{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:23:52Z","timestamp":1788827032784,"version":"build-2803163510"},"reference-count":57,"publisher":"American Medical Association (AMA)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Intern Med"],"published-print":{"date-parts":[[2020,3,1]]},"DOI":"10.1001\/jamainternmed.2019.6130","type":"journal-article","created":{"date-parts":[[2019,12,30]],"date-time":"2019-12-30T11:31:21Z","timestamp":1577705481000},"page":"385","source":"Crossref","is-referenced-by-count":49,"title":["Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations"],"prefix":"10.1001","volume":"180","author":[{"given":"Ellen P.","family":"McCarthy","sequence":"first","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts"},{"name":"Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica A.","family":"Ogarek","sequence":"additional","affiliation":[{"name":"Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lacey","family":"Loomer","sequence":"additional","affiliation":[{"name":"Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro L.","family":"Gozalo","sequence":"additional","affiliation":[{"name":"Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island"},{"name":"Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent","family":"Mor","sequence":"additional","affiliation":[{"name":"Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island"},{"name":"Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Beth","family":"Hamel","sequence":"additional","affiliation":[{"name":"Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan L.","family":"Mitchell","sequence":"additional","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts"},{"name":"Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"3","key":"ioi190103r1","doi-asserted-by":"publisher","first-page":"441","DOI":"10.1377\/hlthaff.2016.1310","article-title":"Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results.","volume":"36","author":"Ingber","year":"2017","journal-title":"Health Aff (Millwood)"},{"key":"ioi190103r2","doi-asserted-by":"publisher","first-page":"f7171","DOI":"10.1136\/bmj.f7171","article-title":"Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study.","volume":"347","author":"Donz\u00e9","year":"2013","journal-title":"BMJ"},{"issue":"4","key":"ioi190103r3","doi-asserted-by":"publisher","first-page":"627","DOI":"10.1111\/j.1532-5415.2010.02768.x","article-title":"Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761.","volume":"58","author":"Ouslander","year":"2010","journal-title":"J Am Geriatr Soc"},{"issue":"13","key":"ioi190103r4","doi-asserted-by":"publisher","first-page":"1165","DOI":"10.1056\/NEJMp1105449","article-title":"Reducing unnecessary hospitalizations of nursing home residents.","volume":"365","author":"Ouslander","year":"2011","journal-title":"N Engl J Med"},{"issue":"13","key":"ioi190103r5","doi-asserted-by":"publisher","first-page":"1212","DOI":"10.1056\/NEJMsa1100347","article-title":"End-of-life transitions among nursing home residents with cognitive issues.","volume":"365","author":"Gozalo","year":"2011","journal-title":"N Engl J Med"},{"issue":"11","key":"ioi190103r6","doi-asserted-by":"publisher","first-page":"1900","DOI":"10.1111\/jgs.2013.61.issue-11","article-title":"Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations.","volume":"61","author":"Xing","year":"2013","journal-title":"J Am Geriatr Soc"},{"issue":"1","key":"ioi190103r8","doi-asserted-by":"publisher","first-page":"E1","DOI":"10.5600\/mmrr","article-title":"Medicare-Medicaid eligible beneficiaries and potentially avoidable hospitalizations.","volume":"4","author":"Segal","year":"2014","journal-title":"Medicare Medicaid Res Rev"},{"issue":"5","key":"ioi190103r9","doi-asserted-by":"publisher","first-page":"821","DOI":"10.1111\/jgs.2012.60.issue-5","article-title":"Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and home- and community-based services waiver programs.","volume":"60","author":"Walsh","year":"2012","journal-title":"J Am Geriatr Soc"},{"issue":"2","key":"ioi190103r11","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1016\/j.jpainsymman.2006.03.007","article-title":"Transitions of care and changes in distressing pain.","volume":"32","author":"Trask","year":"2006","journal-title":"J Pain Symptom Manage"},{"issue":"16","key":"ioi190103r12","doi-asserted-by":"publisher","first-page":"1529","DOI":"10.1056\/NEJMoa0902234","article-title":"The clinical course of advanced dementia.","volume":"361","author":"Mitchell","year":"2009","journal-title":"N Engl J Med"},{"issue":"1","key":"ioi190103r13","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1001\/jamainternmed.2016.7031","article-title":"Effect