Nursing homes (NHs) in the United States can legally discharge residents without their consent for a limited number of reasons detailed in federal regulations (Centers for Medicare & Medicaid Services [CMS], 2017c). Involuntary discharges violating federal regulations have become a growing concern to the public and Medicare and Medicaid programs, which pay for most short-term rehabilitation and long-term custodial care in NHs, respectively, because they can be unsafe and traumatic for residents and can result in higher costs to the public programs (CMS, 2017a). Bolstering these concerns, the federal Long-Term Care Ombudsman Program, which investigates complaints made by or on behalf of NH residents, reported that “discharges/evictions” have become the predominant topic of complaints nationally (Administration for Community Living [ACL], 2018). One possible motivation for inappropriate evictions of Medicaid beneficiaries, who have long been predominant among NH residents, is NHs seeking to reduce the provision of long-term custodial care and increase the provision of short-term rehabilitation, because Medicare rates are substantially higher than Medicaid rates (Lepore et al., 2015).
Although facility-initiated involuntary discharge (FID) is legal in some specific circumstances, such as when a NH closes (CMS, 2018), even legal FID can have adverse impacts on residents. A study from the early 2000s that followed 120 residents for 3 months after FID—as they transferred from a NH that closed to 23 other facilities—found that the FID experience was stressful for residents and families, and residents who required assistance walking or transferring were more likely to fall post-FID (Capezuti, Boltz, Renz, Hoffman, & Norman, 2006).
The increase in and high prevalence of reported complaints about discharges and evictions from NHs (ACL, 2018) and the potential for FID to have negative impacts on NH residents (Capezuti et al., 2006) have placed more attention on FID and heightened interest in better understanding FID. Therefore, a literature review was conducted to describe which NH resident populations are at risk of FID; the prevalence of NH FID; the FID processes and practices used by NHs; where residents go following FID; NH provider motivations for FID; the impacts of policy, regulatory, and financial factors on FID; and outcomes of FID.
The current literature review included three major steps—literature search, record screening, and literature analysis—conducted by three researchers (M.L., P.Y., S.Z.). The literature search and record screening phases are summarized in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher, Liberati, Tetzlaff, & Altman, 2009) diagram (Figure 1).
PRISMA diagram of literature search and screening.
PubMed, Academic Search Premier, AgeLine, and CINAHL were systematically searched for literature about involuntary discharges from NHs. Searches were also conducted on the websites of many organizations, including federal agencies and advocacy organizations. Federal agencies included CMS, the U.S. Department of Health and Human Services (USDHSS) Office of Inspector General, and the USDHSS Office of the Assistant Secretary for Planning and Evaluation. Advocacy organizations included the Center for Medicare Advocacy, Justice in Aging, and the National Consumer Voice for Quality Long-Term Care. The literature search included sources published since 2010, in English, and in the United States. An array of search terms was used across the search engines and websites and included terms matching the medical subject-headings (MeSH) lexicon (Lowe & Barnett, 1994) (Table A, available in the online version of this article).
Literature Search Terms
Searches were conducted with and without the “peer-review” limiter to include peer-reviewed literature, newspapers, trade articles, and other sources. Literature searches were completed on May 30, 2018. A total of 5,262 unique records were obtained (Figure 1).
Screening Records and Confirming Eligibility
The collected records were screened using information in their citations, including the titles of the records, which commonly indicated the main topics covered; the year published; and the publishers, which often indicated the country of study. Most items collected were excluded (n = 5,070; Figure 1), including a large proportion of records that were not about FID and studies conducted outside the United States or before 2010. Some topics of excluded literature were hospital discharges, evacuations from NHs because of natural disasters, medical repatriation from hospitals, and involuntary commitments to psychiatric wards. During record screening, some records were considered “mixed eligible,” such as those with titles that indicated topical relevance, but with publication years that preceded the study period. Mixed-eligible records were included if they were specifically about FID in the United States (even if published before 2010) and the others were excluded.
The remaining 192 records were examined, including all abstracts and some full texts, more thoroughly to verify topical relevance, and irrelevant articles (i.e., articles not about FID) were excluded (n = 118; Figure 1).
