Academic affiliation with a nursing home. Impact on patient outcome

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.     

A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes

OBJECTIVES: to evaluate the effectiveness of a policy of making hip protectors available to residents of nursing homes. DESIGN: a cluster randomised controlled trial of the policy in nursing and residential homes, with the home as the unit of randomisation. SETTING: 127 nursing and residential homes in the greater Belfast area of Northern Ireland. PARTICIPANTS: 40 homes in the intervention group (representing 1,366 occupied beds) and 87 homes in the control group (representing 2,751 occupied beds). INTERVENTIONS: a policy of making hip protectors available free of charge to residents of nursing homes and supporting the implementation process by employing a nurse facilitator to encourage staff in the homes to promote their use, over a 72-week period. MAIN OUTCOME MEASURES: the rate of hip fractures in intervention and control homes, and the level of adherence to use of hip protectors. RESULTS: there were 85 hip fractures in the intervention homes and 163 in the control homes. The mean fracture rate per 100 residents was 6.22 in the intervention homes and 5.92 in the control homes, giving an adjusted rate ratio for the intervention group compared to the control group of 1.05 (95% CI 0.77, 1.43, P = 0.76). Initial acceptance of the hip protectors was 37.2% (508/1,366) with adherence falling to 19.9% (272/1,366) at 72 weeks. CONCLUSIONS: making hip protectors available to residents of nursing and residential homes did not reduce the rate of hip fracture. This research does not support the introduction of a policy of providing hip protectors to residents of nursing homes.     

基于4R危机管理快速康复模式在老年脊柱结核术后并发认知障碍患者中的应用价值

选择解放军总医院第八医学中心骨科2019年2月至2021年12月收治的128例老年脊柱结核手术患者。其中,2019年2月至2020年5月就诊的68例患者术后实施的是常规护理;2020年6月至2021年12月就诊的60例患者术后实施的是基于4R危机管理快速康复模式。通过随机抽签法,从两组中各抽取40例患者作为对照组和观察组。观察组术后无突发事件和术后并发症,对照组术后4例(10.0%)发生不良事件,6例(15.0%)出现并发症,差异均有统计学意义(χ²=4.211,P=0.040;χ²=6.486,P=0.001)。观察组术后第3天、术后第1周、术后第2周的认知功能障碍评分为(26.90±0.58)分、(26.72±0.55)分和(26.57±0.54)分,均低于对照组[分别为(27.12±0.60)分、(27.02±0.57)分和(26.95±0.50)分],差异均有统计学意义(t=1.702,P=0.047;t=2.441,P=0.008;t=3.221,P<0.001)。术后第2周观察组躯体活动具有独立步行能力者29例(72.5%),多于对照组的19例(47.5%),差异有统计学意义(Z=-2.467,P=0.014)。术后观察组住院时间为(14.55±0.67)d,明显少于对照组的(15.02±0.82)d,差异有统计学意义(t=2.836,P=0.003)。研究认为,对于脊柱结核术后伴认知障碍的老年患者,实施4R危机管理快速康复模式可提高临床护理安全性,减少术后并发症发生,有利于患者术后的康复。     

Effects of a care protocol on care outcomes in older nursing home patients with chronic obstructive pulmonary disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Matched, randomized case-control trial. SETTING: Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. PARTICIPANTS: Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. INTERVENTION: Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. MEASUREMENTS: Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. RESULTS: Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. CONCLUSION: Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.     

An evaluation of increased mortality rates in Wisconsin nursing homes

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.     

Length of stay in VA nursing homes. Comparative characteristics of brief-, medium-, and long-stay residents

To examine the patterns and determinants of length of stay among residents of nursing homes of the Department of Veterans Affairs (VA), the authors conducted a retrospective follow-up study of all persons (n = 4,918) admitted to VA nursing homes between October 1986, and April 1987, using computerized records of the VA. Brief-stay (< 1 month; n = 1,139) residents had most often had previous admissions to VA nursing homes and were usually discharged alive from the nursing home. Medium-stay (1-6 months; n = 1,947) residents were the least functionally impaired and most likely to receive rehabilitative services. Long-stay residents (> 6 months; n = 1,832) were older and more functionally impaired than other residents. Medium- and long-stay residents of VA nursing homes most resembled "short-" and "long-stay" residents among non-VA nursing home residents, respectively. Brief-stay residents may be persons admitted for "respite" services or may be serial users of both VA and non-VA health services. Further study of this population may identify opportunities to decrease "revolving-door" use of nursing home services.     