of the goals of care intervention for advanced dementia: a randomized clinical trial.","volume":"177","author":"Hanson","year":"2017","journal-title":"JAMA Intern Med"},{"issue":"10","key":"ioi190103r14","doi-asserted-by":"publisher","first-page":"1442","DOI":"10.1089\/jpm.2018.0103","article-title":"Concordance between goals of care and treatment decisions for persons with dementia.","volume":"21","author":"Ernecoff","year":"2018","journal-title":"J Palliat Med"},{"issue":"3","key":"ioi190103r15","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1016\/j.jpainsymman.2017.04.020","article-title":"Level of care preferences among nursing home residents with advanced dementia.","volume":"54","author":"Mitchell","year":"2017","journal-title":"J Pain Symptom Manage"},{"issue":"9","key":"ioi190103r16","doi-asserted-by":"publisher","first-page":"1257","DOI":"10.1001\/jamainternmed.2017.2657","article-title":"Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program.","volume":"177","author":"Kane","year":"2017","journal-title":"JAMA Intern Med"},{"issue":"24","key":"ioi190103r17","doi-asserted-by":"publisher","first-page":"2647","DOI":"10.1001\/jama.2016.18533","article-title":"Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions.","volume":"316","author":"Desai","year":"2016","journal-title":"JAMA"},{"issue":"16","key":"ioi190103r18","doi-asserted-by":"publisher","first-page":"1543","DOI":"10.1056\/NEJMsa1513024","article-title":"Readmissions, observation, and the Hospital Readmissions Reduction Program.","volume":"374","author":"Zuckerman","year":"2016","journal-title":"N Engl J Med"},{"issue":"20","key":"ioi190103r19","doi-asserted-by":"publisher","first-page":"1796","DOI":"10.1161\/CIRCULATIONAHA.114.010270","article-title":"Hospital readmissions reduction program.","volume":"131","author":"McIlvennan","year":"2015","journal-title":"Circulation"},{"issue":"7","key":"ioi190103r21","doi-asserted-by":"publisher","first-page":"595","DOI":"10.1016\/j.jamda.2012.06.001","article-title":"Overview of significant changes in the Minimum Data Set for nursing homes version 3.0.","volume":"13","author":"Saliba","year":"2012","journal-title":"J Am Med Dir Assoc"},{"issue":"2","key":"ioi190103r22","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1177\/1740774516685298","article-title":"Pragmatic trial of video education in nursing homes: the design and rationale for a pragmatic cluster randomized trial in the nursing home setting.","volume":"14","author":"Mor","year":"2017","journal-title":"Clin Trials"},{"issue":"7","key":"ioi190103r23","doi-asserted-by":"publisher","first-page":"769","DOI":"10.1001\/jama.2016.9374","article-title":"Tube feeding in US nursing home residents with advanced dementia, 2000-2014.","volume":"316","author":"Mitchell","year":"2016","journal-title":"JAMA"},{"issue":"9","key":"ioi190103r24","doi-asserted-by":"publisher","first-page":"e68","DOI":"10.1097\/MLR.0000000000000334","article-title":"The Minimum Data Set 3.0 Cognitive Function Scale.","volume":"55","author":"Thomas","year":"2017","journal-title":"Med Care"},{"issue":"2","key":"ioi190103r25","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1093\/gerona\/gly044","article-title":"Development and validation of the nursing home Minimum Data Set 3.0 mortality risk score (MRS3).","volume":"74","author":"Thomas","year":"2019","journal-title":"J Gerontol A Biol Sci Med Sci"},{"issue":"8","key":"ioi190103r30","doi-asserted-by":"publisher","first-page":"1244","DOI":"10.1093\/ndt\/gfv071","article-title":"Analyzing hospitalization data: potential limitations of Poisson regression.","volume":"30","author":"Weaver","year":"2015","journal-title":"Nephrol Dial Transplant"},{"issue":"1","key":"ioi190103r31","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1001\/jamacardio.2017.4265","article-title":"Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure.","volume":"3","author":"Gupta","year":"2018","journal-title":"JAMA Cardiol"},{"issue":"3","key":"ioi190103r32","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1093\/geronb\/gbv109","article-title":"Hospice use, hospitalization, and Medicare spending at the end of life.","volume":"71","author":"Zuckerman","year":"2016","journal-title":"J Gerontol B Psychol Sci Soc Sci"},{"issue":"9","key":"ioi190103r33","doi-asserted-by":"crossref","DOI":"10.1001\/jamainternmed.2019.1004","article-title":"Regression to the mean in the Medicare Hospital Readmissions Reduction Program.","author":"Joshi","year":"2019","journal-title":"JAMA Intern Med"},{"issue":"5","key":"ioi190103r34","doi-asserted-by":"publisher","first-page":"905","DOI":"10.1111\/jgs.2012.60.issue-5","article-title":"Hospital