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V.L. Keevil1,2,3, A. Liou4, L. Van Der Poel1, S. Wallis1, R. Romero-Ortuno1,5, R. Biram1


1. Department of Medicine for the Elderly, Cambridge University Hospitals NHS Foundation Trust. United Kingdom; 2. Department of Medicine, University of Cambridge. United Kingdom; 3. Cambridge Institute of Public Health, University of Cambridge, United Kingdom; 4. Baylor, Scott and White Medical Center, Temple, Texas, United States of America;
5. Discipline of Medical Gerontology, Trinity College Dublin, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland. Corresponding author: Dr Victoria L Keevil, Box 135, Department of Medicine for the Elderly, Addenbrooke’s Hospital, Hills Road, Cambridge. CB2 0QQ, Email: vlk20@cam.ac.uk. Tel: 01223 217785;

Jour Nursing Home Res 2020;6:104-108
Published online November 18, 2020, http://dx.doi.org/10.14283/jnhrs.2020.27



We describe the frequency, characteristics and outcomes of emergency admissions to one large university hospital in England from residential and nursing homes. Any older adult (>75 years) admitted as an emergency over two years was included. Patient variables were retrieved from an electronic patient record and living status was established using an official register of care homes and manual inspection of medical records. The rate of emergency admission per bed-year was highest from residential homes (mean 0.68, SD 0.24), with lower rates from nursing (mean 0.49, SD 0.20) and dual-registered facilities (mean 0.49, SD 0.23). Older adults admitted from nursing beds had the highest frailty, illness acuity and inpatient mortality but those from residential beds had the highest odds of 30-day readmission, compared to older adults from their own homes (odds ratio 1.63, 95% confidence interval 1.30, 2.04). Residential home residents are frequent users of emergency inpatient services and may benefit most from enhanced community healthcare.

Key words: Care home, hospital outcomes, frailty.



Care home residents are frequent users of emergency hospital services and admission episodes are often complicated by factors such as delirium and deconditioning (1). However, the rates of emergency hospital admission from care homes vary considerably, suggesting that high rates are not inevitable. Some admissions may be avoidable, in that care could have been delivered equally well in the community, or inappropriate, in that the risks of hospital admission outweigh any potential benefits. Lowering the number of avoidable or inappropriate hospital admissions is not only better for patients but could also help reduce pressure on inpatient hospital services (2).
Several vanguard projects across England have sought to optimize the health of care home residents and reduce avoidable or inappropriate hospital admissions. These projects bring together medical, social and voluntary services in new models of care and this ‘Enhanced Health in Care Homes’ (EHCH) framework is due to be applied more widely (3). However, to date these projects have reported mixed success, with results suggesting care home type is an important consideration and interventions appear more successful in residential than nursing homes (4).
It would be helpful to understand more about the care home residents who access emergency hospital services, in order to better inform interventions aimed at reducing unnecessary hospitalization. The characteristics and outcomes of care home residents admitted to a large university hospital in England were previously described (5). However, older adults admitted from residential versus nursing facilities were not differentiated and this is emerging as an important factor. Therefore, we now present updated results examining whether care home residents are homogenous in terms of their rates of admission, characteristics and hospital outcomes or whether nursing and residential home residents differ in these respects.



All emergency inpatient admissions of adults aged >75 years presenting to one hospital were included in this retrospective, observational study approved by the hospital’s Safety and Quality Support Department (Project register number 7368). Presentations to the Emergency Department (ED) without subsequent admission were not included. Data was collected prospectively over two years via an electronic patient record. Additional information on the methodology is available (Appendix 1).
In brief, age, sex, permanent address, admission weight, ED blood tests, discharge specialty, illness acuity (ED Modified Early Warning Score, ED-MEWS), Clinical Frailty Scale score (CFS) (6) and history of ‘dementia or cognitive concern’ were retrieved . A Charlson Co-morbidity Index (CCI) was retrospectively calculated from discharge diagnoses.
Admission post-code was cross-matched with addresses for care homes registered with the United Kingdom regulator, the Care Quality Commission (CQC), within five local counties. Patient records identified as a ‘match’ were further screened using the first line of the address and records were manually checked if this was discordant. The number of registered beds at each care home and care home type (residential, nursing or dual-registered) were ascertained from the CQC website. Patients from dual-registered homes were further investigated to establish whether a nursing or residential bed was occupied at the time of admission.
The following hospital outcomes were available: 30-day inpatient mortality; prolonged length of stay (≥10 days), delayed discharge (stay >1 day beyond the ‘clinically fit date’) and 30-day readmission.

