: Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.

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“…1-3 Avoidable hospitalizations are also common among long-stay residents of nursing homes (see graphs). [2][3][4] In many clinical situations, more nursing home residents with acute changes in their clinical condition could be cared for safely and effectively without having to be transferred to a hospital. But the causes of preventable hospitalizations in this population are complex.…”

mentioning

confidence: 99%

Reducing Unnecessary Hospitalizations of Nursing Home Residents

2011

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Appropriateness of the Decision to Transfer Nursing Facility Residents to the Hospital

Cited by 291 publications

References 72 publications

Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study

Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Reducing Unnecessary Hospitalizations of Nursing Home Residents

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