In one of the largest studies of its kind, researchers found that up to 80% of emergency department visits and more than one-third of hospitalizations in severely impaired and terminally ill nursing home residents were potentially avoidable.

Hospitalizations and emergency department (ED) visits can be distressing and costly for nursing home residents – especially those who are severely impaired or terminally ill. Despite their vulnerability, these individuals are frequently transferred to hospitals, even though up to 40% of such transfers over the past 25 years are considered potentially avoidable by health care professionals.

These unnecessary transfers not only cause distress and discomfort for residents and families but also lead to hospital-acquired complications and added costs for the health care system. In the United States, hospital transfers from nursing homes significantly contribute to health care costs, particularly for Medicare, with an estimated $14.3 billion annually. 

Most studies of hospitalizations and ED visits among severely impaired and terminally ill nursing home residents have not examined diagnoses associated with hospitalizations and potentially avoidable hospitalizations in any detail, nor have they separated severely impaired from terminally ill residents.

In one of the largest studies of its kind, researchers from Florida Atlantic University’s Schmidt College of Medicine and Christine E. Lynn College of Nursing, and collaborators, conducted a secondary analysis of data from 264 nursing homes across the U.S. to dive deeper into this issue.

Using information from a randomized trial of the Interventions to Reduce Acute Care Transfers (INTERACT) program, the study identifies the specific medical conditions most frequently linked to hospitalizations, ED visits and those considered potentially avoidable among severely impaired and terminally ill nursing home residents.

Results of the study, published in the Journal of the American Medical Directors Association, reveal that among more than 6,000 severely impaired nursing home residents, one in three experienced a hospitalization – more than one third of which were potentially avoidable. Nearly 20% visited the ED without being admitted, and 70% of those visits were deemed preventable.

Among more than 5,800 terminally ill residents, hospitalizations and ED visits were less common but even more likely to be unnecessary. Notably, 80% of ED visits in this group could potentially have been avoided.

In the severely impaired group, feeding tube complications were the most common reason for these visits, often due to blockages, dislodgement or infections. Transfers related to trauma – largely from falls, including head trauma and fractures – were common among terminally ill residents. And in many cases, deemed preventable. 

The study also revealed that certain diagnoses were frequently associated with potentially avoidable hospitalizations. Among severely impaired residents, urinary tract infections (UTIs), seizures, and low blood pressure (hypotension) were the most common causes of hospital stays that could have been prevented with timely and appropriate care. UTIs, in particular, are widely known to be over-diagnosed and over-treated in nursing home settings, despite clear clinical guidelines recommending treatment only when specific findings are present.

For terminally ill residents, pneumonia, UTIs, acute kidney failure, and heart failure were most often linked to avoidable hospitalizations. Other common diagnoses across both groups included infections, breathing difficulties, and altered mental status.

“The specific diagnoses we identified such as UTIs, pneumonia, and sepsis aren’t surprising, but they highlight some clear, actionable opportunities to improve care,” said Joseph G. Ouslander, M.D., senior author and professor of geriatric medicine, Schmidt College of Medicine. “These are conditions we know how to manage better in nursing homes, using existing guidelines, care paths and preventive strategies. With the right tools and staffing, many of these hospital transfers could be avoided, reducing both resident suffering and unnecessary health care costs.”

While the definition of “potentially avoidable” varies, the findings align with previous studies and underscore the urgent need for proactive care strategies. Many of these hospitalizations could be prevented through clearer care protocols, timely symptom management, and, critically, regular advance care planning.

The researchers say ensuring that residents have documented care preferences and that families understand their options can help avoid crisis-driven decisions and reduce needless transfers. However, barriers such as reluctance to enroll in hospice and financial constraints still pose challenges. Addressing these issues could improve quality of life for residents and free up hundreds of millions in health care spending for reinvestment in other aspects of care.

“To reduce potentially avoidable hospital transfers, we need to strengthen the capabilities of nursing home staff and ensure active involvement from skilled medical directors and clinicians,” said Ouslander. “This isn’t just about individual effort – it requires support from nursing homes, provider organizations and policymakers. We need bold changes, like pragmatic national staffing standards, better-resourced facilities for complex care, and payment models that truly support high-quality, person-centered care for the most vulnerable residents.”

Study co-authors are Gabriella Engstrom, Ph.D., corresponding author and a research assistant professor of emergency medicine, FAU Schmidt College of Medicine; Zhiyou Yang, a data analyst at Massachusetts General Hospital; Bernardo Reyes, M.D., program director, internal medicine, HCA Florida Aventura Hospital; Ruth Tappen, Ed.D., professor and Christine E. Lynn Eminent Scholar, FAU Christine E. Lynn College of Nursing; and Peter J. Huckfeldt, Ph.D., Vernon E. Weckwerth Professor in Healthcare Administration Leadership, Division of Health Policy & Management, University of Minnesota. 

This work was supported by the National Institutes of Health/National Institute for Q5 Nursing Research. 

The study analyzed data from the federally mandated Minimum Data Set (MDS 3.0), which includes assessments of nearly all residents in Medicare- or Medicaid-certified U.S. nursing homes. Researchers focused on a specific subset of nursing home residents with defined clinical and functional impairments, allowing for a more detailed examination of outcomes in this high-risk group. While the findings offer important insights into this vulnerable population, they are most applicable to residents with similar characteristics.

-FAU-