Resident and Facility Factors Associated with High Risk of Discharge from Nursing Facilities 

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

People can be discharged from nursing homes for many reasons. Discharges may be a positive outcome that reflects an individual’s choice. In other cases, discharges may be at the direction of the facility and against the will of the resident. There are strict rules about when involuntary facility-initiated discharges (FIDs) are allowed. FIDs may be unsafe and traumatic for the residents involved and may result in higher costs of care, raising concerns to the public and to Medicare and Medicaid programs. Prior to the COVID-19 pandemic, news media and Ombudsman programs reported that FIDs were becoming the leading cause of complaints for nursing home residents. This study identifies resident characteristics related to increased risk of discharges and how these relationships vary across time, states, and facility types. It also presents findings on the relationship between discharges of residents with risk factors and post-discharge outcomes.

This study identified several resident characteristics associated with a higher risk of discharges from nursing facilities, including behavioral symptoms, impairments requiring more staff time, transitions to Medicaid eligibility, and psychiatric and mood disorders, especially when these conditions newly developed or worsened in the past year. However, for many of these risk factors, the prevalence and strength varied across states and facility types. For profit, government and chain facilities were more likely to discharge residents with risk factors than non-profit and non-chain facilities. We also found that residents discharged with these risk factors, particularly severe behavior symptoms and impairments requiring more staff time, experienced higher rates of acute care (hospitalizations, emergency department visits, and observational stays) than residents discharged without these risk factors.

 Although the discharges of residents with the risk factors identified in this research may be legal, our goal was to identify patterns in discharges to gain insight into the prevalence of FIDs. These findings are intended to serve as a foundation for continued discussion and analyses and to inform strategies and policies for reducing potentially inappropriate FIDs. Further research would be needed to discern unlawful FIDs from legal discharges. Additional recommendations for future research include examining the discharge locations of residents and better understand residents’ outcomes post-discharge, and the impact of state policies, facility closures, and the COVID-19 pandemic on FIDs.

The 4-page Issue Brief can be viewed here.

The 106-page Final Report can be viewed here.