Impact of prospective payment and discharge location on the outcome of hip fracture

OBJECTIVE: To determine the impact of prospective payment by diagnosis-related groups (DRGs) on length of stay in the hospital, ambulatory status, and level of post-hospital care needed for patients hospitalized with hip fracture. DESIGN: Retrospective chart review of a consecutive series of cases before and after the reference date of implementation of the prospective payment system (PPS). SETTING: Academic, tertiary-care hospital. PATIENTS/PARTICIPANTS: 181 patients 69 years of age or older admitted with International Classification of Diseases (ICD) or DRG codes for hip fracture. RESULTS: Length of stay was shorter by 1.37 days in the post-PPS era (p = 0.05). Poorer discharge ambulation was found in the post-PPS group (p = 0.089). At one year, differences in ambulation and nursing home residence were found to be related not to the implementation of PPS, but rather to the nursing home to which the patient was discharged. Patients discharged to a facility with active physical rehabilitation were less likely to remain institutionalized (p = 0.0025) than those in "ordinary" nursing homes and ambulated more independently (p = 0.05). CONCLUSIONS: The PPS did not have a significant long-term impact on hip fracture outcome. Post-hospital care may be of crucial importance to the future quality of life of hip fracture patients.     

Organizational relationships between nursing homes and hospitals and quality of care during hospital-nursing home patient transfers

OBJECTIVES: To identify organizational factors and hospital and nursing home organizational relationships associated with more-effective processes of care during hospital-nursing home patient transfer. DESIGN: Mailed survey. SETTING: Medicare- or Medicaid-certified nursing homes in New York State. PARTICIPANTS: Nursing home administrators, with input from other nursing home staff. MEASUREMENTS: Key predictor variables were travel time between the hospital and the nursing home, affiliation with the same health system, same corporate owner, trainees from the same institution, pharmacy or laboratory agreements, continuous physician care, number of beds in the hospital, teaching status, and frequency of geriatrics specialty care in the hospital. Key dependent variables were hospital-to-nursing home communication, continuous adherence to healthcare goals, and patient and family satisfaction with hospital care. RESULTS: Of 647 questionnaires sent, 229 were returned (35.4%). There was no relationship between hospital-nursing home interorganizational relationships and communication, healthcare goal adherence, and satisfaction measures. Geriatrics specialty care in the hospital (r=0.157; P=.04) and fewer hospital beds (r=-0.194; P=.01) were each associated with nursing homes more often receiving all information needed to care for patients transferred from the hospital. Teaching status (r=0.230; P=.001) and geriatrics specialty care (r=0.185; P=.01) were associated with hospital care more often consistent with healthcare goals established in the nursing home. CONCLUSION: No management-level organizational relationship between nursing home and hospital was associated with better hospital-to-nursing home transfer process of care. Geriatrics specialty care and characteristics of the hospital were associated with better hospital-to-nursing home transfer processes.     

Cherished possessions and adaptation of older people to nursing homes

One hundred older people (75 females, 25 males), in nursing homes rated as above or below a combined criterion (based on Lieberman and Tobin's scales of physical attractiveness, affiliation fostering, and tolerance for deviancy), responded to questionnaires on cherished possessions and on adaptation to the nursing home. The main findings indicated: 1) relative to those residents without possessions, those with possessions were better adapted to the nursing home; 2) possessions served the major functions of historical continuity, comforter, and sense of belongingness; 3) relative to men, significantly more women had cherished possessions and were more likely to associate them with self-other relationships; and 4) relative to residents in nursing homes below the mean of the combined criterion, those in homes above the mean felt more in control, less helpless, more supported by staff, and were judged as more realistic in response to conflict. Interpretations regarding the role of possessions in adaptation and suggestions for institutional policies concerning possessions are discussed.     

