Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Susan E. Hickman, Kathleen T. Unroe, Mary Ersek, Timothy E. Stump, Wanzhu Tu, Monica Ott, Greg A. Sachs

Research output: Contribution to journalArticle

3 Scopus citations


BACKGROUND/OBJECTIVES: The Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. Systematic advance care planning (ACP) is a core component of the intervention, based on research suggesting ACP is associated with decreased hospitalizations of nursing facility residents. The purpose of this study was to describe associations between ACP documentation resulting from the OPTIMISTIC intervention and hospitalizations. DESIGN: Specially trained project nurses were embedded in 19 nursing facilities and systematically engaged in ACP as part of a larger demonstration project. PARTICIPANTS: Residents (n = 1482) enrolled in the demonstration project for a minimum of 30 days between January 1, 2015, and June 30, 2016. MEASUREMENTS: ACP status: (1) Physician Orders for Scope of Treatment (POST) comfort measures or do not hospitalize (DNH) orders; (2) ACP orders with no hospitalization limit (eg, code status only); and (3) no ACP (potentially avoidable and all-cause hospitalizations per 1000 resident days). RESULTS: Residents with POST comfort measures/DNH orders (33.2% or n = 493) were less likely than residents with no ACP (14.7% or n = 218) to experience a potentially avoidable hospitalization (P =.001) or all-cause hospitalization (P =.001). These differences became statistically nonsignificant after adjusting for age, functional status, and cognitive functioning. CONCLUSION: In this successful multicomponent demonstration project to reduce potentially avoidable hospitalizations, ACP outcomes were not associated with hospitalization rates of nursing facility residents after adjusting for resident characteristics. These findings highlight the challenge of measuring the contributions of individual components of complex, multicomponent interventions. Associations between lower hospitalization rates and ACP completion may be influenced by contextual factors, such as clinical expertise and resources to manage acute conditions leading to hospitalization, in addition to interventions to increase ACP. J Am Geriatr Soc 67:1649–1655, 2019.

Original languageEnglish (US)
Pages (from-to)1649-1655
Number of pages7
JournalJournal of the American Geriatrics Society
Issue number8
StatePublished - Jan 1 2019


  • advance care planning
  • nursing facility
  • nursing home
  • palliative care

ASJC Scopus subject areas

  • Geriatrics and Gerontology

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