Characteristics and place of death in home care recipients in Germany - an analysis of nationwide health insurance claims data.

BACKGROUND: Most care-dependent people live at home, where they also would prefer to die. Unfortunately, this wish is often not fulfilled. This study aims to investigate place of death of home care recipients, taking characteristics and changes in care settings into account. METHODS: We retrospectively analysed a cohort of all home-care receiving people of a German statutory health insurance who were at least 65 years and who deceased between January 2016 and June 2019. Next to the care need, duration of care, age, sex, and disease, care setting at death and place of death were considered. We examined the characteristics by place of care, the proportion of dying in hospital by care setting and characterised the deceased cohort stratified by their actual place of death. RESULTS: Of 46,207 care-dependent people initially receiving home care, 57.5% died within 3.5 years (n = 26,590; mean age: 86.8; 66.6% female). More than half of those moved to another care setting before death with long-term nursing home care (32.3%) and short-term nursing home care (11.7%) being the most frequent transitions, while 48.1% were still cared for at home. Overall, 36.9% died in hospital and in-hospital deaths were found most often in those still receiving home care (44.7%) as well as care in semi-residential arrangements (43.9%) at the time of death. People who died in hospital were younger (mean age: 85.5 years) and with lower care dependency (low care need: 28.2%) as in all other analysed care settings. CONCLUSION: In Germany, changes in care settings before death occur often. The proportion of in-hospital death is particularly high in the home setting and in semi-residential arrangements. These settings should be considered in interventions aiming to decrease the number of unwished care transitions and hospitalisations at the end of life.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters.

BACKGROUND: Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. AIMS: We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. METHODS: We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. RESULTS: A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). DISCUSSION: Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. CONCLUSION: Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study.

BACKGROUND: Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce. AIMS: The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer. METHODS: We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively. RESULTS: Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3-83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%). DISCUSSION: Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences. CONCLUSION: Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.

How Do German General Practitioners Assess Medical Specialist Care Needs of Nursing Home Residents? Results of a Postal Survey in North-Western Germany.

The frequency of contacts of nursing home residents with medical specialists is lower compared to the general population of the same age group in Germany. The aim of this study was to assess general practitioners' (GPs) views on specialist care needs of nursing home residents, on questions of qualification and care coordination. A cross-sectional study was conducted with a postal questionnaire among a representative sample of 1121 GPs in north-western Germany in 2018. The perceptions of GPs about the relative importance of the type of specialist care that is required in nursing homes was assessed on a five-point Likert scale (0 = very low to 4 = very high). A total of 375 GPs (response 33.5%; mean age 54.4 years; 57.6% male) participated in the survey. GPs assessed care needs as highest for neurologists and psychiatrists (68.7%) and lowest for gynecologists (6.5%). Almost all respondents (96.2%) strongly agreed that medical care for nursing home residents should be coordinated by GPs and that GPs should initiate the referral for further specialist care when required (87.5%). A minority (25.7%) agreed that quality of medical care would improve when care for a nursing home was provided by only one GP practice. GPs perceive the needs of nursing home residents for specialist care as high only in relation to care by neurologists and psychiatrists. GPs consider their own coordination function for medical care in nursing homes as very important.

Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project.

Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff's perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.

Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study.

Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics' experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics' point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.

Needs and availability of medical specialists' and allied health professionals' visits in German nursing homes: a cross-sectional study of nursing home staff.

BACKGROUND: The medical care for nursing home residents is estimated to be partly inadequate in Germany. The aim of this study is to investigate the needs and utilization of general practitioners (GPs), medical specialists and allied health professionals. METHODS: A survey was sent to a nationwide random sample of 1069 nursing homes in Germany in January 2019. Nursing staff managers were asked about medical care. Regular nursing home visits by medical specialists and allied health professionals were defined as at least one contact per year to at least one nursing home resident. RESULTS: A total of 486 persons responded (45.5%). On average, nursing homes have contact to 8.6 (interquartile range: 4-10) different GPs. Almost 70% of respondents agreed that residents' medical care should be coordinated by GPs. However, only 46.0% stated that specialist treatment should require GP referral. A high need was seen for care from physiotherapists (91.0%), neurologists or psychiatrists (89.3%), dentists (73.7%), and urologists (71.3%). Regarding the actual utilization of medical specialists and health professionals, most nursing homes have regular contact to physiotherapists (97.1%), psychiatrists or neurologists (90.4%), speech therapists (85.0%), and dentists (84.8%). Remarkable discrepancies between need and utilization were found for urologists and ophthalmologists. CONCLUSION: There is large variance in the number of GPs per nursing home, and needs for medical specialists, especially urologists and ophthalmologists, seem unmet. Interprofessional collaboration between GPs, medical specialists and allied health professionals should be improved, and GPs should play a more coordinating role.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies.

BACKGROUND: Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. METHODS: Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. RESULTS: We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). CONCLUSIONS: A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey.

BACKGROUND: Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS: A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS: 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS: Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

Acute health care services use among nursing home residents in Germany: a comparative analysis of out-of-hours medical care, emergency department visits and acute hospital admissions.

BACKGROUND: Nursing home (NH) residents often utilise acute health care services. However, comparative data on those are lacking. AIMS: Investigating German NH residents' use of out-of-hours medical care (OOHC), visits to emergency departments (EDs) and acute hospital admissions (AHAs). METHODS: Using claims data of 1665 residents for 2014-2015, we conducted a retrospective cohort study, examining the incidence rates involving the different services. Multivariate Poisson regression analyses were performed to calculate relative risks (RRs). Differences in the utilisations over the days of the week and of the reasons for contacts were assessed. RESULTS: In total, 3576 contacts occurred (mean age 80.5 years, women 66.3%), resulting in an overall incidence rate of 2.7 per person-year (95% confidence interval 2.6-2.8). Strongest predictors were polypharmacy (RR 1.79; 95% CI 1.50-2.12), followed by male sex and higher care dependency. Among the three services AHAs showed the highest rates. Injuries were the most common reasons for visiting EDs, whereas for OOHC use and AHAs, coded diagnoses covered a broader spectrum. Utilisation of the services on weekdays varied, particularly for OOHC. DISCUSSION: Polypharmacy, a higher care dependency and male sex seem to play a role in predicting acute health care services. Considering the distribution of the diagnoses of all three types, certain patterns concerning the symptoms' acuity become apparent. CONCLUSIONS: Our findings revealed high acute health care services use among NH residents in Germany and differences among the three available services. This information can be used to design studies for investigating the appropriateness of these contacts.

Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research.

BACKGROUND: Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents' health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. METHODS: A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. RESULTS: After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident's best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. CONCLUSION: The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account.