Influenza outbreak detection and control measures in nursing homes in the United States

OBJECTIVE: To evaluate the use of influenza vaccine, rapid influenza testing, and influenza antiviral medication in nursing homes in the US to prevent and control outbreaks. METHODS: Survey questionnaires were sent to 1017 randomly selected nursing homes in nine states. Information was collected on influenza prevention, detection and control practices, and on outbreaks during three influenza seasons (1995-1998). RESULTS: The survey response rate was 78%. Influenza vaccine was offered to residents and staff by 99% and 86%, respectively, of nursing homes. Among nursing homes offering the influenza vaccine, the average vaccination rate was 83% for residents and 46% for staff. Sixty-seven percent of the nursing homes reported having access to laboratories with rapid antigen testing capabilities, and 19% reported having a written policy for the use of influenza antiviral medications for outbreak control. Nursing homes from New York, where organized education programs on influenza detection and control have been conducted for many years, were more likely to have reported a suspected or laboratory-confirmed influenza outbreak (51% vs 10%, P = .01), to have access to rapid antigen testing for influenza (92% vs 63%, P = .01), and to use antivirals for prophylaxis and treatment of influenza A for their nursing home residents (94% vs 55%, P = .01) compared with nursing homes from the other eight states. CONCLUSIONS: Influenza outbreaks among nursing home residents can lead to substantial morbidity and mortality when prevention measures are not rapidly instituted. However, many nursing homes in this survey were neither prepared to detect nor to control influenza A outbreaks. Targeted, sustained educational efforts can improve the detection and control of outbreaks in nursing homes.     

Geriatrician input into nursing homes reduces emergency hospital admissions

Nursing home residents are often very dependent, very frail and have complex care needs. Effective partnerships between primary and secondary care will be of benefit to these residents. We looked at 1954 admission episodes to our Trust from April 2006 to March 2009 inclusive. 3 nursing homes had the highest number of multiple admissions (≥ 4). Four strategies to reduce hospital admissions were used at these nursing homes for 3 months. An alert was also sent to the geriatrician if one of the residents was admitted so that their discharge from hospital could be expedited. The project was then extended for another 4 months with 6 nursing homes. The results showed that geriatrician input into nursing homes had a significant impact on admissions from nursing homes (χ(2)(2)=6.261, p < 0.05). The second part of the project also showed significant impact on admissions (χ(2)(2) = 12.552, p < 0.05). Furthermore, in both parts of the project the length of stay in hospital for the residents was reduced. Geriatricians working together with co-ordinated multidisciplinary teams are well placed to manage the care needs of frail, elderly care home residents.     

Home from home: residents' opinions of nursing homes and long-stay wards

OBJECTIVE: To compare the levels of satisfaction expressed by residents of nursing homes with those of patients in geriatric long-stay wards. DESIGN: A structured satisfaction questionnaire containing 37 closed and two open questions was used to elicit responses from residents of nursing homes in the former South West Thames Regional Health Authority area. This was compared with a similar survey using the same questionnaire among patients in geriatric long-stay wards surveyed in 1989. SETTING: respondents came from a sample of nursing homes chosen to be representative of both size and geographical location. Nursing homes were stratified by number of beds (1-19, 20-29, 30+) and clustered by location (to reflect the urban, semi-rural and coastal nature of the region). SUBJECTS: A random sample was drawn from each grouping (size and location) to yield a resident sample of 850 in 36 nursing homes. This figure was similar to the number of patients (808) in geriatric long-staywards surveyed in 1989. All eligible nursing home patients were assessed for physical dependency. Mental confusion was ascertained by the Abbreviated Mental Test Score (AMTS). Patients who scored three or less on the AMTS (indicative of severe confusion) or had dysphasia, profound deafness or concurrent serious illness were excluded from further study. RESULTS: 377 nursing home residents were able to complete the questionnaire and their answers were compared with those of 291 long-stay geriatric patients. The responses to the five themes--relations with staff, autonomy, amenities, privacy and social environment-show some minor differences between the two groups but what is more noticeable is the similarity of their views. This is important as much social policy assumes that the more 'homely' atmosphere of the nursing home should elicit higher levels of satisfaction than the 'institutional' setting of the hospital ward. CONCLUSION: We conclude that the difference between nursing homes and hospital wards in terms of their institutionalizing capacities is not as profound as policy-makers believe.     

