Avoiding Hospitalizations From Nursing Homes for Potentially Burdensome Care: Results of a Qualitative Study

Nursing home residents are often hospitalized for care that has the potential to be burdensome, in the sense that the risks outweigh the expected benefits.¹ These hospitalizations offer little hope of improving quality of life or changing the course of illness and usually involve residents close to death who are vulnerable to iatrogenic harms. Certain facilities are more successful than others at preventing potentially burdensome hospitalizations. The reasons for their success, however, are poorly understood. We sought to explore the causes of these transfers and identify practices that help facilities avoid them.

We conducted a qualitative study involving Connecticut nursing homes with hospitalization rates in the top or bottom 10% from 2008 to 2010. We identified facilities using publicly available data (http://www.ltcfocus.org) and conducted in-depth, semistructured interviews with key staff members, using a standard interview guide, until theoretical saturation was reached; this occurred after the eighth facility visit and 31 interviews. Transcripts were analyzed according to the principles of grounded theory, using the constant comparative method.²

Interviews occurred at 4 high-hospitalizing and 4 low-hospitalizing facilities and involved directors of nursing (8), facility administrators (7), social workers (6), physicians (2), advanced practice clinicians (5), and other staff (3).

Participants at all facilities recognized that residents were hospitalized for potentially burdensome care and identified a common set of barriers that made it difficult to avoid such transfers (Table 1). There were key differences in how staff at low- and high-hospitalizing facilities approached decisions about hospitalization. Participants at high-hospitalizing facilities described an algorithmic process and tended to leave complex choices about hospitalization to families. Those at low-hospitalizing facilities emphasized their involvement in case-by-case decision-making and were willing to disagree with family members and attempt to change their minds (Table 2).

Participants in this qualitative study of nursing homes with high and low hospitalization rates encountered similar barriers to avoiding potentially burdensome hospitalizations. Staff at low-hospitalizing facilities, however, described a conviction that certain patients should not be hospitalized and felt a responsibility to help patients and families reach the same conclusion. They avoided decision-making algorithms and followed the “enhanced autonomy” model recommended by experts, in which medical personnel do not remain neutral but explore disagreements with patients in an “intense exchange of medical information, values, and experiences.”^3(p766) They acknowledged how hard this was to do.

Our findings suggest that, to reduce potentially burdensome transfers, staff at less successful facilities will need to be encouraged to adopt similar attitudes and practices. How best to accomplish this kind of institutional culture change is unclear. The prevailing approach at the Centers for Medicare and Medicaid Services involves payment reform,⁴ but there is only modest evidence to suggest that financial incentives will change clinician behavior in the nursing home or improve facility quality.⁵ Another strategy, taken by the Interventions to Reduce Acute Care Transfers (INTERACT) program, involves providing written materials to patients and clinicians, but facilities using INTERACT have had limited success in reducing hospitalizations for potentially burdensome care.⁶ While our study adds key information about the behaviors that help nursing homes avoid such transfers, research is needed to understand how to promote these behaviors more broadly.

Our work has several limitations. We performed interviews in Connecticut, which has a high number of nursing home beds per capita. We interviewed an advanced practice clinician at every facility but only a few physicians, who were on-site irregularly.

In summary, there were key differences in behavior toward potentially burdensome hospitalizations at nursing homes with high and low hospitalization rates. Work should focus on developing ways to encourage less successful facilities to adopt practices found at more successful ones.

Corresponding Author: Andrew B. Cohen, MD, DPhil, Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025 (andrew.b.cohen@yale.edu).

Published Online: November 28, 2016. doi:10.1001/jamainternmed.2016.7128

Author Contributions: Dr Cohen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cohen, Fried.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cohen, Knobf.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: Cohen.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Cohen was supported by a training grant from the National Institute on Aging (T32AG1934) and by the Hartford Centers of Excellence National Program at Yale University.

Role of the Funder/Sponsor: The funding sources were not involved in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, and approval of the manuscript.