Physician factors associated with outpatient palliative care referral.

Outpatient palliative care can provide significant benefits to seriously ill patients, but several barriers to appropriate referrals remain. No study has examined the physician factors associated with referral to outpatient palliative care. To determine physician factors, with a focus on physician beliefs, associated with referral to palliative care. Cross-sectional study of 170 primary care physicians at Kaiser Permanente (KP), a large non-profit Health Maintenance Organisation (HMO), using a self-administered questionnaire. Of the 145 respondents, 100 (70%) reported referring any patients to the palliative care program in the prior year, with a median of 3 referrals (interquartile range 2, 6). Factors associated with referral included working at KP between 10 and 20 years as compared to <10 years [Odds ratio [OR] 6.29 (95% confidence interval [CI] 1.38, 28.6)] and having personal experience with palliative care [OR 2.13 (95% CI 0.95, 4.976)]. None of the beliefs scales was associated with referral. Physician characteristics other than their beliefs about palliative care played a significant role in determining referral. Palliative care programs should aim to increase their visibility in the outpatient setting to increase referrals by primary care physicians. Tools that help physicians identify seriously ill patients who could benefit from palliative care may also serve to increase appropriate referrals.

Functional disability and health care expenditures for older persons.

BACKGROUND: The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. METHODS: Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. RESULTS: The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. CONCLUSIONS: Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.

Documentation of discussions about prognosis with terminally ill patients.

PURPOSE: Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. SUBJECTS AND METHODS: Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. RESULTS: Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR = 2.2; 95% CI: 1.1 to 4.2). CONCLUSIONS: Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.

Nurses' use of palliative care practices in the acute care setting.

This study examines the reported use of palliative care practices by nurses caring for terminally ill patients in the acute care setting. Randomly selected nurses (n = 180) from six randomly selected hospitals in Connecticut completed a self-administered questionnaire. Factors associated with use of palliative care practices were examined by using bivariate and multivariate analyses. Most nurses surveyed (88.5%) reported using palliative care practices when caring for their terminally ill patients. Factors associated with greater use included greater knowledge about hospice, having practiced nursing for less than 10 years, and having had hospice training in the past 5 years. A substantial proportion of nurses reported that they never discuss hospice (51.7 per cent of nurses) and prognosis (26.6 per cent of nurses) with their terminally ill patients. Educational preparation (bachelor's degree versus less education) was not associated with greater use of palliative care practices. Palliative care practices are commonly used by nurses in the acute care setting. However, many report having limited training and substantial gaps in knowledge about hospice among this group of nurses, suggesting greater attention to palliative care and hospice may be warranted in nursing educational programs.

Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.

Several initiatives to improve care at the end of life involve educational programs to influence clinicians' attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians' and nurses' attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Older person's preferences for home vs hospital care in the treatment of acute illness.

BACKGROUND: Although the home is expanding as a potential site for acute illness treatment, little is known about patients' preferences for home vs the hospital. OBJECTIVE: To determine older persons' preferences for home or hospital as a treatment site for acute illness and factors associated with preference. METHODS: Two hundred forty-six community-dwelling persons aged 65 years or older hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia were identified in 2 urban teaching hospitals and received telephone interviews 2 months after hospitalization. They were asked their preference for home or hospital treatment, given the availability of equivalent therapies and outcomes at the 2 sites and a nursing visit and several hours of home health aide assistance daily in the home. They were also asked about changes in preference with changes in the description of the outcome or the availability of services. RESULTS: If home and hospital offered equivalent outcomes, 46% of the sample preferred treatment at home. Preferences were heavily dependent on the outcome of the illness, physician opinion about the best site of care, and the provision of house calls. Higher education, white race, living with a spouse, being deeply religious, and having 2 or more dependencies in activities of daily living were associated with a preference for home treatment. CONCLUSIONS: Under conditions of equivalent outcome, preferences for treatment site are almost equally divided between home and hospital. Explicit elucidation of preferences is necessary if patients' preferences are to play a meaningful role in decision making about site of care.

Referral of terminally ill patients for hospice: frequency and correlates.

BACKGROUND: Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral. METHODS: Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral. RESULTS: On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians' knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice. CONCLUSION: Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

Older persons' perceptions of home and hospital as sites of treatment for acute illness.

