Nursing home residents typically suffer from a constellation of chronic illnesses that leave them frail and vulnerable. For these individuals, hospital care may be necessary to cure serious acute illness, manage clinically complex chronic care, and restore lost function. However, it can also be disruptive and escalate functional decline. Hospitalization rates among nursing home residents are notably higher than for the elderly as a whole. Further, a recent study found that nearly half of all hospitalizations for nursing home residents were inappropriate. Both the costs and the clinical implications for this population point to the need for a more comprehensive evaluation of factors contributing to variations in practice style and unnecessary hospitalization.

We use an expert panel of practicing geriatricians to distinguish hospitalizations that are unavoidable from those that involved considerable discretion in the decision to hospitalize. The clinical capabilities available within a nursing facility may influence these classifications. Using administrative data, we developed a model of the necessity of hospitalization for nursing home residents with different diagnoses. The model is not intended to compare the appropriateness of individual decisions to hospitalize but rather to be used to compare nursing home approaches to hospitalization.

Surveys of nursing home medical directors and directors of nursing provide data on staffing, resources, attitudes toward the importance of hospitalization, and the causes of overhospitalization. These surveys are used to provide insight into the determinants of hospitalization and the variation in hospitalization rates across nursing homes.