Journal of the American Medical Directors Association
Original StudyDescribing Transfers Originating Out-of-Facility for Nursing Home Residents
Section snippets
Methods
The full scope of the OPTIMISTIC project has been described in prior literature.17,20,27,30 Data collection for this study occurred between January 1, 2015, and June 30, 2016, by project RNs and nurse practitioners assigned to 19 NHs in central Indiana. There were 1362 direct transfers and 82 community transfers during this time frame. Per Centers for Medicare & Medicaid Services guidelines, eligible long-stay residents lived in the NH for at least 100Ā days and did not opt out of OPTIMISTIC
Results
There were 870 NH residents with transfers of any origin between January 1, 2015, and June 30, 2016, who were included in this study. The majority of these residents were white (72.9%) and female (63.5%). The mean age at first transfer was 77.9Ā years. The mean number of transfers per resident was 1.7 (range 1-12) during this time frame, and 6.3% had been hospitalized in the 30Ā days prior to their initial transfer (TableĀ 1).
Of all the residents with transfers, 62 residents had 82 transfers
Discussion
Reducing potentially avoidable hospital transfers of NH residents is a priority of multiple stakeholders. Interventions such as the OPTIMISTIC clinical model have shown promise in reducing acute care transfers by introducing protocols that respond to and treat acute conditions in the NH, as well as facilitating advance care plan discussions with residents. However, community transfers present additional challenges in that NH staff familiar with the resident's baseline and active medical
Conclusions and Implications
To our knowledge, this is the first publication to describe community transfers in NH residents. Our analysis suggests cardiovascular symptoms are a more frequent reason for community transfers. Future studies could focus on transfers originating at dialysis sessions and may include root cause analyses by clinicians working in other health care settings. In addition, more research is needed on how advance care planning differs in these residents, as well as tailored approaches for residents
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Cited by (0)
Funding sources: Jennifer L. Carnahan was supported by the National Institute on Aging division of the National Institutes of Health (Grant K23AG062797). OPTIMISTIC was supported by the Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (HHS) (Grant 1E1CMS331488). The contents and views expressed in this article are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS, HHS, the US Government, or US Department of Veterans Affairs.,
Conflicts of Interest: Author KTU is the former CEO and Founder of Probari, a business intended to disseminate the OPTIMISTIC clinical care model. The other authors declare no conflicts of interest.