PURPOSE: Home care is increasingly being used as a substitute for hospital care. This study examined older patients' perceptions of the home and of the hospital as treatment sites for acute illness and the patient characteristics that are associated with these perceptions. SUBJECTS AND METHODS: A series of questions derived from open-ended interviews supplemented by literature review were administered by telephone in a cross-sectional, descriptive study to community-dwelling persons age 65 years or older who had been hospitalized 2 months earlier with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. RESULTS: Among 246 participants, nearly equal proportions agreed with statements that the home and the hospital would be comfortable sites of care (54% versus 55%), that the home and the hospital would provide rapid recovery (41% versus 37%), and that home treatment and hospital treatment would be burdensome on family and friends (40% versus 33%). Although 93% would feel safe in the hospital, only 42% would feel safe at home. Perceptions were not associated with sociodemographic characteristics, primary diagnosis, self-rated health, depression, or social support. Functionally dependent patients had more positive perceptions of treatment at home. CONCLUSIONS: Evaluation of perceptions of home and hospital can facilitate assessing the acceptability of shifting acute care from hospital to home. Our findings suggest that successful expansion of acute home care will require flexibility in the use of home and hospital as well as education to change perceptions about the safety and efficacy of treatment at home.

Older persons' preferences for site of terminal care.

BACKGROUND: Little is known about patients' preferences for site of terminal care. OBJECTIVE: To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN: Cross-sectional quantitative and qualitative interviews. SETTING: Participants' homes. PATIENTS: Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS: Preference for site of terminal care and the reasons for that preference. RESULTS: In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS: Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.

Who dies at home? Determinants of site of death for community-based long-term care patients.

OBJECTIVE: To determine characteristics associated with site of death in a cohort of long-term homecare patients. DESIGN: Cohort study. SETTING: Community-based long-term care program. SUBJECTS: All patients 65 years of age or older who died within 1 year of admission during 1989 and 1990. MAIN OUTCOME MEASURE: Site of death. RESULTS: Of 620 subjects, site of death was hospital for 302 (49%), home for 132 (21%), nursing home for 124 (20%), and inpatient hospice for 45 (7%). Among patients living at home before death, factors associated with dying at home rather than in a hospital or inpatient hospice included female gender (relative risk (RR) 1.40, 95% confidence interval (CI) 1.00, 1.90); severely dependent functional status (RR 2.38, CI 1.39, 4.17) and cognitive status (RR 1.51, CI 1.10, 2.06); and dying of cancer (RR 1.68, CI 1.11, 2.55), chronic lung disease (AOR 1.75, CI 1.04, 2.95), or coronary artery disease (RR 1.93, CI 1.21, 3.09). Living with a child (RR 1.45, CI .99, 2.11) showed a trend toward association with dying at home. CONCLUSIONS: Even among a subgroup of older persons receiving community-based long-term care, the frequency of home death is low. The finding of an association between functional, social, and disease status and site of death suggests that the relationship between these factors and patients' preferences and care needs must be examined in order to understand how to optimize the site of terminal care.

Older persons' preferences for site of treatment in acute illness.

OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care. DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method. SETTING: Respondents' homes. PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services. MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents' views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences. CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care.

Factors associated with six-month mortality in recipients of community-based long-term care.

OBJECTIVES: To determine factors associated with short-term mortality in recipients of community-based long-term care (CBLTC). DESIGN: A cohort study. SETTING: A Medicaid home- and community-based waiver and state-funded homecare program. PARTICIPANTS: All persons age 65 and older newly admitted to the program from January 1, 1988, to March 31, 1991. MEASUREMENTS: Demographics, functional, cognitive, and health status, depression, and social support were obtained in an admission assessment. Six-month mortality data were obtained by linking assessment data to a state mortality registry. RESULTS: There were 718 deaths among 6784 CBLTC clients. Male sex (AOR 1.8, 95% CI 1.5-2.1), the presence of cancer (AOR 3.2, CI 2.6-3.9), heart disease (AOR 1.3, CI 1.1-1.5), chronic obstructive pulmonary disease (AOR 1.8, CI 1.4-2.2), or nutritional problems (AOR 1.7, CI 1.4-2.0), functional impairment (AOR for lowest compared to highest quartile 2.9, CI 2.0-4.1), severe cognitive impairment (AOR 1.6, CI 1.3-2.1), self-assessment of health as poor (AOR 1.5, CI 1.1-2.0), feeling depressed (AOR 1.2, CI 1.1-1.3), and hospitalization (AOR 2.7, CI 2.2-3.2) were independently associated with 6-month mortality in bivariate and multivariate analyses. CONCLUSIONS: Clinical data obtained during routine assessment of CBLTC clients can be used to assess short-term mortality. Six-month mortality is associated with poor functional and cognitive status, the presence of cancer, heart disease, COPD, and nutritional problems, depression, perception of poor health, and hospitalization.