Data analysis

Rates of admission to our hospital from each care home were calculated by: total number of admission episodes from the care home/ (study time [years] x number of beds in the care home); and described by care home type (nursing / residential / dual-registered).
The sample size was then restricted to the first admission episode for each patient and patient characteristics were described as count with percentage (%), mean with standard deviation (SD) or median with inter-quartile range (IQR). Relationships between living status and hospital outcomes were evaluated using logistic regression (prolonged LOS, delayed discharge and 30-day readmission) and Cox proportional hazards regression (inpatient mortality). Living status was categorized as admission from ‘own home’ versus ‘residential bed’ versus ‘nursing bed’ rather than care home type, since the proportional hazards assumption was violated by those living in dual-registered care homes.



Out of 26,700 admission episodes, 2599 were older adults admitted from a care home (residential: 1365, nursing: 518, dual: 716). The majority were from one county (1933). On average the rate of admission from care homes to our centre was 0.59 admission episodes/bed-year (SD 0.25; median 0.59, IQR 0.42-0.77). Residential homes had the highest rate of admission (mean 0.68, SD 0.24; median 0.73, IQR 0.54-0.83), with lower rates from homes offering nursing care (Dual-registered homes: mean 0.49, SD 0.23; median 0.45, IQR 0.31-0.59; Nursing homes: mean 0.49, SD 0.20; median 0.51, IQR 0.41-0.65).
There were 14,766 first admission episodes with complete data for age, sex and living status (32 episodes deleted). Care home residents were more likely to be older, female, have cognitive impairment, higher frailty and present with higher illness acuity compared to older adults admitted from their own homes, with those occupying nursing beds exhibiting the highest frailty and illness acuity (Table 1).

Table 1
Patient Characteristics by Living Status (Own home vs residential bed vs nursing bed)

#characteristics described as mean (standard deviation) unless otherwise indicated; ## median (interquartile range); ###percentages may not add up to 100% due to missing data. *figures exclude those who died during the inpatient admission episode (n=1014). Kg: kilograms. CFS: Clinical Frailty Score. ED-MEWS: Emergency Department Modified Early Warning Score. CRP: C-reactive protein; CCI: Charlson Co-morbidity Index;’ after the sentence ending kilograms. and before CFS.


Hospital outcomes varied by living status (Table 1) and these trends were further explored using multiple regression. Inpatient mortality was higher in those admitted from a nursing bed, then residential bed, then own home (Appendix 2, Figure 1) and associations persisted after adjustment for demographics, co-morbidity and illness acuity (Table 2). Adjustment for frailty completely attenuated associations between admission from a residential bed and inpatient mortality but admission from a nursing bed remained an independent predictor of inpatient mortality.

Table 2
Associations between living status and hospital outcomes (N= 10 145)

Model 1: age and sex adjusted; Model 2: model 1 + CCI, ED-MEWS category (0–3 ‘low acuity’ and ≥4 ‘high acuity’), discharge specialty (medical versus non-medical), and history of dementia or cognitive concern; Model 3: model 2 + clinical frailty scale category (0–4 ‘up to vulnerable’; 5 ‘mild frailty’; 6 ‘moderate frailty’; 7–8 ‘severe–very severe frailty’; and 9 ‘terminally ill’). Prolonged LOS: N=10,145; Delayed discharge: N=8,482; 30-day re-admission: N=9,527. CCI: Charlson Co-morbidity Index; ED MEWS: Emergency Department Modified Early Warning Score. Those who died during the admission episode were excluded from analyses of delayed discharge and 30 day readmission.


All care home residents had lower odds of prolonged length of stay and delayed discharge compared to older adults admitted from their own home, with the strongest associations in those admitted from nursing beds. However, there was no association between admission from a nursing bed and higher odds of 30-day readmission to hospital whereas admission from a residential bed was a strong predictor of this outcome (OR 1.63, 95% CI 1.30-2.04; Table 2).