To analyze the included records (n = 74; Figure 1), a list of codes (e.g., prevalence of involuntary discharge) and subcodes (e.g., geographic variations in prevalence) were developed similar to other qualitative health services research that started with a preliminary code list (Bradley, Curry, & Devers, 2007; Miles & Huberman, 1994). Text was read and coded in 74 records. During coding, codes were added or revised to better match the content of the records. The final code list, which was used to code all 74 records, included 14 major codes and two subcodes (Table 1).
Final Code List
The coded text was reviewed and key points about each coded segment of text, each code overall, and linkages between codes, including causal and explanatory links, were summarized. For example, linking the codes that address FID types and FID destinations, it was noted that “FID due to NH closures include destinations that may be farther from residents' original homes.” The analysis was considered complete when all coded text was reviewed and summary statements about each code and linkages between codes were confirmed by the study team.
Analysis of the coded text generated findings about NH FIDs in eight distinct categories (Table 2).
Summary of Findings
Types of FID
Residents' right to stay in NHs is discussed in the Code of Federal Regulations (CFR; 2017). The CFR details the requirements for FID, including documentation requirements, and CMS (2017c) provides guidance regarding how the regulations apply in a State Operations Manual. Using the regulatory guidance as an organizing framework, two general types of FID were identified: legal and unlawful. Within each general type, multiple specific types of FID were identified and are described in the remainder of this subsection.
Legal FID. According to federal regulations, FID is lawful only if it is conducted for one or more of the six types of legal FID detailed in Table 3.
Legal Facility-Initiated Involuntary Discharge (FID)
Unlawful FID. Unlawful FID is referred to by a variety of terms, such as “patient dumping,” “hospital dumping,” “improper eviction,” and “wrongful discharge” (Curtin, 2016; Pipal, 2012).
Populations at Risk
Several categories of residents appear to be most at risk of FID, including Medicaid beneficiaries (State of Maryland v. Neiswanger Management Services LLC, 2018), delinquent payors (HCPro, 2016), and individuals with challenging medical needs or disruptive behaviors, including residents with dementia (Jaffe, 2016; Pipal, 2012). Information on the populations at risk of FID was reported most often in the grey literature; little scientific evidence was available.
The prevalence of FID is under debate, but multiple data sources indicate that it has increased in recent years. In general, consumer advocates (including some state officials [e.g., ombudsmen]) depict a high prevalence. According to the Center for Medicare Advocacy (2018), the Long-Term Care Ombudsman program handled more than 9,000 complaints about FID in 2016, whereas NH providers argue that many complaints about FID are unsubstantiated (Jaffe, 2017b). According to Caudill (2017), the Long-Term Care Ombudsman in Morehead, Kentucky, “Each year, thousands of citizens are involuntarily evicted and/or transferred from nursing facility homes” (para. 1). However, no definitive research has clarified the prevalence, and data regarding FID nationwide are not maintained (Francis, 2008).
The literature, including multiple peer-reviewed articles, suggests that compared with other types of FID, relatively strong data are available regarding FID resulting from NH closures (Castle, Engberg, Lave, & Fisher, 2009; Feng et al., 2011; Massachusetts Senate Post Audit and Oversight Committee, 2003; Zinn, Mor, Feng, & Intrator, 2009). Because NH closures are facility-level events wherein all residents are discharged, rather than a resident-level event wherein only one resident is discharged, estimating the prevalence of FID resulting from NH closures is possible with just facility-level data. For example, between 1999 and 2008, approximately 16% of NHs closed, which was accompanied by a cumulative net loss of >5% of NH beds (Feng et al., 2011), resulting in FID for residents who occupied those beds.
Processes and Practices
Several FID processes and practices are described in the literature, including legal and unlawful FID processes.
Legal FID Processes and Practices. In most cases, NHs must provide to the resident (and physician and family member when available) a written notice at least 30 days before the proposed FID. The notice must include the reason for the discharge, proposed discharge date and destination, resident's rights to a hearing to appeal the discharge and to representation at the hearing, and contact information for the state Long-Term Care Ombudsman program. If the resident will be transferred to a hospital, the notice must also include information about the state bed-hold policy (i.e., requirements that specify how long a NH must retain a bed for a resident who it has discharged), including the bed-hold duration and reserve bed payment, if any; and re-admission to the NH (exceptions listed at CFR ). In addition, if the resident is mentally ill or has a developmental disability, the notice must include contact information for other appropriate agencies. Furthermore, before a resident is discharged, the NH must help prepare that individual for relocation and work with the resident or his/her surrogate to design a care plan to assist with transitioning to the new setting (Carlson, 2010; Caudill, 2017; CMS, 2017c). Some state rules provide more detailed and specific procedures for relocating a resident and address repercussions of unlawful FID (Isele, 2010).
