Improving Transitional Care and Reducing Hospitalization for Nursing Facility Residents

In JAMA Network Open, Birtwell et al¹ conducted a careful meta-analysis of controlled studies that examined the association of transitional care interventions with reduction of hospitalization and other adverse outcomes for individuals 65 years and older who reside in long-term care facilities (LTCFs). The selected studies (n = 15) included a variety of interventions, delivered in multiple countries, particularly the US and Australia, and incorporated 32 722 individual patients. The authors correctly highlight the serious medical, human, and financial costs of having persons with serious chronic health problems and frailty moving back and forth between health care settings.

The most compelling finding is the 1.7-fold relative reduction in the likelihood of hospitalization with a transitional care intervention. This should motivate us to work harder on solutions to an ongoing problem. The findings in this study highlight 2 key themes: (1) the complexity of this serious problem and the intricacy of its potential solutions and (2) the likelihood that with concerted effort, adverse events can be reduced.

For broader context, Australia has a national program of aged care that has produced many effective innovations,² providing examples of what is possible when resources are systematically focused on the problem at hand. Still, despite the more impressive reductions in hospitalizations seen in the included Australian transition studies, the subanalyses in this meta-analysis did not show country of origin to be a significant contributor to the overall result.

There was considerable heterogeneity across the interventions, signaling the complexity of the problem, and also making for more difficult comparisons. Notably, despite considerable investment, the largest US study,³ a multicenter investigation with 85 voluntarily participating nursing homes and 36 717 residents, demonstrated that an intervention combining the INTERACT (Interventions to Reduce Acute Care Transfers) communication tool with staff training as methods was not effective at preventing hospital admissions. However, another intervention, the Missouri Quality Initiative (MoQI)⁴—which spanned 16 facilities, involved clinical information continuity, and included structured quality improvement efforts also based on INTERACT in addition to placement of an advance practice nurse at each facility to help with patient care and process improvement—reduced hospital use by 30%. Ouslander et al⁵ reported on root causes of LTCF resident hospitalization in a sample of cases from the INTERACT study. The causes notably included family preference in 16%; and hospitalizations were thought to be preventable by earlier recognition and intervention at the facility in 23%.

Success factors and barriers were codified by Tappen et al⁶ in the comprehensive INTERACT trial, in which they repeatedly interviewed staff at 71 participating facilities regarding barriers to implementation. Six major barriers to implementation were identified: the magnitude and complexity of the needed change in care process (35%), instability of facility leadership (27%), competing demands (40%), stakeholder resistance (49%), scarce resources (86%), and technical problems (31%). Six facilitating strategies were also reported: organization-wide involvement (68%), leadership support (41%), use of administrative authority (14%), adequate training (66%), persistence and oversight on the part of the champion (73%), and unfolding positive results (14%).⁶

During a span of decades, experts on care transitions across multiple care settings, such as a large workgroup organized by Naylor et al 6 years ago,⁷ have systematically categorized key elements for improved transitional care, specifically patient engagement, caregiver engagement, management of medical complexity and medications, patient education, caregiver education, focus on patients’ and caregivers’ well-being, care continuity, and accountability.

Successful local and regional reports such as the MoQI seem to suggest that a focused multilateral effort organized at a local institutional and community level is likely to be the most successful approach. In the MoQI, improved care process was augmented by adding a clinician who focused on problem solving at the facility level and provided for timely care and continuity. In addition, there must be systematic efforts to effectively motivate clinical care teams by way of economic incentives, support systems, and public reporting, which are important enabling factors.

As an academic physician, I am honored by the opportunity to comment. Further, having spent 40 years as a physician longitudinally treating sick patients in the clinic, in their homes, and in nursing homes, I know that improved care transitions and reduced hospital admissions are possible but require hard, committed work by teams of well-trained people focused on this effort. At the end of the day, the foundational elements we should all strive for and insist on include the following: a strong handover to the facility from the hospital; a proactive, properly trained, and engaged care team addressing issues within the facility; and strong communication back to the hospital in the event of a decline in health.

Published: May 4, 2022. doi:10.1001/jamanetworkopen.2022.10200

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Boling PA. JAMA Network Open.

Corresponding Author: Peter A. Boling, MD, 2116 W. Laburnum Ave, Richmond, VA 23227 (peter.boling@vcuhealth.org).

Conflict of Interest Disclosures: None reported.