We report findings consistent with other studies suggesting that residential home residents have higher rates of emergency hospital admission compared to nursing home residents (4). We also found that admission from a nursing bed is an independent risk factor for inpatient mortality and admission from a residential bed is an independent predictor of 30-day readmission.
Our data is not able to untangle why emergency hospital admission rates are highest from residential homes. It is possible that existing community healthcare resources, which are under considerable strain (7), are less able to support older adults in residential compared to nursing care. This is consistent with interim results from several EHCH vanguard projects, which suggest that strategies such as alignment of care homes with a named primary care practice and improved access to a range of community healthcare professionals are only effective in residential homes (8-11). Care homes that have a nursing component are likely to already have links with such community resources, limiting the benefit of additional resource allocation.
Older adults admitted from residential beds also had higher odds of 30-day hospital readmission, consistent with the higher admission rates from residential homes overall. Each admission is an opportunity to provide older adults access to multidisciplinary comprehensive geriatric assessment (12). For those admitted from residential care, our results suggest this should include a focus on factors influencing readmission. It is likely that residents may need extra support immediately after an acute illness episode, beyond the level normally provided by a residential home, mirroring the experience of older adults discharged back to their own homes (13). We have also observed anecdotally that residential homes sometimes continue to look after residents who develop nursing needs, e.g., during terminal decline. We were unable to find any literature describing the extent of this practice and very little evaluating available support, apart from some evidence of confusion around the roles and responsibilities of healthcare professionals providing end of life care in this setting (14). This is a significant knowledge gap.
Admission from a nursing bed was an independent predictor of inpatient mortality and both residential and nursing home residents presented with higher illness acuity and had higher inpatient mortality compared to older adults admitted from their own homes. This reinforces the need for early advanced care planning and development of personalized treatment plans in both residential and nursing home patients admitted to hospital (12). Our findings also support the development of specialized frailty measures to describe the heterogeneity of the nursing home population since it is likely that our measure of frailty, the CFS, exhibited a ceiling effect (15).
Our study has several limitations. We utilized routinely collected data from one hospital limiting the generalizability of results and our ability to capture all admissions from care homes in our area, although it is unlikely that care homes would routinely transfer residents to multiple different hospitals for urgent care. We also had more missing data than a traditional research study and we did not have data on all desired variables, e.g., admission diagnoses (5). Misclassification of living status may also have occurred, although this error will be less than in other studies where manual inspection of individual patient records was not possible (4).
In summary, older adults living in residential homes have high rates of hospital admission and high odds of 30-day readmission. Residential home residents may benefit most from strategies to strengthen community healthcare resources.


Acknowledgements: We would like to thank the Clinical Informatics team at our centre for their help with data retrieval from the electronic patient record system. There are no conflicts of interest to declare.

Funding: No funding was received to conduct this study. VLK is currently funded by a MRC/ NIHR Clinical Academic Research Partnership grant (MR/T023902/1). RRO is funded by Science Foundation Ireland (https://www.sfi.ie) under the 2018 President of Ireland Future Research Leaders Programme, grant number 18/FRL/6188.

Declaration of Conflicts of Interest: The authors declare no conflicts of interest.





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J. De Kerimel1, N. Tavassoli1, C. Mathieu1, P. De Souto Barreto1,2, C. Berbon1, H. Blain3, B. Vellas1,2, Y. Rolland1,2

1. Gérontopôle de Toulouse; 31059 Toulouse, France; 2. INSERM 1027; 31059 Toulouse, France; 3. Pole Gérontologie. Montpellier University Hospital, Montpellier University, MUSE, Montpellier, France. Corresponding author: Professor Yves Rolland, Gerontopôle de Toulouse, 20 rue du Pont Saint Pierre, 31 059 Toulouse, France; Tel: 05 61 77 64 45, E-Mail : rolland.y@chu-toulouse.fr

Jour Nursing Home Res 2020;6:82-88
Published online September 30, 2020, http://dx.doi.org/10.14283/jnhrs.2020.22


Background: Few researches describe old people living in residential homes despite this population being reported to consume much of medical care. Our hypothesis is that many older people living in these structures are frail and that residential home may be targeted places for the implementation of strategy to prevent functional decline. Objective: Our goal is to describe the geriatric characteristics of older people living in residential homes. Methods: This study was a cross-sectional, observational survey carried out in residential homes in Toulouse (France). A questionnaire covering general informations about the residential homes and services offered to residents and a self-assessment questionnaire for all residents (including, FinD questionnaire for frailty, SARC-F for sarcopenia, loneliness, and depressive symptoms, fear of falling) were completed. Results: 1,274 older adults living in 29 residential homes received the questionnaire and 807 (63.3%) people participated (mean age; standard deviation, SD = 83.0; 9.5, female 74.5%). A large majority are not disabled (mean ADL score; SD = 5.4; 0.9), lived alone (83.9%) and suffer from loneliness (29.8%). More than half were positively screened for frailty (53.7%) and 37.2% for sarcopenia; 53.5% had depressive symptoms, and 59.1% reported a fear of falling. Conclusion: Our study suggests that prevalence of frailty in older people living in residential homes is high. This result supports that older people living in residential homes could be a target population to implement strategy to prevent functional decline.

Key words: Frailty, residential home, ICOPE, prevention.