Although legally required FID processes and practices are described in the literature, awareness of these requirements is limited across many stakeholder groups—including residents, families, and NH operators—and these requirements are frequently violated (Curtin, 2016; Pipal, 2012; Schneidewinde, 2018). Although FIDs are addressed in some law journals (Carlson, 2010; Pipal, 2012), literature on their legal aspects has been scarce.
Unlawful FID Processes and Practices. Many unlawful FID processes and practices are described in the grey literature, including noncompliance with 30-day advance notice requirements (Curtin, 2016), false reporting of reasons for FID (Francis, 2008; Ho, 2009; Pipal, 2012), and strategically timing FID to prevent readmissions (Ho, 2009). Additional unlawful FID processes and practices discussed in the grey literature include using admissions agreements between residents and NHs that appear to give facilities latitude to conduct FID for reasons that are not legal justifications (e.g., for being “objectionably untidy”) (Pipal, 2012, pp. 258–259) and offering bounties (Jaffe, 2017b) or placement fees (Greene, Lepore, Lux, Porter, & Vreeland, 2015) to discharge destinations or placement agencies to facilitate FID. Some unlawful practices are reportedly facilitated by residents, families, and NH staff who are unaware of the legal requirements for FID (Pipal, 2012).
The grey literature identifies many destinations for residents after FID, including hospitals, other NHs, psychiatric facilities, homeless shelters, motels, unlicensed care homes, residents' family members' homes, and the street (Bernard & Pear, 2018; Francis, 2008; Ho, 2009; Jaffe, 2017b). Although the frequency of FID to these destinations or the extent of choice that individuals have in their destinations was reported in the literature, resident destinations after NH closures were determined in multiple studies in the peer-reviewed literature. After a NH closure, Laughlin, Parsons, Kosloski, and Bergman-Evans (2007) reported that residents were “dispersed to a number of different institutions” (p. 24) and depicted these destinations as rather varied in comparison with the discharging NH: “…some environments were similar to that of the closed facility, others were different” (p. 24). Capezuti et al. (2006) found that after one NH closed, residents' destinations included locations outside the community and state where the NH had closed. Although the literature discusses FID destinations after NH closures, it is unclear how long residents stay at their initial FID destinations even after NH closures (Holder & Jolley, 2012).
The grey literature indicates that NH provider motivations for legal FID include concerns about the well-being of the resident or other residents in the NH, NH closure, and nonpayment (Jaffe, 2017a; State of Maryland v. Neiswanger Management Services LLC, 2018), whereas motivations for unlawful FID include preferences for private pay and Medicare rates compared with Medicaid rates (Curtin, 2016; HCPro, 2016; Ho, 2009; Pipal, 2012).
Debate about provider motivations is reflected in the grey literature, generally with providers reporting motives for legal FID and consumer advocates reporting motives for unlawful FID. Distinguishing between motives for legal and unlawful FID can be difficult. Debate about FID legality has some basis in a reported “tension in the regulations” (Bernard & Pear, 2018, para. 15), which Dr. David Gifford of the American Health Care Association explained as follows:
[The regulations] clearly state that if someone can harm themselves or others…the individual can be discharged. But the regulations also clearly say that the goal is to not discharge people, and they have a right to stay there and receive care.
Policy, Regulatory, and Financial Factors
Many policy, regulatory, and financial factors appear to affect FID. These factors are described as follows.
Medicaid Rates. Medicaid rates for NH services are substantially lower than Medicare rates, and Medicare rates can be lower than private rates. These differences are commonly depicted in the grey literature as promoting FID among individuals covered by lower rates (e.g., Medicaid beneficiaries), but some provider representatives refute this impact (Bernard & Pear, 2018; Francis, 2008).
