Why We Created the Guide

Almost one in four people admitted to a skilled nursing facility in the U.S. is rehospitalized in less than 30 days at an estimated cost of $14.3 billion per year. Research has shown that many of these rehospitalizations are avoidable if the change in the resident’s condition is noted soon enough, if treatment can be provided in the nursing home and/or if a resident has advance directives in place.

“Residents and families sometimes insist on transfer despite assurance that they can be cared for in the nursing home,” says Dr. Ruth Tappen, Professor and Christine E. Lynn Eminent Scholar at the Florida Atlantic University College of Nursing. “Their insistence accounts for a substantial proportion of unnecessary transfers.” The idea behind the Guide was that if the residents and families knew what treatment could and could not be provided in their nursing home and had time to think about this question in advance, fewer residents and families would insist on transfer to the hospital when their providers tell them it is not necessary.

To address this issue, the College of Nursing was awarded a grant by the Patient-Centered Outcomes Research Institute (PCORI) to develop and test a decision guide for patients and families facing the possibility of rehospitalization.

This grant was one of 50 awarded in this highly competitive initiative. More than 800 applications were submitted to PCORI, which funds research to help patients and health care providers make more informed decisions.

How We Developed the Guide

Dr. Tappen led the diverse interprofessional team working on this guide. Hundreds of hours of research have been spent by Drs. Debra Hain and Maria Ordonez from the College of Nursing; Drs. Michelle Duhaney and Joseph Ouslander from the College of Medicine; and Dr. Mauricio Almonte from the College of Arts and Letters. Deborah Elkins, Gail Sullivan, and Christine Moffa, three doctoral students from the College of Nursing and Sarah Worch, a graduate student from the Department of Psychology were also on the team. Dr. Nancy Henry from the INTERACT team and retired Boca Raton Regional Hospital Nurse MaryAnn Weglinski completed the research team.

To ensure the decision guide has the most relevant information, the team conducted more than 271 interviews with a diverse group of patients, families and health care providers in 19 nursing homes across South Florida. Their input was incorporated into the Guide.

Evaluation of the Guide

Then the value of the printed decision guide was tested in English and Spanish at cooperating nursing homes. The team gathered feedback from residents and families and obtained hospital readmission data to evaluate the guide’s effectiveness. Residents and family members have overwhelmingly praised the Guide for its helpfulness. Nursing homes have given it an enthusiastic reception.

New Versions of the Guide

The team also created electronic versions of the guide for easy distribution to residents and families at nursing homes and students at the College of Nursing. An 8 ½” X 11” trifold version of the Guide has also been created to make in-house printing easy. The Guide and trifold have been translated into Spanish, French, Creole, Chinese and Filipino. They are copyrighted but may be downloaded free of charge.

“Rehospitalization transfers are not only expensive, but extremely stressful on patients. Many people are unaware of the level of treatment available in a nursing home or rehab center. By putting this important information in the hands of residents and families, we hope to improve care and reduce unnecessary hospitalizations.” –Dr. Ruth M. Tappen.