Nursing home performance in a trial to reduce hospitalizations: Implications for future trials

Joseph G. Ouslander, Bernardo Reyes, Zhiyou Yang, Gabriella Engstrom, Ruth Tappen, David Newman, Peter J. Huckfeldt

Research output: Contribution to journalArticlepeer-review


Background: Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. Design: Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. Participants: Seventy-one NHs that completed the 12-month trial. Intervention: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. Measurements: Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. Results: The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. Conclusion: Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.

Original languageEnglish (US)
Pages (from-to)2316-2326
Number of pages11
JournalJournal of the American Geriatrics Society
Issue number8
StatePublished - Aug 2021

Bibliographical note

Funding Information:
Dr. Ouslander is a full‐time employee of Florida Atlantic University (FAU) and has received support through FAU for research on INTERACT from the National Institutes of Health, the Centers for Medicare & Medicaid Services, The Commonwealth Fund, the Retirement Research Foundation, the Florida Medical Malpractice Joint Underwriting Association, PointClickCare, Medline Industries, and Think Research. Dr. Ouslander serves as a paid advisor to and receives licensing royalties from Pathway Health. Work on funded INTERACT research is subject to the terms of Conflict of Interest Management plans developed and approved by the FAU Financial Conflict of Interest Committee. Drs. Engstrom and Reyes have received support from the Florida Medical Malpractice Joint Underwriting Association and PointClickCare.

Funding Information:
The authors thank the NHs and staff who participated in this project. This work was supported by the National Institutes of Health/National Institute for Nursing Research (1R01NR012936).

Publisher Copyright:
© 2021 The American Geriatrics Society


  • implementation effectiveness
  • nursing homes
  • quality improvement

PubMed: MeSH publication types

  • Journal Article


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