How Memory Care Programs Can Reduce Hospitalizations for Residents with Dementia

The high rate of hospitalizations for residents with dementia raises complex issues. A research article published by the Alzheimer’s Association reveals that although nursing home residents with dementia are at a high risk for hospital transfer, many of those transfers are avoidable. The article sheds light on the need for enhanced awareness and specific discussions and documentation to ensure resident and family care desires are met while also reducing Medicare and Medicaid costs.

Research Article Finds Prevalence in Avoidable Hospital Transfers

Kimberly Powell, PhD, RN, FAMIA, Assistant Professor, University of Missouri, Sinclair School of Nursing

The article, published in October 2024, encompassed the analysis of data collected from 2016 to 2020 as part of the Missouri Quality Initiative CMS Innovations Center demonstration project. Kimberly Powell, leading author of the article, explains that the study is different from previous studies. “In many studies on avoidable transfers of nursing home residents, “avoidable” is determined based on the diagnosis of the resident once they get to the hospital,” she says. For example, if a resident goes to the hospital and is diagnosed with a UTI, that is often categorized as an avoidable transfer.

“We don’t know the context of that clinical situation nor the decision making,” says Powell. “There could have been something going on even though the diagnosis alone leads us to believe it could have been treated in the nursing home; we just don’t know.”

The study examined not only quantitative data, but also took into account qualitative data, such as the context and what was happening in the situation. “Some of the predictors from quantitative data are age and state of dementia,” she says. But the study also examined contextual factors, such as changes in resident condition, the resources available in the nursing home, and what matters to the resident and their family.

The study found that, over a five-year period, nursing home residents with an Alzheimer’s disease or related dementia diagnosis were 1.22 times more likely to have an avoidable hospital transfer than residents with other diagnoses.

These transfers have significant impacts on residents. They not only result in the physical stress of the move, but also emotional stress. They also consume significant resources, including the resources needed to move the person to the hospital and the financial cost of the hospital stay. “It’s estimated that preventative transfers cost our healthcare system about $2.6 billion annually,” says Powell.

Strategies to Reduce Avoidable Hospital Transfers

Advance care planning for residents with Alzheimer’s and dementia plays a key role in hospitalizations. The study examined residents’ CPR status, indicating whether they wanted to be a full code or DNR. “Those are some of the conversations that go into advance care planning,” says Powell. “What’s interesting, and what we found is, those conversations need to happen more often and they need to be more nuanced.”

While discussions might include talk of categories of CPR status, there’s much more involved that needs to be discussed. “One grey area is the notion of a do not transfer and do not hospitalize order,” says Powell. “We’re just not using that enough.” Powell believes that events, such as when a resident moves into a nursing home, may prompt a conversation about advance care planning and whether they want to be resuscitated. But with a progressive disease like Alzheimer’s, there aren’t enough follow-up conversations as the disease progresses. “It’s so important because especially with a neurocognitive disease like this, over time the resident will lose their ability to communicate,” says Powell. If family members know the resident’s wishes, they can advocate for the resident.

Those advance care planning decisions also need to be documented so that they’re accessible to all of the staff. When decision-making about a possible transfer takes place, it could be the middle of the night, and a nurse might not be familiar with the resident. Powell also highlights the importance of ensuring that nursing home staff have the skills and experience needed to make such complicated decisions, and that they have necessary supports in place.

Staffing ratios matter, too. The study found that nurses’ comfort level and experience is important, but there is also a relationship between staffing and care that can impact transfers.

When it comes to training staff, Powell believes telehealth may be a valuable support, and is currently doing another study on telehealth in nursing homes. “I’m really interested in the availability for staff training that could happen as the result of using telehealth and conferencing,” she says. This technology could help ensure that staff have the skills, experience, and supports needed to help prevent avoidable transfers and deliver quality care to residents with Alzheimer’s and dementia.

Ultimately, Powell encourages nursing homes to center care around the resident’s care goals. “That should be at the core and the one thing that drives all of our decision making,” she says. The resident’s care goals should not only guide whether they should be transferred, but should really impact every aspect of their care.

“Just keep what matters at the forefront of decision making,” Powell recommends. “At the end of the day, that’s what is driving our decisions – not convenience, not cost. We’re honoring this person and making sure that our care is aligned with principles of dignity.”

Paige Cerulli

Paige Cerulli is a contributing writer to i Advance Senior Care.