An authority on long-term care offers a targeted approach that could help hospitals get the most bang out of their efforts to reduce unnecessary hospitalizations and readmissions.

Nursing home residents who visit the emergency department (ED) represent a prime target for hospital admission reduction efforts, says Joseph G. Ouslander, MD, senior associate dean for geriatric programs, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla.

Ouslander’s recommendation is based on three facts:

  • More than half of all hospital admissions and readmissions begin in the ED, according to a February 2006 statistical brief.
  • Nursing home residents who have an ED visit are highly likely to be hospitalized, according to an October 2011 study in the Journal of the American Geriatrics Society:
    • In 2008, 48 percent of the 9.1 million ED visits by nursing home residents resulted in hospitalization, compared to only 13 percent of ED visits by non-nursing home residents.
  • More than 70 percent of potentially preventable hospitalizations start in the ED, according to the 2006 statistical brief cited above.

A Two-Step Framework

Given these facts, Ouslander suggests that hospitals work collaboratively with their local nursing homes to develop and track a set of quality measures for all nursing home patients who are transferred to the ED. He offers this framework to get started:

  • Track all unplanned hospital admissions
  • Track admissions or readmissions for specific diagnoses and conditions that are associated with potentially preventable hospitalizations:
    • Altered mental status or delirium
    • Cellulitis
    • Congestive heart failure
    • Chronic obstructive pulmonary disease
    • Dehydration/electrolyte imbalance
    • Gastrointestinal conditions, including nausea, vomiting and diarrhea
    • Pneumonia/respiratory infection
    • Sepsis
    • Urinary tract infection

More Improvement Opportunities

Ouslander also suggests establishing joint quality improvement initiatives and interdisciplinary teams to review:

  • Clinical information from nursing home discharge transfer forms to determine whether the transfer was preventable
  • Data about adherence to clinical practice guidelines for medical conditions associated with potentially preventable hospitalizations in nursing homes as well as in the ED and the hospital.

Analysis of these data should help hospital leaders identify opportunities for reducing unnecessary hospitalizations for nursing home residents, says Ouslander, who is also past president and board chair of the American Geriatrics Association. This may involve collaborating with nursing home staff or changing ED processes.

For example, the pressure on ED physicians to move patients quickly through the ED may lead to unnecessary admissions. “Emergency room physicians and nurses are tasked with doing things quickly. They are there to see a problem and make a judgment about it, so if they are under a lot of time pressure, they have no choice but to take complicated patients and just admit them,” he says.

An Important Target

Avoiding unnecessary hospitalizations for frail elderly patients is not just good for the hospital’s bottom line; it is also best for patients’ health status, Ouslander says. “The majority of admissions of older people are appropriate and necessary for safe care. But there’s a certain proportion of them that are not, and they lead to a whole variety of complications that affect peoples’ ability to function and quality of life,” he says. “That’s what we need to target. I truly believe that by working together to reduce these unnecessary hospitalizations, we can improve care, reduce complications, and reduce costs.”

Lola Butcher is a freelance writer and editor based in Missouri.

Interviewed for this article: Joseph G. Ouslander, MD, is project director, INTERACT, and senior associate dean for geriatric programs, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla. (  

Learn more about nursing home readmissions in the HFMA Leadership article, Nursing Homes and Hospitals INTERACT to Reduce Readmissions.

Discussion Starters

Forum members: Please add your insights, questions, and comments about this article on the CFO Forum’s LinkedIn discussion board:

  • What is your health system’s strategy for reducing potentially avoidable admissions and readmissions?
  • In your health system, what percentage of admissions start in the ED?