When the patient cannot come to the doctor: a medical housecalls program.

OBJECTIVES: To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems. PARTICIPANTS: Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home. PROGRAM EVALUATION: The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes. CONCLUSIONS: A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

Frailty and hospitalization of long-term stay nursing home residents.

OBJECTIVE: To determine the relationship between characteristics of older, long-term stay nursing home patients and hospitalization. DESIGN: A cohort study. SETTING: One hundred three proprietary nursing homes. PARTICIPANTS: All residents of these nursing homes aged 65 or older admitted between January 1, 1991, and December 30, 1993, who had no transitions out of the nursing home during the first 6 months of their stay. MEASUREMENTS AND MAIN RESULTS: Among the cohort of 3782 residents, 931 (25%) were hospitalized at least once during the second 6 months of their nursing home stay. In a logistic regression model, severe functional impairment (adjusted odds ratio (AOR) 1.20, 95% confidence interval (CI) 1.01, 1.43), worsening ADL self-performance (AOR 1.22, 95% CI 1.04, 1.43), presence of a decubitus ulcer (AOR 1.62, 95% CI 1.17, 2.24), presence of a feeding tube (AOR 2.03, 95% CI 1.54, 2.67), primary diagnosis of congestive heart failure (AOR 1.61, 95% CI 1.11, 2.34), and primary diagnosis of respiratory disease (AOR 1.77, 95% CI 1.24, 2.54) were associated with hospitalization. No form of advance directive was associated with a lower rate of hospitalization. CONCLUSIONS: Physically frail patients, who may be the least likely to benefit from hospitalization, are the most likely to be hospitalized. The lack of an association between "Do not-hospitalize" orders and lower rates of hospitalization suggests that there are substantial barriers to providing acute care in the nursing home. The association between recent functional decline, primary diagnoses of congestive heart failure and respiratory disease, and hospitalization indicates, however, that certain patient groups may be targeted successfully to reduce hospitalization rates.

Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer.

OBJECTIVE: To determine 2-month mortality and functional status outcomes after resolution of pneumonia in older long-term care facility (LTCF) patients treated with and without hospital transfer. DESIGN: Retrospective cohort study. SETTING: Hebrew Rehabilitation Center for Aged, a 725-bed LTCF affiliated with an academic medical center, whose residents are cared for by staff physicians and geriatric fellows. PATIENTS: LTCF residents with an acute episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate on chest radiograph. MEASUREMENTS: Functional decline or death in the 2 months after the resolution of pneumonia. RESULTS: Of 312 cases of pneumonia, 246 (79%) were treated in the LTCF and 66 (21%) were treated in the hospital. Equal proportions of patients died of their pneumonia (13% vs 12%), but a larger proportion of those hospitalized had either worsening in their functional status or had died at 2 months (P = .005, Mantel-Haenszel trend test). In a logistic regression model controlling for differences between patients treated at the two sites, hospital treatment remained associated with poorer 2-month outcome (AOR 3.02, 95% CI 1.32, 7.22), with a significant interaction between respiratory rate and treatment site. LTCF treatment was associated with better 2-month outcomes only among patients with a lower respiratory rate. For these patients, the difference in outcome between LTCF treatment and hospital treatment was greatest for patients who were independent or mildly dependent at baseline. CONCLUSIONS: In this academic LTCF, treatment for pneumonia without hospital transfer resulted in better 2-month outcomes compared with hospital treatment. Although the difference in outcome may be explained in part by differences between patients treated with and without hospital transfer, it persisted after correcting for these differences. The benefits of LTCF treatment appear to be greatest for those with less severe pneumonia and more independent functional status.

