Published On: 07-01-2020

Across studies, the risk of hospital transfer for nursing home residents is highest for people without documented advance directives and for people with chronic health conditions (eg, diabetes and congestive heart failure), mental health conditions (eg, depression), and limited functional abilities. Care transitions can be disruptive, distressing, and potentially harmful for residents particularly when continuity of care is impacted by ineffective communication, medication errors, and lack of awareness of advance directives. Although family engagement in care transitions is important, nursing home staff report feeling pressured by family members to transfer their resident to the hospital, which can result in unnecessary hospital transfers. Similarly, although having a written advance directive is associated with fewer hospital transfers and subsequent admissions, this alone does not guarantee the directive will be honored when needed. Health care staff may be unaware of the presence of advance directives during medical emergencies. Previous research highlights that care transitions can be improved by involving residents and their family in decision-making, discussing advance care plans before medical emergencies, and improving communication between providers, family members, and residents.

While previous studies investigated care transitions between nursing facilities and hospitals, only one examined transitions from the nursing home to the hospital and back, and none examined the latter experience exclusively from the resident perspective. This study contributes to what is known about resident perspectives of care transitions from the nursing home to the hospital and back by exploring resident perspectives of communication prior to hospital transfer, whether choices for care were honored, family engagement during and after the transfer, and their overall experience with the hospital transfer.

Canada, K. E., Galambos, C., Pritchett, A., Rollin, L., Popejoy, L., Vogelsmeier, A., & Rantz, M. (2020). Transitions of care: Perspectives of patients living in long term care. Journal of Nursing Care Quality, 35(3), 189-94.

View the PDF