Black family members are more likely to seek aggressive treatment for their loved ones in a nursing home, new study says.
The percentage of Black nursing home residents and those under 65 years old transferred to outside facilities is higher than the 25% of residents overall that are transferred at least once, according to a new study by the University of Missouri.
Transferring 25% of residents at least once results in a cost of $14.3 billion to Medicare, according to a federal report by the Office of Inspector General
Looking at data from the Missouri Quality Initiative, the research team specifically looked at repeat transfers of four or more instances. Within this group 32% of transfers were Black residents; however nationally, about 14% of nursing home residents are Black.
“That, to us, was a pretty compelling statistic,” Dr. Amy Vogelsmeier, associate professor for the University of Missouri’s Sinclair School of Nursing and one of the study's authors, told HealthLeaders. “And then the same was the significant number of residents who were under the age of 65 who were transferred repeatedly.”
Past studies have shown that Black residents who are transferred typically have more chronic conditions, and financial constraints often interfere with the care they receive. Vogelsmeier mentioned in a news release how some studies found that Black family members are less likely to have conversations about the goals of their loved one’s care and are more likely to seek aggressive treatment.
“It could be distrust in the healthcare system, it could be providers making assumptions that they don’t want to discuss these things, which could be rooted in structural racism,” she explained. “So, these topics should be further investigated going forward to ensure racial equity in the healthcare industry.”
There are no criteria nursing homes follow when determining whether a resident should be transferred, and Vogelsmeier added that it often depends on the equipment and staff the nursing home has available. In some instances, the residents or their family members will insist on them being transferred, or the resident’s provider or physician may want them to be.
“What we know is that around half of transfers are likely avoidable, meaning they could have been safely cared for in the nursing home had the resources been there,” Vogelsmeier said. “But in terms of what decides when a resident goes, that’s variable across the board.”
The study also found that residents under the age of 65, as well any resident with the full code designation, were more likely to be transferred than others. When a resident’s heart fails or they stop breathing, staff will act based on whether they’re designated full-code or do not resuscitate (DNR), with the full code designation meaning they can initiate CPR to attempt to resuscitate them.
“What we think happens is that people sort of make the assumption that if my family member is [designated] do not resuscitate, that they won’t get the necessary treatment or the best types of treatment, simply because they’re not full code,” Vogelsmeier said. “And that’s not the truth.”
For residents designated DNR, resuscitation attempts such as CPR and the potential trauma from transferring them can cause more harm, especially for those who are frailer with chronic or multiple conditions.
One takeaway from the study is the importance of the role advanced practice nurses (APRNs) play in nursing homes and skilled nursing facilities. While they provide guidance and leadership to support staff and work with physicians to coordinate treatment, they weren’t always consulted when it came to deciding if a patient needed to be transferred, the study showed.
“We know just from a larger study that the APRNs were really effective in keeping the majority of residents that they were working with in the nursing home reduced,” Vogelsmeier said. “One thing it told us was that the majority of residents, we were able to keep out of a hospital, and that was a good thing, but what we wanted to do was examine those that actually did get transferred to understand why particularly if they went repeatedly.”
“What we know is that around half of transfers are likely avoidable, meaning they could have been safely cared for in the nursing home had the resources been there. But in terms of what decides when a resident goes, that’s variable across the board.”
Amy Vogelsmeier, MD, associate professor, University of Missouri Sinclair School of Nursing
Jasmyne Ray is the revenue cycle editor at HealthLeaders.
KEY TAKEAWAYS
Nursing home residents are given one of two designations, full code and DNR (do not resuscitate), which determine staff response when their heart stops or they stop breathing.
Whether a resident is transferred is based on their designation and the resources the nursing home has readily available.
The results of the study emphasized the importance of the role of advanced practice nurses in nursing homes.