Consequences of an intervention to reduce restrictive side rail use in nursing homes

OBJECTIVES: To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls. DESIGN: Pre- and posttest design. SETTING: Four urban nursing homes. PARTICIPANTS: All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline. INTERVENTION: APN consultation with individual residents and facility-wide education and consultation. MEASUREMENTS: Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data. RESULTS: At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030). CONCLUSION: An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported.     

The incidence of attempted CPR in nursing homes

We studied the frequency with which cardiopulmonary resuscitation (CPR) is attempted on residents of American nursing homes. Each author (all members of the Clinical Practice Committee of the American Geriatrics Society) completed a questionnaire in 1989 about policy and practice regarding CPR during 1988 in each of three to seven nursing homes, by questioning the medical or nursing director or the administrator. Because of the vagaries of nursing home record-keeping, data from some homes were allowed when they were "accurate to within 10%." Data from 58 nursing homes, totalling 10,836 bed-years were available. In 33 of these homes, accounting for 5,425 bed-years, CPR was never attempted. CPR was more likely to be foregone in nursing homes with religious affiliation than in nursing homes without (13 of 17 vs 18 of 38; chi 2 = 4.0; P less than 0.05). Religious affiliation was unknown for three nursing homes. Academic affiliation (10 of 16 vs 20 of 37 in non-affiliated nursing homes) and non-profit status (14 of 19 vs 16 of 23 in for-profit nursing homes) did not significantly affect the likelihood that CPR would never be used. In 31 of 54 nursing homes with explicit do not resuscitate (DNR) policies, CPR was never performed, compared to 2 of 4 homes without such policies. For nursing homes with complete data, there were 1,196 deaths in 32 facilities where CPR was never attempted compared to 1,294 deaths for 24 nursing homes with CPR. For 22 nursing homes without CPR, there were 2,172 emergency room transfers compared to 1,363 emergency room transfers in 18 nursing homes where CPR was attempted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reduction of urinary incontinence in nursing homes: does it reduce or increase costs?

Labor and supply costs associated with the care of urinary incontinent patients in three nursing homes were measured. First, normal nursing home changing patterns and their associated costs were measured. Second, the costs were documented when patients were checked by research staff and changed on an hourly basis as needed. Nursing home staff changed patients significantly less frequently than patient voiding as detected by the hourly checking system. Thus, cost of incontinence during the hourly checking condition ($3.35) per 12-hour patient-day was significantly higher than the cost normally incurred in nursing homes ($1.52) per 12-hour patient-day. The cost of an incontinence rehabilitation program, which significantly reduced incontinence episodes, was contrasted to the cost of incontinence as measured under both of the previous conditions. The rehabilitation program produced significant labor and supply savings only when compared with the hourly checking and changing system. Maintaining patients in a more continent condition costs significantly more than the direct incontinence cost normally incurred by the nursing home. Quality of life and other second-order benefits must be considered if continence rehabilitation is to be judged cost-effective.     

Undiagnosed diabetes mellitus and metabolic control assessed by HbA(1c) among residents of nursing homes.

AIMS/HYPOTHESIS: Diabetes prevalence and diabetes care in residents of nursing homes is a neglected area of research although the growing number of elderly people with diabetes represents a growing challenge for health care in most countries. In this study, we used HbA(1c) measurement to estimate the percentage of residents with undiagnosed diabetes and the quality of metabolic control of subjects with known diabetes in nursing homes. METHODS: All 41 nursing homes in the county of Heinsberg in Northrhine-Westfalia were asked to complete a structured questionnaire on the prevalence of known diabetes among all residents. In addition, all residents were offered measurement of glycated haemoglobin A1c (HbA(1c)) from a capillary blood sample. Undiagnosed diabetes was defined by a HbA(1c) level greater than 6.0%. RESULTS: 39 nursing homes participated in the study comprising 99.6% of all residents. Among the 1936 residents 507 (26.2%) were known to suffer from diabetes. Among the latter 37.0% were under insulin treatment. Blood samples for the determination of HbA(1c) were obtained from 979 subjects from 20 nursing homes. Among those 60 years old or above (n = 843) the mean level of HbA(1c) in those with known diabetes was 7.3 +/- 1.5% and in those without 6.1 +/- 0.9%. Only 16.7% of the subjects with known diabetes had a HbA(1c) greater than 8.5% indicating poor metabolic control. Among the residents previously not known to have diabetes 47.2% had a HbA(1c) equal to or greater than 6.1%, but among those only 8.5% had a HbA(1c) greater than 7.0%. CONCLUSIONS/INTERPRETATION: Although the prevalence of undiagnosed diabetes mellitus defined by HbA(1c) above the normal range in elderly nursing home residents is high, only few may require treatment. The quality of metabolic control among those with known diabetes mellitus is better than expected.     

