Skip to main content Accessibility help

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

  • Margaret J. McGregor (a1) (a2) (a3), Jennifer Baumbusch (a4), Riyad B. Abu-Laban (a2) (a5), Kimberlyn M. McGrail (a3), Dug Andrusiek (a6), Judith Globerman (a7), Shannon Berg (a3), Michelle B. Cox (a1), Kia Salomons (a1), Jan Volker (a1) and Lisa Ronald (a1) (a2)...


Hospitalization of nursing home residents can be futile as well as costly, and now evidence indicates that treating nursing home residents in place produces better outcomes for some conditions. We examined facility organizational characteristics that previous research showed are associated with potentially avoidable hospital transfers and with better care quality. Accordingly, we conducted a cross-sectional survey of nursing home directors of care in Vancouver Coastal Health, a large health region in British Columbia. The survey addressed staffing levels and organization, physician access, end-of-life care, and factors influencing facility-to-hospital transfers. Many of the modifiable organizational characteristics associated in the literature with potentially avoidable hospital transfers and better care quality are present in nursing homes in British Columbia. However, their presence is not universal, and some features, especially the organization of physician care and end-of-life planning and services, are particularly lacking.

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie.


Corresponding author

*Correspondence and requests for offprints should be sent to / La correspondance et les demandes de tirés-à-part doivent être adressées à: Margaret J. McGregor, M.D., MHSc Department of Family Practice University of British Columbia Room 713, 828 West 10th Avenue Vancouver, BC V5Z 1L8(


