Injuries, infections, behavioral incidents and family insistence often drive hospital admissions among nursing home residents, and a new study finds many of those transfers may be unavoidable.

The findings, set to be published in July’s Journal of Nursing Care Quality, highlight the challenges faced by 16 Missouri nursing homes participating in a Centers for Medicare & Medicaid Services-backed initiative to reduce hospitalizations.

A team of advanced practice nurses modeled best practices and implemented several quality improvement measures over a 20-month period. The buildings managed to reduce hospitalizations by 30% overall, but the interventions only netted a 17% reduction in unavoidable transfers.

In 2018, CMS began docking reimbursement by up to 2% for SNFs with poor 30-day readmission rates back to hospitals. The study calls into question how much facilities can improve their rates based on quality care alone.

“The reality is that not all hospitalizations can be avoided, and payers realize this,” lead author Amy Vogelsmeier, Ph.D., R.N., told McKnight’s. “The issue however for nursing homes is that the vast majority of hospitalizations can be avoided. So by focusing on those, the overall numbers of hospital transfers can be greatly reduced and penalties can be minimized.”

In some cases in the Missouri study, residents called 911 for an ambulance without alerting staff; in others, families insisted their loved one be removed from hospice and sent to a hospital for surgical interventions. Of equal concern was patient denial of treatments such as dialysis, followed by later demands for hospitalization.

Ensuring that residents complete advanced directives may help address some of those issues.

“Nursing homes will continue to face accidents and inference, which places more impetus on their obligation to investigate, understand and mitigate underlying causes of transfers that might otherwise be avoided,” said Vogelsmeier, associate professor at the University of Missouri Columbia’s Sinclair School of Nursing. “This is why advance directives are so critical. They not only help the resident express their wishes but help bring families to the table.”

Lack of trust may also be an issue when family members demand a hospital trip. The researchers recommended nursing home leaders or medical directors educate families about their in-house abilities.