Clinicians' predictions of nursing home placement for hospitalized patients.

Identifying patients who will need long-term care may improve the efficiency and effectiveness of acute hospital care. This prospective study evaluated clinicians' ability to identify patients requiring nursing home care. The study had two principal objectives. The first objective was to measure whether registered nurses, physicians, and social workers made similar estimates of the probability of nursing home placement early in an acute care hospitalization. The second objective was to identify the clinical characteristics of patients for whom the clinicians incorrectly predicted that they would return home. The study subjects were 342 patients older than age 55 who were admitted to the medicine, surgery, and neurology services of two university-affiliated Veterans Affairs hospitals. Fifteen percent were discharged to nursing homes. The nurses, physicians, and social workers had high agreement in their estimates of the probability of nursing home placement for each patient. However, each of the provider groups assigned low probability estimates to more than 20% of the patients discharged to nursing homes. Examination of the characteristics of patients assigned low probability estimates revealed that mental impairment and functional disability were higher in those patients who ultimately were discharged to nursing homes than in those patients who returned to their homes. These findings suggest that better assessment and interpretation of patient characteristics early in the hospital stay may improve discharge planning. Some clinicians appear to underestimate mental and functional impairment as risk factors for long-term care needs.     

Infection control in German nursing homes

Infection control in German nursing homes has become an issue during the past 10 years. The changing demographics and the introduction of the diagnosis-related group reimbursement system, as well as the increasing number of residents who are colonized with methicillin-resistant Staphylococcus aureus, may worsen already-existing infection control problems. The publication of national infection control guidelines for nursing homes that should be implemented and supervised by infection control nurses may increase the standard. However, the lack of responsibility of the caring physicians for the whole population of a nursing home may hinder the process. This article discusses the state of infection control in German nursing homes.     

Growth of the teaching nursing home. The Veterans Administration experience

Nursing homes are becoming increasingly involved with medical education, and the Veterans Administration (VA) has been particularly active in this movement. We conducted a system-wide survey of VA nursing home facilities to determine the degree to which they participate in medical and other professional training and the features associated with such training. Of the 116 VA nursing homes in 1987, 113 (97.4%) returned completed questionnaires. Compared to "standard" VA facilities (n = 85), "teaching" nursing homes (n = 28)--those in which physicians received at least 20 hours of training per capita annually--were significantly larger, admitted and discharged significantly more patients per occupied bed, and placed a significantly larger proportion of discharged patients in noninstitutional community settings. Care costs in the teaching nursing homes were slightly but not significantly higher, despite significant increases in levels of professional staffing and amounts of training activities in all disciplines. During the survey year, teaching nursing homes provided training experiences for 440 students, residents, and fellows in internal and rehabilitation medicine, as well as for 2,700 other health professionals. The growth of teaching nursing homes in the VA system appears to be associated with positive changes in the pattern of health-care delivery, and it is increasing the number of health-care professionals trained in long-term care.     

Immunization roulette: influenza occurrence in five nursing homes

Immunization with A/Bangkok 1/79 (H3N2) vaccine appeared to be protective for immunized nursing home residents during an influenza outbreak in 1983. All thirteen deaths during the 4-month period of the study were among residents of two of five nursing homes where influenza immunization was low or nonexistent. Death certificates included a diagnosis of I-ILI for only six of the 13 decedents, showing that I-ILI may be greatly underreported as a cause of death, and skewing statistical evaluation of the impact of influenza in nursing home populations. The cost of protection is only a small fraction of the cost to society of caring for seriously ill nursing home residents with I-ILI who must be admitted to a hospital.