Hide All
Ackermann, R.J., & Kemle, K.A. (1998). The effect of a physician assistant on the hospitalization of nursing home residents. Journal of the American Geriatrics Society, 46(5), 610614.
Allman, R.M., Laprade, C.A., Noel, L.B., Walker, J.M., Moorer, C.A., Dear, M.R., et al. . (1986). Pressure sores among hospitalized patients. Annals of Internal Medicine, 105(3), 337342.
Barry, T.T., Brannon, D., & Mor, V. (2005). Nurse aide empowerment strategies and staff stability: effects on nursing home resident outcomes. The Gerontologist, 45(3), 309317.
Bates-Jensen, B.M., Schnelle, J.F., Alessi, C.A., Al-Samarrai, N.R., & Levy-Storms, L. (2004). The effects of staffing on in-bed times of nursing home residents. Journal of the American Geriatric Society, 52(6), 931938.
Bergman, H., & Clarfield, A.M. (1991). Appropriateness of patient transfer from a nursing home to an acute-care hospital: A study of emergency room visits and hospital admissions. Journal of the American Geriatrics Society, 39(12), 11641168.
Bottrell, M.M., O’Sullivan, J.F., Robbins, M.A., Mitty, E.L., & Mezey, M.D. (2001). Transferring dying nursing home residents to the hospital: DON perspectives on the nurse’s role in transfer decisions. Geriatric Nursing, 22(6), 313317.
Bourbonniere, M., Feng, Z., Intrator, O., Angelelli, J., Mor, V., & Zinn, J.S. (2006). The use of contract licensed nursing staff in U.S. nursing homes. Medical Care Research and Review, 63(1), 88109.
Brooks, S., Warshaw, G., Hasse, L., & Kues, J.R. (1994). The physician decision-making process in transferring nursing home patients to the hospital. Archives of Internal Medicine, 154(8), 902908.
Buchanan, J.L., Murkofsky, R.L., O’Malley, A.J., Karon, S.L., Zimmerman, D., Caudry, D.J., et al. . (2006). Nursing home capabilities and decisions to hospitalize: A survey of medical directors and directors of nursing. Journal of the American Geriatrics Society, 54(3), 458465.
Canadian Healthcare Association. (2009). New directions for facility-based long term care. Ottawa, Ontario, Canada: Canadian Healthcare Association. Retrieved July 31, 2010, from
Canadian Healthcare Association. (2010). Guide to Canadian Healthcare Facilities. Ottawa, Ontario, Canada: Canadian Healthcare Association.
Canadian Union of Public Employees. (2009). Residential long-term care in Canada – Our vision for better senior’s care. Ottawa, Ontario, Canada: Canadian Union of Public Employees.
Carter, K.S. (2009). The best of care: Getting it right for seniors in British Columbia (Part 1). Victoria: BCOmbudsperson, Retrieved July 31, 2010, from,M.W.2003.
Carter, M.W., & Porell, F.W. (2005). Vulnerable populations at risk of potentially avoidable hospitalizations: The case of nursing home residents with Alzheimer’s disease. American Journal of Alzheimer’s Disease and Other Dementias, 20(6), 349358.
Casarett, D., Karlawish, J., Morales, K., Crowley, R., Mirsch, T., & Asch, D.A. (2005). Improving the use of hospice services in nursing homes: A randomized controlled trial. Journal of the American Medical Association, 294(2), 211217.
US Centers for Medicare and Medicaid Services. (2001). Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes: Phase II final report. Report No.: 2 of 3. Prepared by Abt Associates Inc. Baltimore: US Center for Medicare and Medicaid Services. Retrieved August 29, 2011 from
Cohen, M., Tate, J., & Baumbush, J. (2009). An uncertain future for seniors – BC’s restructuring of home and community health care, 2001–2008. Canadian Centre for Policy Alternatives. Vancouver Retrieved August 29, 2011 from
Decker, F.H. (2008). The relationship of nursing staff to the hospitalization of nursing home residents. Research in Nursing and Health, 31(3), 238251.
Dosa, D. (2005). Should I hospitalize my resident with nursing-home acquired pneumonia? Controversies in Long-term Care, 6(5), 327333.
Engle, VF. (1998). Care of the living, care of the dying: Reconceptualizing nursing home care. Journal of the American Geriatric Society, 46(9), 11721174.
Finucane, P., Wundke, R., Whitehead, C., Williamson, L., & Baggoley, C. (2000). Use of in-patient hospital beds by people living in residential care. Gerontology, 46(3), 133138.
Fried, T.R., Gillick, M.R., & Lipsitz, L.A. (1997). Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. Journal of the American Geriatric Society, 45(3), 302306.
Gillick, M.R, Serrell, N.A., & Gillick, L.S. (1982). Adverse consequences of hospitalization in the elderly. Social Science and Medicine, 16(10), 10331038.
Grabowski, D.C., O’Malley, A.J., & Barhydt, N.R. (2007). The costs and potential savings associated with nursing home hospitalizations. Health Affairs (Millwood), 26(6), 17531761.
Grabowski, D.C., Stewart, K.A., Broderick, S.M., & Coots, L.A. (2008). Predictors of nursing home hospitalization: A review of the literature. Medical Care Research and Review, 65(1), 339.
Harrington, C., & Swan, J.H. (2003). Nursing home staffing, turnover, and case mix. Medical Care Research and Review, 60(3), 366392.
Horn, S.D., Buerhaus, P., Bergstrom, N., & Smout, R.J. (2005). RN staffing time and outcomes of long-stay nursing home residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. American Journal of Nursing, 105(11), 5870.
Hutt, E., Ecord, M., Eilertsen, T.B., Frederickson, E., & Kramer, A.M. (2002). Precipitants of emergency room visits and acute hospitalization in short-stay Medicare nursing home residents. Journal of the American Geriatrics Society, 50(2), 223229.
Hutt, E, Frederickson, E., Ecord, M., & Kramer, A.M. (2003). Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure. Journal of the American Medical Directors Association, 4(4), 195199.
Intrator, O., Castle, N.G., & Mor, V. (1999). Facility characteristics associated with hospitalization of nursing home residents: Results of a national study. Medical Care, 37(3), 228237.
Intrator, O., Grabowski, D.C., Zinn, J., Schleinitz, M., Feng, Z., Miller, S., et al. . (2007). Hospitalization of nursing home residents: The effects of states’ Medicaid payment and bed-hold policies. Health Services Research, 42(4), 16511671.
Intrator, O., Zinn, J., & Mor, V. (2004). Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. Journal of the American Geriatrics Society, 52(10), 17301736.
Jones, J., Dwyer, P., White, L., & Firman, R. (1997). Patient transfer from nursing home to emergency department: Outcomes and policy implications. Academic Emergency Medicine, 4(9), 908915.
Konetzka, R.T., Spector, W., & Limcangco, M.R. (2008). Reducing hospitalizations from long-term care settings. Medical Care Research and Review, 65(1), 4066.
Lee, S. W., Goh, C., & Chan, Y.H. (2003). Emergency department usage by community step-down facilities – patterns and recommendations. Annals of the Academy of Medicine, Singapore, 32(5), 697702.
McGregor, M.J., Pare, D., Wong, A., Cox, M.B., & Brasher, P. (2010). Correlates of a “Do Not Hospitalize” designation in a sample of frail nursing home residents in Vancouver, Canada. Canadian Family Physician, 56(11), 11581164.
McGregor, M.J., Tate, R.B., McGrail, K.M., Ronald, L.A., Broemeling, A.M., & Cohen, M. (2006). Care outcomes in long-term care facilities in British Columbia, Canada. Does ownership matter? Medical Care, 44(10), 929935.
Miller, S.C., Gozalo, P., & Mor, V. (2001). Hospice enrollment and hospitalization of dying nursing home patients. American Journal of Medicine, 111(1), 3844.
Molloy, D.W., Guyatt, G.H., Russo, R., Goeree, R., O’Brien, B.J., Bedard, M., et al. . (2000). Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. Journal of the American Medical Association, 283(11), 14371444.
Rantz, M.J., Hicks, L., Grando, V., Petroski, G.F., Madsen, R.W., Mehr, D.R., et al. . (2004). Nursing home quality, cost, staffing, and staff mix. The Gerontologist, 44(1), 2438.
Schnelle, J.F., Simmons, S.F., Harrington, C., Cadogan, M., Garcia, E., & Bates-Jensen, M. (2004). Relationship of nursing home staffing to quality of care. Health Services Research, 39(2), 225250.
Sharkey, S. (2008). People caring for people – Impacting the quality of life and care for residents of long-term care homes – A report of the independent review of staffing and care standards for long-term care homes in Ontario. Ontario Governnment. Retrieved August 29, 2011 from
Spector, W.D., Selden, T.M., & Cohen, J.W. (1998). The impact of ownership type on nursing home outcomes. Health Economics, 7(7), 639653.
Travis, S.S., Loving, G., McClanahan, L., & Bernard, M. (2001). Hospitalization patterns and palliation in the last year of life among residents in long-term care. The Gerontologist, 41(2), 153160.
Zimmerman, S., Gruber-Baldini, A.L., Hebel, J.R., Sloane, P.D., & Magaziner, J. (2002). Nursing home facility risk factors for infection and hospitalization: Importance of registered nurse turnover, administration, and social factors. Journal of the American Geriatric Society, 50(12), 19871995.
Zweig, S.C., Kruse, R.L., Binder, E.F., Szafara, K.L., & Mehr, D.R. (2004). Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections. Journal of the American Geriatrics Society, 52(1), 5158.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed