Be Prepared: Reducing Nursing Home Transfers Near End of Life

Kathy Glasmire
Kathleen Kerr, Partner, Transforming Care Partners


This is archived content, for historical reference only.

Nursing home residents too often are hospitalized during the last weeks and months of life, resulting in unnecessary suffering and the potential for increased health care costs.

A recent regional initiative, the PREPARED project, sought to reduce such transfers by improving advance care planning, including use of Physician Orders for Life-Sustaining Treatment (POLST). The intervention included hospital-provided clinician educators assigned to nursing homes to offer education, role modeling, and coaching of key staff.

An independent evaluation of the PREPARED project showed a statistically significant increase in the nursing home as the site of death for residents who died, and a modest reduction in hospitalizations from 9.6 per month per facility to 8.9. There was a 6 percentage point increase in family members’ overall rating of their dying loved one’s quality of care and a 13 percentage point decrease in the number of family members who thought that their dying loved one was not always treated with respect.

The evaluation identified a number of factors that contributed to progress in certain facilities, including:

  • Sustained administrative support and leadership
  • Facility advance care planning champions and involved physicians
  • A focus on quality improvement
  • Opportunities for resident and family education

The complete issue brief with the evaluation findings is available as a Document Download. More information on POLST is available at the link listed under Related CHCF Pages.

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