Transfer Trauma

Transfer Trauma & Preventing Hospitalizations in Skilled Nursing: What the Latest Evidence Says—and How Leaders Can Act

Hospital transfers are sometimes necessary—but for many residents, they are harmful, preventable, and destabilizing. The cascade is familiar: unfamiliar environments, fragmented information, iatrogenic complications, and a resident who returns weaker than before. The good news: recent research sharpens our understanding of transfer trauma and what works to reduce avoidable hospitalizations. Here’s a concise, evidence-backed playbook for clinical leaders.

What we mean by “transfer trauma”

“Transfer trauma” (often framed as relocation stress syndrome) captures the psychological and functional harm that occurs when older adults are moved from one care setting to another—especially when the move is urgent or poorly controlled. Newer work is formalizing how we measure it. In 2024, investigators developed a composite measure of transfer trauma among nursing-home–to–nursing-home movers, underscoring that even intra-facility relocations can precipitate anxiety, confusion, and decline.    Earlier foundational nursing literature validates relocation stress as a real, clinically recognizable syndrome in older adults. 

Why it matters clinically: transfers heighten the risks we already battle—delirium, functional decline, and mortality—particularly once residents hit the emergency department. Contemporary studies link delirium in older ED patients with worse functional and cognitive outcomes and higher 6-month mortality, reinforcing the imperative to prevent destabilizing transfers whenever safe to do so. 

What works: proven and promising strategies to cut avoidable transfers

1) Build an early-warning + communication “spine”

• INTERACT tools (e.g., Stop and Watch early-warning, decision support, SBAR handoffs) help teams recognize and respond to subtle changes before they snowball. A randomized trial of an INTERACT-based quality-improvement program reduced hospital admissions and ED visits versus controls.  
• Make SBAR your default language (TeamSTEPPS/AHRQ) for all change-in-condition calls and shift handoffs; structured handoffs are associated with better safety outcomes.  

Leadership move: hard-wire Stop and Watch for CNAs and non-nursing staff (dietary, EVS, activities) and require SBAR for every provider escalation; audit for completeness weekly for 90 days. 

2) Put clinical capacity at the bedside

Payment incentives alone don’t move the needle; on-site clinical staff do. Evaluations of the CMS multi-state initiative to reduce avoidable hospitalizations show the strongest results when facilities are supported by embedded advanced practice clinicians (e.g., NPs), achieving significant reductions in all-cause and potentially avoidable hospitalizations and related Medicare spending. 

Leadership move: prioritize NP coverage (even part-time or shared), clear standing orders for common acute issues, on-site diagnostics (POC labs, bladder scans, ECG), and protocols for IV fluids/antibiotics when appropriate—so “treat in place” is safe and real. (Program descriptions and toolkits available via INTERACT.) 

3) Use advance care planning (ACP) and POLST to align care with goals

When residents’ goals are explicit and accessible, burdensome transfers fall. A 2024 integrative review finds POLST use positively associated with quality-of-care and action outcomes; broader ACP meta-analyses suggest ACP can reduce hospitalizations among nursing-home residents, though effects on ED visits are mixed—so implementation quality matters. 

Leadership move: adopt a standardized ACP pathway (e.g., Respecting Choices/POLST), with quarterly audits for documentation accessibility in the EHR and real-time retrieval during off-hours. (Indiana teams are actively studying facility-wide ACP integration.) 

4) Scale models with strong evidence: INTERACT & OPTIMISTIC

• INTERACT: Multiple studies—including a randomized trial and multi-site implementations—show reductions in hospitalizations and ED visits when the program is implemented with fidelity.  
• OPTIMISTIC (Indiana): A sustained, multi-year demonstration cut hospitalizations by ~25% overall, with up to ~40% reductions in potentially avoidable diagnoses in some analyses; facility-to-facility variation is expected.  

Leadership move: combine INTERACT’s early-recognition and communication tools with OPTIMISTIC-style advanced practice support and transitional care management.

5) Target high-risk populations and times

Residents with Alzheimer’s disease and related dementias experience more avoidable transfers; tailor behavior, infection, dehydration, and falls protocols to this cohort.    Also address out-of-hours risk: staffing and escalation pathways overnight and on weekends are pivotal predictors of conveyances to the ED. 

A practical bundle you can deploy this quarter

1. Detect early: Stop and Watch for all staff; nurse assessment guides; daily “change-in-condition” huddles on high-risk residents.  
2. Escalate cleanly: SBAR as the only accepted format for provider calls and inter-shift handoffs; monthly simulation drills.  
3. Treat in place: stock and train for IV hydration/antibiotics where appropriate; rapid access to diagnostics; on-call NP coverage or tele-ACP/tele-hospitalist backup. (CMS initiative data emphasize staffing support over incentives alone.)  
4. Clarify goals: complete/review POLST or ACP for all long-stay residents; verify after every hospitalization or change in condition.  
5. Close the loop: after any transfer, perform a 48-hour post-event review (root cause + “could this have been managed here?”) and feed lessons into QAPI.

Measuring success (dashboard cues for leaders)

Track these five metrics monthly and trend them by unit, shift, and diagnosis:

• All-cause hospital transfers and potentially avoidable transfers per 1,000 resident-days. (Expect a decline with fidelity to INTERACT/OPTIMISTIC-style programs.)  
• ED visits without admission (often a signal of preventable transfer).  
• Time-to-provider contact after a Stop and Watch trigger (process reliability).  
• ACP/POLST availability at point of care (percent of long-stay residents).  
• 30-day return-to-baseline function post event (therapy/nursing composite), to keep “transfer trauma” visible—even when a transfer is necessary.  

Bottom line for nursing executives

Preventing avoidable hospitalizations is not one project—it’s a system. The most consistent results come when early recognition + structured communication + on-site clinical capacity + ACP/POLST + after-action learning are implemented together, with leadership attention to staffing and fidelity. The national CMS initiative and state exemplars (e.g., OPTIMISTIC) show this approach safely reduces transfers and spending while improving resident experience.