Nursing Homes Can Avoid Unnecessary Hospitalizations By Talking With Families: Study

New research suggests that many hospital stays for nursing home residents nearing the end of their lives may be unnecessary, and may be avoided if staff maintains good communication with families. 

In a study published this week in the journal JAMA Internal Medicine, researchers from the Yale School of Medicine report that nursing homes often transfer end of life patients to hospitals for unnecessary, and potentially burdensome hospital stays, even knowing the patient will not get better. The findings suggest that these unnecessary expenses may be avoided by communicating the resident’s proper needs to their family members.

The new qualitative study focused on eight Connecticut nursing homes with hospitalization rates in the top or bottom 10% from 2008 to 2010. Facilities were identified using publicly available data. Interviews with key staff members were conducted, including directors of nursing, facility administrators, social workers, physicians, advanced practice clinicians and other staff.

Overall, participants recognized residents were hospitalized for “potentially burdensome care” and also indicated a common set of barriers that made it difficult to avoid transfers to a hospital from a nursing home. Researchers said they were able to find important differences in how the staff at different performing facilities approached the decision of whether to hospitalize a patient or not.

The high-hospitalizing nursing homes described their decision-making process as an “algorithmic process,” and often left difficult choices about hospitalization to family members. Healthcare staff at these facilities found it difficult to tell family members their loved ones were not doing well and would not recover, even if hospitalized.

In comparison, low-hospitalization nursing homes made sure to be involved in the decision. They made decisions on a case by case basis, and described a willingness to disagree with family members. Healthcare professionals at those facilities also said they often tried to change family member’s minds about insisting on hospitalization, which often doesn’t accomplish much for patients at that stage of care.

During the interviews, the staff at those facilities also said at times they held convictions that certain patients should not be hospitalized. The staff also said they felt it was important to help patients and families reach the same conclusion, calling it their responsibility.

Those facilities also avoided decision making algorithms, unlike the high-hospitalizing facilities. They tended to focus on a model that allowed for autonomy and recommendations by experts. In these types of situations, medical staff did not remain neutral and simply allow the care decisions to be made by the patient’s loved ones. Instead, they allowed for disagreements with family members and an exchange of medical information, value, and experiences.

Medical care staff at the low-hospitalizing facilities said this was often difficult to do because it involved “intense” disagreements at times, but they attempted to explain to family members the problems with aggressive hospitalizations; especially if those hospitalizations would not benefit the patient in any way.

The overarching theme was in the low-hospitalizing facilities, the responsibility of hospitalization decision making should be shared among health care staff and family members.

“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,” the researchers determined.

Researchers said another way to address the problem can include using advanced directives. Those would indicate what, if any, types of interventions should be used and what to avoid at the end of life. Decisions that would be made ahead of time include using ventilators, feeding tubes or other mechanical support.

The study’s authors point to previous research which indicates that nursing home facilities with a practice of advanced care planning for end of life or palliative care also had lower rates of terminal hospitalizations.