Medicaid Eligibility Policies. Federal and state guidelines shape Medicaid eligibility policies and are important for determining the legality of FID. For example, attention to federal and state Medicaid eligibility policies helps distinguish between a NH resident who is refusing to pay and is thus subject to legal FID from one who is unable to pay and is not subject to legal FID (Isele, 2010). Isele (2010) explains that state policies help clarify the federal requirements that apply when a NH resident has applied for Medicaid eligibility but before the eligibility determination has been made (CMS, 2017c; Justice in Aging, National Consumer Voice for Quality Long-Term Care, & Center for Medicare Advocacy, 2017). As CMS (2017c) explains, “A resident cannot be discharged for nonpayment while their Medicaid eligibility is pending” (p. 162).
The combination of federal and state Medicaid guidelines also has implications for FID that could result from NH residents losing their Medicaid coverage. For example, potential Medicaid cuts in a state could eliminate coverage of NH services and thereby result in FID for many NH residents, but such a cut would need to be federally approved first (Begnaud, 2018).
Managed Long-Term Services and Supports (MLTSS) Programs. State Medicaid programs adopting MLTSS plans might increase FID prevalence by encouraging the transition of Medicaid beneficiaries out of NHs. A local newspaper discussed this situation leading up to Florida's adoption of MLTSS, which warned of a “granny dumping bonus” and stated, “Florida's new Medicaid reform law will reward health plans for cutting numbers of seniors in nursing homes” (Singer, 2011, para. 1). According to an attorney interviewed for the newspaper article, “the law could result in eviction of seniors from nursing home care…. Managed care companies will be paid bonuses for evicting seniors from nursing homes” (Singer, 2011, para. 2 and 10). However, arguing against these contentions, State Senator Joe Negron (R-Stuart), who helped write the law, said such FID concerns are unfounded (Singer, 2011).
Distinct Part Regulations and Financial Screening. Distinct part regulations, whereby nursing facilities set aside parts of the facility by specific funding sources (e.g., Medicaid, Medicare), may also impact FID. According to the USDHHS Office of Inspector General (2000), facilities might use distinct part rules in coordination with financial screening to facilitate unlawful FID when individuals “spend down” to qualify for Medicaid, eligibility for which requires limited financial resources (Lepore, 2019).
FID Process Requirements. In addition to the requirements described above in the section on legal FID processes and practices, NHs are required to send a notice of proposed FID to the Long-Term Care Ombudsman program (CMS, 2017b). Although it is unclear how commonly or consistently NHs adhere to this requirement, the requirement was discussed in the grey literature as a potentially effective way to limit unlawful FID (Justice in Aging et al., 2017).
Policy and Regulatory Enforcement. Grey literature about FID often discussed the enforcement of federal and state policies and regulations as being weak, and as contributing to, or at least not deterring, FID (Schneidewinde, 2018). The dearth of policy enforcement—even when the state has the power to enforce, and even after court rulings in favor of inappropriately discharged residents—was also discussed in the grey literature (Jaffe, 2016, 2017a). Enforcement of bed-hold policies, in particular, was depicted as weak by consumer advocates who contend that some facilities ignore bed-hold requirements so that they can inappropriately discharge Medicaid beneficiaries (Laise, 2012). Although requirements exist for legal FID, the limited enforcement of requirements leaves the legal ramifications of unlawful FID unclear.
In addition to disrupting residents' housing and care routines through involuntary relocation, FID is reported to have negative outcomes for resident safety, health, and well-being, but the evidence of those impacts is limited. Heightened risk of falls after FID was reported in the peer-reviewed literature (Capezuti et al., 2006; Holder & Jolley, 2012). Advocacy literature reports multiple negative outcomes and risks of FID, including increases in mortality, morbidity, distance from loved ones, confusion, apprehension, depression, loneliness, sleep disturbance, self-care deficits, and anxiety (Carlson et al., 2016; CMS, 2018). The terms “NH transfer trauma” and “relocation stress syndrome” are used in the grey literature to depict multiple negative outcomes of FID, including increased mortality, morbidity, depression, anxiety, and falls, and reduced immunocompetence and psychosocial functioning (Capezuti et al., 2006). Some NH operators acknowledge potential risks of FID including mortality (Burnside & Simon, 2018).
