Hospital transfers for nursing home residents with advanced dementia may be reduced by  promoting best practices that integrate palliative care and infection management, according to a new study from the Columbia University School of Nursing and RAND Corp.

Integration of palliative care and infection management at the end of life in nursing homes is a relatively new concept centered on three factors: involvement, advance care planning, and routine practice, according to lead author Andrew W. Dick, Ph.D., of RAND Corp., and colleagues. He and his study team in 2019 said they were surprised to find that although most nursing homes involve patients and caregivers in care planning, fewer facilities report having integrated formalized advance care planning and even fewer have integrated routine practices for dying patients — despite a national focus on advance directives and increased implementation of portable medical orders, or POLST.

In the current study, they sought to evaluate the effectiveness of this integrated care concept on all-cause hospital transfers and hospital transfers due to infection. Approximately 50% of nursing home residents are transferred to a hospital in the last year of life, often due to infections — even though transfers and aggressive treatment often are ineffective and inconsistent with goals of care, the authors explained. 

The study team analyzed nationally representative nursing home survey data (2017–2018), resident data from the Minimum Data Set 3.0, and Medicare inpatient data. Study participants included more than 43,000 U.S. nursing home residents, the majority of whom were in the advanced stages of dementia, congestive heart failure and chronic obstructive pulmonary disease. 

Results showed that the more faithfully a nursing home adhered to best practices in combined palliative care and infection management, the fewer hospital transfers there were for all causes and for infection in residents with advanced dementia.

Best practices also reduced all-cause transfers in residents with COPD, but not transfers due to infection. In contrast, there was no association with either outcome for residents with congestive heart failure.

“Nursing home policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia,” the researchers concluded. “For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at the end of life.”

The study was published in the Journal of Palliative Medicine.