transfers of nursing home residents with advanced dementia.","volume":"60","author":"Givens","year":"2012","journal-title":"J Am Geriatr Soc"},{"issue":"7","key":"ioi190103r35","doi-asserted-by":"publisher","first-page":"1265","DOI":"10.1377\/hlthaff.2017.0164","article-title":"A national strategy for palliative care.","volume":"36","author":"Meier","year":"2017","journal-title":"Health Aff (Millwood)"},{"issue":"11","key":"ioi190103r36","doi-asserted-by":"publisher","first-page":"2280","DOI":"10.1111\/jgs.14469","article-title":"Palliative care consultations in nursing homes and reductions in acute care use and potentially burdensome end-of-life transitions.","volume":"64","author":"Miller","year":"2016","journal-title":"J Am Geriatr Soc"},{"issue":"6","key":"ioi190103r37","doi-asserted-by":"publisher","first-page":"878","DOI":"10.1016\/j.jpainsymman.2016.05.017","article-title":"Palliative care consultations in nursing homes and end-of-life hospitalizations.","volume":"52","author":"Miller","year":"2016","journal-title":"J Pain Symptom Manage"},{"issue":"2","key":"ioi190103r38","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1016\/j.jamda.2014.08.010","article-title":"The effect of hospice on hospitalizations of nursing home residents.","volume":"16","author":"Zheng","year":"2015","journal-title":"J Am Med Dir Assoc"},{"issue":"10","key":"ioi190103r39","doi-asserted-by":"publisher","first-page":"1640","DOI":"10.1377\/hlthaff.2018.0379","article-title":"Nursing facilities can reduce avoidable hospitalizations without increasing mortality risk for residents.","volume":"37","author":"Feng","year":"2018","journal-title":"Health Aff (Millwood)"},{"issue":"5","key":"ioi190103r42","doi-asserted-by":"publisher","first-page":"246","DOI":"10.1007\/BF02599879","article-title":"Whether to transfer? factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.","volume":"10","author":"Fried","year":"1995","journal-title":"J Gen Intern Med"},{"issue":"21","key":"ioi190103r43","doi-asserted-by":"publisher","first-page":"2503","DOI":"10.1001\/jama.295.21.2503","article-title":"Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.","volume":"295","author":"Loeb","year":"2006","journal-title":"JAMA"},{"issue":"13","key":"ioi190103r44","doi-asserted-by":"publisher","first-page":"1102","DOI":"10.1001\/archinternmed.2010.181","article-title":"Survival and comfort after treatment of pneumonia in advanced dementia.","volume":"170","author":"Givens","year":"2010","journal-title":"Arch Intern Med"},{"issue":"1","key":"ioi190103r45","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1093\/intqhc\/mzv110","article-title":"Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting.","volume":"28","author":"McAndrew","year":"2016","journal-title":"Int J Qual Health Care"},{"issue":"3","key":"ioi190103r46","doi-asserted-by":"publisher","first-page":"162","DOI":"10.1016\/j.jamda.2013.12.005","article-title":"The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care.","volume":"15","author":"Ouslander","year":"2014","journal-title":"J Am Med Dir Assoc"},{"key":"ioi190103r47","article-title":"Trends in hospitalization vs observation stay for ambulatory care-sensitive conditions","author":"Figueroa","journal-title":"JAMA Intern Med"},{"issue":"7","key":"ioi190103r48","doi-asserted-by":"publisher","first-page":"1207","DOI":"10.1377\/hlthaff.2019.00096","article-title":"Impact of Medicare readmissions penalties on targeted surgical conditions.","volume":"38","author":"Chhabra","year":"2019","journal-title":"Health Aff (Millwood)"},{"issue":"4","key":"ioi190103r50","doi-asserted-by":"publisher","first-page":"585","DOI":"10.1377\/hlthaff.2018.05412","article-title":"Patient readmission rates for all insurance types after implementation of the Hospital Readmissions Reduction Program.","volume":"38","author":"Ferro","year":"2019","journal-title":"Health Aff (Millwood)"},{"issue":"11","key":"ioi190103r52","doi-asserted-by":"publisher","first-page":"994","DOI":"10.1016\/j.jamda.2016.05.012","article-title":"Decisions to transfer nursing home residents to emergency departments: a scoping review of contributing factors and staff perspectives.","volume":"17","author":"Trahan","year":"2016","journal-title":"J Am Med Dir Assoc"},{"key":"ioi190103r53","article-title":"Nursing home resident symptomatology triggering transfer: avoiding unnecessary hospitalizations.","volume":"2012","author":"Ashcraft","year":"2012","journal-title":"Nurs Res