Resource Factors Associated With Avoidable Transfers in Nursing Homes

OBJECTIVES: Reducing avoidable hospital transfers among nursing home (NH) residents remains a critical priority, with 20% to 67% of transfers potentially preventable. Despite evidence that embedded advanced practice registered nurses (APRNs) and enhanced resources reduce transfers, chronic underinvestment leaves NHs with inadequate staffing and limited diagnostic capabilities. This study examined which resource constraints contributed to avoidable transfers among NH residents with dementia. DESIGN: Cross-sectional analysis of transfer events collected during the Missouri Quality Initiative, a Centers for Medicare and Medicaid Services-funded intervention (2016-2020) that embedded APRNs, implemented INTERACT tools, and enhanced health information technology to reduce avoidable hospitalizations. SETTING AND PARTICIPANTS: Sixteen Missouri NHs participated, encompassing 3683 hospital transfer events from long-term residents. APRNs completed INTERACT surveys documenting resource availability and transfer context. METHODS: Eleven resource indicators were extracted from APRN surveys. Exploratory factor analysis identified latent resource domains. Factor scores were analyzed using Bayesian generalized linear mixed models to assess associations with avoidable transfers, accounting for facility-level variation. RESULTS: Half (50.2%) of transfers were avoidable. Four resource domains emerged: Delayed Diagnostics, Lack of Expertise/Staffing, APRN and Registered Nurse (RN) Availability, and On-site Clinical Resources. Limited APRN availability and staff discomfort (factors 2 and 3) significantly increased the odds of avoidable transfers (OR ≈1.7), whereas the lack of on-site clinicians and equipment (factor 4) were associated with nonavoidable transfers (OR ≈0.37). In addition, facility-level differences contributed meaningfully to transfer decisions, suggesting that unmeasured organizational factors influence outcomes. CONCLUSIONS AND IMPLICATIONS: Avoidable transfers are driven by staff discomfort and limited APRN availability, revealing gaps in nursing jurisdiction and decision-making capacity. Practice and policy reforms should expand APRN access, strengthen diagnostic partnerships, leverage telehealth, and support closed provider models. These interventions are urgently needed to reduce costly, traumatic transfers and improve resident-centered care.