Diagnoses Associated With Hospitalization of Nursing Home Residents With Severe Functional Impairment and Terminal Illness

Background: Hospitalizations and emergency department (ED) visits can be uncomfortable and burdensome for severely impaired and terminally ill nursing home (NH) residents. Very few studies have examined specific diagnoses associated with these events. Methods: This is a secondary analysis of a trial that implemented a 12-month quality improvement program to reduce potentially avoidable hospitalizations (PAH) and ED visits of NH residents. The Minimum Data Set (MDS) was used to define residents with severe impairment of cognitive and physical functioning and those with terminal illness. Medicare claims data were used to identify hospital diagnoses for all cause hospitalizations (ACH), PAH, ED visits without hospitalization, and potentially avoidable ED visits. Results: Among 6011 severely impaired residents of the 264 NHs, 34% had one or more ACHs, of which one-third met the criteria for PAH, and 18% had at least one ED visit without hospitalization, of which 70% met the criteria for potentially avoidable. Among 5810 residents identified as terminally ill, 14% had at least one ACH, of which 31% were PAH, and 8% had at least one ED visit, of which 80% met the criteria for potentially avoidable. The most common diagnoses associated with PAH were pneumonia and other infections, shortness of breath/respiratory failure, and altered mental status. In the severely impaired group, problems with feeding tubes were the most common diagnoses associated with potentially avoidable ED visits, and in the terminally ill group, it was fall-related trauma. Conclusions and Implications: ACH and ED visits without hospitalization are common among severely impaired and terminally ill NH residents. About one in three ACH in both groups met the criteria for PAH, and 70%-80% of ED visits met the criteria for potentially avoidable. Understanding the specific diagnoses associated with these potentially avoidable events can help target educational and quality improvement efforts to reduce their frequency, risk of hospital acquired complications, morbidity, and costs.