Pract"},{"issue":"8","key":"ioi190103r54","doi-asserted-by":"publisher","first-page":"673","DOI":"10.1097\/MLR.0b013e3182984bff","article-title":"Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes.","volume":"51","author":"Spector","year":"2013","journal-title":"Med Care"},{"issue":"5","key":"ioi190103r55","doi-asserted-by":"publisher","first-page":"895","DOI":"10.1111\/jgs.15286","article-title":"The complexity of determining whether a nursing home transfer is avoidable at time of transfer.","volume":"66","author":"Unroe","year":"2018","journal-title":"J Am Geriatr Soc"},{"issue":"2","key":"ioi190103r56","doi-asserted-by":"crossref","DOI":"10.1093\/geroni\/igy017","article-title":"Investigating the avoidability of hospitalizations of long stay nursing home residents: opportunities for improvement.","volume":"2","author":"Unroe","year":"2018","journal-title":"Innov Aging"},{"key":"ioi190103r28","volume-title":"CPT Professional 2019: Current Procedural Terminology","author":"American Medical Association","year":"2019"},{"key":"ioi190103r7","unstructured":"PolniaszekS, WalshEG, WienerJM. United States Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Office of Disability, Aging and Long-Term Care Policy. Hospitalizations of nursing home residents: background and options. https:\/\/aspe.hhs.gov\/system\/files\/pdf\/76296\/NHResHosp.pdf. Accessed October 6, 2019."},{"key":"ioi190103r10","unstructured":"IngberMJ, FengZ, KhatutskyG, . Evaluation initiatives to reduce avoidable hospitalizations among nursing facility residents: final report. https:\/\/downloads.cms.gov\/files\/cmmi\/irahnfr-finalevalrpt.pdf. Published 2017. Accessed October 6, 2019."},{"key":"ioi190103r20","unstructured":"Centers for Medicare & Medicaid Services. Long-term care facility resident assessment instrument 3.0 user's manual v1.16. https:\/\/downloads.cms.gov\/files\/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf. Accessed October 6, 2019."},{"key":"ioi190103r26","unstructured":"MedPAR data documentation. Research Data Assistance Center website. https:\/\/www.resdac.org\/cms-data\/files\/medpar\/data-documentation. Accessed November 19, 2019."},{"key":"ioi190103r27","unstructured":"2019 HCPCS codes level II. HCPCS website. https:\/\/hcpcs.codes. Accessed November 19, 2019."},{"key":"ioi190103r29","unstructured":"Master Beneficiary Summary File (MBSF) base. Research Data Assistance Center website. https:\/\/www.resdac.org\/cms-data\/files\/mbsf-base. Accessed November 19, 2019."},{"key":"ioi190103r40","unstructured":"WalshE, FreimanM, HaberS, BraggA, OuslanderJ, WienerJ. Cost drivers for dually eligible beneficiaries: potentially avoidable hospitalizations from nursing facility, skilled nursing facility, and home and community-based services waiver programs: final task 2 report. https:\/\/www.cms.gov\/Research-Statistics-Data-and-Systems\/Statistics-Trends-and-Reports\/Reports\/downloads\/costdriverstask2.pdf. Accessed October 6, 2019."},{"key":"ioi190103r41","unstructured":"MitchellSL, CaticAG, GivensJL, KnoppJ, MoranJA. Advanced dementia: a guide for families. https:\/\/www.marcusinstituteforaging.org\/sites\/default\/files\/files\/DementiaGuideForFamilies.pdf. Accessed October 6, 2019."},{"key":"ioi190103r49","unstructured":"BrennanN, EngelhardtT. Data brief: sharp reductions in avoidable hospitalizations among long-term care facility residents. Centers for Medicare & Medicaid Services blog page. https:\/\/www.cms.gov\/blog\/data-brief-sharp-reduction-avoidable-hospitalizations-among-long-term-care-facility-residents. Accessed October 6, 2019."},{"key":"ioi190103r51","unstructured":"Data.Medicare.gov. FY 2019 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. Nursing Home Compare database. https:\/\/data.medicare.gov\/Nursing-Home-Compare\/SNF-VBP-Facility-Level-Dataset\/284v-j9fz. Accessed October 6, 2019."},{"key":"ioi190103r57","unstructured":"MedPAC. Hospital and SNF use by Medicare beneficiaries who reside in nursing facilities. http:\/\/www.medpac.gov\/docs\/default-source\/reports\/jun17_ch9.pdf?sfvrsn=0. Accessed November 19, 2019."}],"container-title":["JAMA Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/articlepdf\/2757790\/jamainternal_mccarthy_2019_oi_190103.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,3,2]],"date-time":"2020-03-02T11:01:20Z","timestamp":1583146880000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/fullarticle\/2757790"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,1]]},"references-count":57,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2020,3,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamainternmed.2019.6130","relation":{},"ISSN":["2168-6106"],"issn-type":[{"value":"2168-6106","type":"print"}],"subject":[],"published":{"date-parts":[[2020,3,1]]}}}