Evolution of Programs to Improve Transfers between Hospitals and Nursing Homes at the Community Level


This study described the evolution of programs to improve the efficiency of patient movement between hospitals and nursing homes in the metropolitan area of Syracuse, New York. These programs were needed in order to improve coordination among providers in the absence of networks that included both acute and long term care providers. The mechanisms included the exchange of data and monitoring the movement of Difficult to Place patients from hospitals to nursing homes. Between 2006 and 2014, the annual number of Difficult to Place patients increased from 983 to 1836. During this period, annual hospital medical/surgical discharges increased by 7.5 percent, severity of illness increased by 13.7 percent, and the population aged 65 years and over increased by 9.8 percent. Most of the Difficult to Place patients were admitted by the four largest facilities in the community, which accounted for 60 percent of the nursing home beds. The initiatives also included Subacute and Complex Care Programs that provided financial incentives for admission of certain types of patients, such as intravenous therapy and extensive wound care. The programs described how these programs were implemented using minimal financial resources and without adding positions to the participating provider organizations.

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Lagoe, R. , Pernisi, L. , Haag, D. and Drapola, B. (2015) Evolution of Programs to Improve Transfers between Hospitals and Nursing Homes at the Community Level. Open Journal of Nursing, 5, 587-595. doi: 10.4236/ojn.2015.57062.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Martin, A.B., Hartman, M., Whittle, L. and Catlin, A. (2014) National Health Care Spending in 2012: Rate of Health Spending Growth Remains Low for the Fourth Consecutive Year. Health Affairs, 33, 67-77.
[2] Dentzler, S. (2011) Urgent Measures for an Old Problem. Health Affairs, 30, 1626.
[3] Friedman, B., De La Mare, J., Andrews, R. and McKenzie, D.H. (2002) Practical Options for Estimating the Cost of Hospital Stays. Journal of Health Care Finance, 291, 1-13.
[4] Cushing, W.T. (2004) Extra Hospital Days Can Cost You Plenty. Medical Economics, 81, 83.
[5] Andersen, G. and Knickman, J.R. (2001) Changing the Chronic Care System to Meet People’s Needs. Health Affairs, 20, 146-160.
[6] Marek, K.D. and Rantz, M.J. (2000) Aging in Place: A New Model for Long Term Care. Nursing Administration Quarterly, 24, 1-11.
[7] Capitman, J.A., Haskins, B. and Bernstein, J. (1986) Case Management Approaches in Community Oriented Long Term Care Demonstrations. Gerontologist, 26, 298-404.
[8] Oriol, W. (1985) The Complex Cube of Long Term Care. American Health Planning Association, Washington DC.
[9] Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J. and Bonomi, A. (2001) Improving Chronic Illness Care: Translating Evidence into Action. Health Affairs, 20, 64-78.
[10] Evans, M. (2012) The Early Returns on Accountable Care. Modern Healthcare, 42, S1-S5.
[11] Fisher, E.S., Shortell, S.M., Kriendler, S.A., Van Citters, A.D. and Larson, B.K. (2012) A Framework for Evaluating the Formation and Implementation of Accountable Care Organizations. Health Affairs, 31, 2368-2378.
[12] Lagoe, R., Pasinski, T., Kronenberg, P., Quinn, T. and Schaengold, P. (2006) Linking Health Services at the Community Level. Canada Healthcare Quarterly, 9, 60-65.
[13] Lagoe, R.J., Westert, G.P., Kendrick, K., Morreale, G. and Mnich, S. (2005) Managing Hospital Length of Stay Reduction: A Multihospital Approach. Health Care Management Review, 30, 89-92.
[14] Lagoe, R.J., Noetscher, C., Vargason, A. and Buttiglieri, M. (2008) Reducing Hospital Stays for Patients Discharged to Nursing Homes: An Evolving Program. Topics in Advanced Practice Nursing eJournal, 8.
[15] Lagoe, R., Noetscher, C., Markle, A. and Johnson, P. (2010) Community Wide Programs to Support Hospital Discharges to Nursing Homes. Topics in Advanced Practice Nursing eJournal, 10.

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