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Objectives: To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns., Design: This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns., Setting: NHs in central Indiana were utilized (N = 19)., Participants: This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers)., Measurements: The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses., Results: Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses., Conclusion: Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns., (© 2020 The American Geriatrics Society.)

Context: Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur., Objectives: Describe nursing facility residents with comfort measures and their hospital transfers., Methods: Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods., Results: Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care., Conclusion: Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)