The association between age of hospitalized patients and the delivery of advanced cardiac life support.

OBJECTIVE: To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. DESIGN: Retrospective cohort. SETTING: Urban teaching hospital. PATIENTS: One hundred twenty-two adult inpatients without a "do-not resuscitate" order who suffered cardiopulmonary arrest during 1993. MEASUREMENTS AND MAIN RESULTS: Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a "short ACLS trial") for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). CONCLUSIONS: Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics.

Older community-dwelling adults' attitudes toward and practices of health promotion and advance planning activities.

OBJECTIVE: To describe the attitudes toward and practice of health prevention and advance planning measures by a group of community-dwelling older adults and to examine the effect of age on these practices. DESIGN: A descriptive study performed by mail survey. PARTICIPANTS: Members of a research registry who were 65 years of age or older. MEASUREMENTS: By means of a written questionnaire, we asked about knowledge of various health prevention and advance planning topics, including exercise, cholesterol screening, rectal examination, influenza vaccination, sigmoidoscopy, mammography, prostate cancer screening, organ donation, autopsy, health care proxy, and advance directives. Of those who knew about the topic, we asked if the respondent had discussed it with a physician, who initiated the conversation, and if the respondent participated in the activity. We also asked how important the topic was to the respondent. RESULTS: We received 598 completed surveys, a response rate of 83%. Respondents had a mean age of 74 years, were predominately white (96%), and were well educated, with 44% having completed college. The respondents were all knowledgeable about the topics, and, with the exception of sigmoidoscopy, organ donation, and autopsy, more than 70% thought these topics were important. In the case of health screening and prevention activities, a large percentage of respondents reported having discussed the topic with a physician, and a slightly smaller percentage reported regular participation. In the case of health care proxies and advance directives, however, only about one-half of those who had made these arrangements said they had discussed them with a physician. When discussion did occur, it was much more likely to have been initiated by the respondent. Controlling for level of education, age was inversely associated with the likelihood of a woman reporting she had undergone mammography (P < .05). Age, however, was not associated with decreased frequency of undergoing other screening tests. CONCLUSIONS: Among a group of well educated older adults, reported interest in and compliance with health screening, health promotion, and advance planning activities were high. However, sigmoidoscopy, a relatively more invasive procedure that is generally recommended as a screening tool, is reported less likely to be practiced than prostate cancer screening, a less invasive procedure without such recommendation. Older adults state they are pursuing health care proxies and advance directives, often without the involvement of their physicians. Of the screening tests about which we asked, age was associated only with less frequent practice of mammography.

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.

OBJECTIVE: To determine factors associated with the decision to treat elderly long-term care patients with pneumonia in the hospital vs in the long-term care facility (LTCF) and factors associated with patient outcomes. DESIGN: Retrospective cohort study. SETTING: Hebrew Rehabilitation Center for Aged. PATIENTS: Nursing home residents who had an episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate. MEASUREMENTS AND MAIN RESULTS: The majority of the 316 pneumonia episodes (78%) were managed in the LTCF, most (77%) with oral antibiotics. Both patient-related factors, such as elevated respiratory rate, and non-patient-related factors, such as evening evaluation, were associated with hospitalization. No patient who had a do-not-hospitalize (DNH) order was hospitalized. Equal proportions of patients given LTCF therapy (87%) and hospital therapy (88%) survived. Elevated respiratory rate was associated with dying from pneumonia in the LTCF but not in the hospital. Dependent functional status was associated with dying from pneumonia in both sites. CONCLUSIONS: Many episodes of pneumonia can be managed in the LTCF with oral antibiotics. Because, in the absence of DNH orders, both patient-related and non-patient-related factors are associated with hospital transfer, discussion regarding preferences for hospitalization should occur prior to the development of an acute illness. A high respiratory rate may be a good marker for those LTCF patients requiring hospitalization. Dependent functional status may be a good marker for those LTCF patients unlikely to benefit from hospital transfer.