CASE REPORT Inpatient Care for Nursing Home Patients: An Opportunity to Improve Transitional Care Huai Y. Cheng, MD, MPH, Emily Tonorezos, MD, Robert Zorowitz, MD, MBA, CMD, John Novotny, MD, Shelly Dubin, GNP, and Mathew S. Maurer, MD Elderly residents of long-term care facilities are often af- flicted with multiple medical, psychological, and social prob- lems resulting in frequent transfers to the acute care hospital for various complex needs. 1–7 Many of these transfers are inappropriate. 8 During transfers between the long-term care facility and the acute care facility, this population is particu- larly vulnerable to experiencing poor quality and fragmented care. 9 –11 Repeated transfers are common and have been de- scribed as a “ping-pong” pattern, 1,6 –7 and are known to have negative effects on health. 6,8 One study of the 2-year follow-up period after transfer between facilities that had both skilled nursing and intermediate care components noted that 19% of residents from skilled nursing facilities and 42% of residents from intermediate care facilities had 1 extra hospi- talization. Furthermore, 8% of residents from skilled nursing facilities and 13% of residents from intermediate care facilities had more than 2 extra hospitalizations. 1 Despite how com- mon these transitions have become, the challenges of improv- ing the process of transitional care have only begun to receive attention from policy makers, clinicians, and quality improve- ment entities. 10 –13 Here we describe the case of a nursing home resident who had multiple transfers back and forth to an acute care hospital during a 6-week period. This case revealed multiple opportu- nities for improving the process of transitional care, which could partially improve the overall quality of care for nursing home residents. We will describe these opportunities and review some of the potential efforts that could be undertaken to improve outcomes as specified in a position statement by the American Geriatrics Society. 11 CASE INFORMATION An 89-year-old woman with severe dementia was trans- ferred from a nursing home to our acute care facility with a tense, distended abdomen and respiratory distress. Of note, 9 days prior to this presentation, she had been admitted to our hospital for apparent lethargy, hypotension, and a tempera- ture of 100°F. The urinalysis revealed pyuria. Although no organism was identified on routine culture, she was treated with oral antibiotics and intravenous fluids. She was also noted to have fecal impaction that resolved with enemas. After this 4-day hospitalization, she was transferred back to the nursing home with discharge diagnoses of urinary tract infection and fecal impaction. At the nursing home, she became constipated and did not respond to enemas or sorbitol. On the day of her presentation, she began to vomit. In the emergency room, her temperature was 99.8°F, blood pressure 80/60 mm Hg, heart rate 113 beats per minute, and respiratory rate 26 breaths per minute. The oxygen saturation was 92% on room air. A nasogastric tube was placed, and brown nonfeculent material was recovered. The patient’s past medical history included type 2 diabetes mellitus, coronary artery disease, peripheral vascular disease, and cerebrovascular disease. She had undergone an open reduction and internal fixation of a left femoral fracture 2 years earlier. The patient was widowed, with a daughter and granddaughter residing in the region. She had no advance directives. Her medications upon transfer included amoxicil- lin, aspirin, iron sulfate, multivitamins, NPH insulin, meto- clopromide, docusate sodium, senna, milk of magnesia, so- dium phosphate enema, and sorbitol. Her examination was notable for tachycardia, without any murmur. Auscultation of the lungs revealed diffuse bilateral rhonchi. The abdomen was diffusely distended, without ten- derness, rebound, or guarding. She was noted to have a large sacral ulcer without surrounding erythema. Her stool was positive for occult blood. Her abnormal lab tests included a white count of 13.7 with 87% neutrophils, a hemoglobin of 7.9 mg/dL, an albumin of 2.4 mg/dL, an arterial lactate of 2.5 mmol/L (normal range of 0.5 to 1.60) and a D-dimer of 2.59 Columbia University, Department of Medicine, Division on Aging, New York, NY (H.Y.C., S.D., M.S.M.); Columbia University, Department of Medicine, Hos- pitalist Program, New York, NY (J.N.); Department of Medicine, Johns Hopkins University, Baltimore, MD (E.T.); The Hebrew Home at Riverdale, Riverdale, New York, NY (R.Z.). Address correspondence to Mathew S. Maurer, MD, Columbia University, Allen Pavilion, 5141 Broadway, 3 Field West, Room 035, New York, NY 10034. E-mail: msm10@columbia.edu Copyright ©2006 American Medical Directors Association DOI: 10.1016/j.jamda.2006.01.025 CASE REPORT Cheng et al. 383