In the grey literature, loss of functional independence, loss of needed services, and unmet needs were reported outcomes in one FID case when the resident was discharged to a hospital (Jaffe, 2017b). Peer-reviewed studies published before the current study period (i.e., before 2010) also report negative outcomes, including decline in health, accelerated death, and reduced long-term survival (Carlson, 2010). In addition to outcomes of actual FIDs, the threat of FID was reported in the grey literature to have negative outcomes, including depressive symptoms, for residents (Ho, 2009).
FID is a major concern for NH residents, their advocates, policymakers, and NH providers, as discharges and evictions have become the top category of NH complaints reported to the federal Long-Term Care Ombudsman program (ACL, 2018), and research shows adverse health and functional outcomes for residents post-FID (Capezuti et al., 2006). The current review synthesized information from peer-reviewed and grey literature about the previously discussed eight FID topics. Although substantial gaps persist in the knowledge of FID, findings distinguish between six types of legal and unlawful FID and identify common FID destinations. Findings also highlight challenges with understanding foundational information about FID, including challenges with differentiating legal from unlawful FID, determining the prevalence of FID, and identifying motivations for FID. Findings have implications for policy, practice, and research.
The literature suggests that Medicaid beneficiaries (State of Maryland v. Neiswanger Management Services LLC, 2018), delinquent payors (HCPro, 2016), and individuals with challenging needs or disruptive behaviors (Jaffe, 2016; Pipal, 2012) are at a particular risk of FID, but the literature about who experiences FID is inconclusive. Research is needed to clarify which characteristics of NH populations—including clinical and coverage characteristics—are predictive of FID and which populations experience specific types of FID. Clarifying which populations are most at risk of FID could be an important step in policy planning for addressing FID because it could help steer resources, attention, and regulatory protections to residents who are most at risk and to NHs that predominantly serve those residents. Furthermore, because the current study was inclusive of grey and peer-reviewed literature, rather than exclusively focused on research literature, it did not include several methodological components of systematic reviews, such as assessing risk of bias of individual studies or conducting quantitative meta-analyses. As a more substantive body of scientific literature on FID is established, these analytic steps will be beneficial.
Findings also highlight a range of negative outcomes from FID, such as heightened risk of falls (Capezuti et al., 2006; Holder & Jolley, 2012) and increases in morbidity and mortality, confusion, depression, and loneliness (Carlson et al., 2016; CMS, 2018). Although the risk of adverse outcomes from FID appears evident, more rigorous research is needed to clarify many outcomes issues and identify strategies that diminish adverse outcomes of FID and promote positive outcomes. Some outcomes issues include how different types of FID impact specific outcomes for different resident populations (e.g., residents with cognitive impairment, residents who paid down to Medicaid eligibility) and how outcomes differ by FID destination.
Determining the legality of FID is challenging because legal and unlawful FIDs are often not distinguishable by existing data sources and because NHs might falsely report reasons for FID so that unlawful FIDs appear to be legal (Francis, 2008; Ho, 2009; Pipal, 2012). To address this challenge, research is needed to advance the capacity to distinguish between legal and unlawful FIDs of individual residents. This focus on FIDs of individual residents is needed because they are not discernible in the current literature, whereas mass FID resulting from NH closures can be determined in a relatively straightforward manner by using publicly available administrative NH data (Feng et al., 2011). Longitudinal research that tracks resident health and payment sources over time may help distinguish legal versus unlawful FIDs because changes in health might precipitate a variety of different types of legal FIDs. These different types include FIDs that are necessary to the resident's welfare (i.e., if the resident's level of need progresses to surpass the level of services that can be provided at the NH) and FIDs that are required because the resident no longer needs NH care or for the health or safety of others. In contrast, changes in payment sources (e.g., from private pay or Medicare to Medicaid) might precipitate unlawful FIDs.
Although federal policies and regulations play a major role in specifying the legality of FIDs and the requirements of FID processes, state policies, regulations, and long-term care financing and delivery systems can also impact the prevalence of FID. For example, the literature indicates that state adoption of Medicaid MLTSS programs might increase FID prevalence (Singer, 2011), but no known research regarding this issue has been conducted. Research is needed to clarify the possible impacts of state policies, regulations, and long-term care financing and delivery systems on FID. To clarify these impacts, studies are recommended that compare FID prevalence or complaints about FID across states with different features (e.g., with and without MLTSS programs) and within states over time as different polices, regulations, or NH financing approaches are adopted (e.g., before and after MLTSS adoption).