In France, residential homes are institutions for older people that can be described as intermediaries: they host older adults between the community-dwelling people who are mainly autonomous subjects and the Long-Term Care (LTC) residents where dependent older people live. Residential homes offer residents common and personalized equipment or services, which vary from one institution to another and whose use is optional. Older people who live there are considered institutionalized. Residential homes are frequently the first step before living in LTC Facilities (LTCFs), when higher level of care is needed. Resident in residential homes may own or rent their homes. Both family doctors and healthcare professionals (eg, nurses, physiotherapist) respond to their patients in the same way as in the community without a structured organization of care in these facilities as it exists in LTC Facilities (LTCFs). A French national survey reports that residential homes have 101,880 beds among the 727,930 places in all aged care facilities (1) (13.99% of all the places of institution for older adults). This survey reports that 77.3% of residents living in residential home are barely or not dependent on basic activities of daily living. Residents enter about 5 years younger than in the LTCFs (80 years and 8 months versus 85 years and 3 months). Clinical profile and health events of these residents are almost unknown in France and abroad. A recent study in the UK shows that the rate of transfer to the emergency room per year and by bed of older people living in residential homes is significantly higher than that observed in LTCFs (around 68% versus 49% respectively) (2). Other studies in Asia point out that the usual practice in residential homes is to hospitalize residents when an acute problem occurs (3).
This high rate of use of care services in a still autonomous population suggests that this population is frail and could therefore be a suitable population for the implementation of interventions to prevent functional decline. Research in Australia confirms that many subjects living in residential homes are frail (up to 60% using THE FRAIL-NH score) (4) and that their use of hospitalizations is high (5). The current organization of care in these facilities does not seem to be currently focused on strategies for detecting frailty or towards actions to prevent functional decline. However, observational data suggests that in residential homes, an environment conducive to the maintenance of functional capacities is associated with a lower prevalence of frailty (6), suggesting that lifestyle may influence the functional decline of these residents.
Our aim is to describe the geriatric characteristics of older people living in residential homes. Our hypothesis is that many older people living in these structures are frail and that residential homes may be targeted places for the implementation of strategy such as ICOPE (Integrated Care for Older People) to prevent their functional decline (7).




This study is a cross-sectional, observational and descriptive survey of older people living in residential homes. LTCFs or nursing home settings were not involved in this work. Residential homes in the center and suburbs of Toulouse (South-West, France) were contacted by email and phone call and invited to participate in the study. The administrative directors of these facilities were met during a physical interview to explain the purpose of the investigation.


Before data collection, an information meeting was held in each residence to inform residents and their families of the investigation. A poster for the residents, their families and the health care professionals involved was also placed at the reception of each facility. The data collection was carried out over a four-month period (from April 2nd to July 2nd, 2017) for all residential homes and for the resident. Residents could get help from a third party such as a family caregiver in the event of difficulties. A member of the research team (Gérontopôle of the University Hospital of Toulouse) was able, in a place that respected confidentiality, to help people if they had any trouble filling in the forms.

Variables of interest

Two questionnaires were filled out: the first questionnaire provided by the Administrative Director of the residential homes, covered general information about the facility and services offered to residents. This questionnaire provided information on the administrative characteristics of the residential home, the waiting time for the residents before entering the facility, the number of residents in the facility and the number of residents participating in prevention activities. Type of prevention activities (physical activity, nutritional activity, memory workshop, others) organized in the facility was collected.
The second questionnaire was composed of self-reported questions and scales, explained and provided by the administrative directors of the institutions to all their residents. This self-reported questionnaire was accompanied by an information leaflet. The self-reported questionnaire asked for: marital/living status (alone, spouse, other), age, sex, frailty screening (using the FiND (Frail Non-Disabled) instrument) (8), functional status (Katz ADL score for the 6 items of the basic activities of daily life (9) and the 8 items of the Lawton IADL for the instrumental activities of daily life) (10), fear of falling («Are you afraid of falling?» yes/no) and its impact (Does this fear lead you to reduce your activity? yes/no), memory complaint («Do you complain about memory? yes/no), depressive symptoms (Mini-GDS Scale) (11), sleep disturbances (Do you have sleep difficulties? yes/no), feeling of loneliness (Do you suffer from loneliness? yes/no), nutritional status (Body Mass Index (BMI) defined by weight divided by squared height; BMI of less than 21 was considered underweight), screening for sarcopenia (SARC-F Questionnaire) (12), hearing (Are you embarrassed to hear ? Due to hearing disturbances, are you embarrassed for the acts of everyday life) and visual disturbances (due to visual disturbances, are you embarrassed to distinguish faces? are you embarrassed to move? are you embarrassed for other activities?).
The questionnaire FiND (8) is a self-questionnaire with a very good ability to correctly identify frail elderly people living in homes. This questionnaire consists of 5 questions: A. Do you have difficulty walking 400 meters? B. Do you have difficulty climbing stairs? C. In the past year, have you unintentionally lost more than 4.5 kg? D. How many times in the last week have you felt that everything you did was an effort or that you couldn’t go? E. What is your level of physical activity?
If A+B≥1, the individual is considered dependent. If A+B = 0 and C+D+E≥1, the individual is considered frail. If A+B+C+D+E = 0, the individual is considered robust. This questionnaire identifies seniors living at home with an increased risk of functional decline. FiND is a tracking tool to identify at risk subjects, with a pertinence close to the reference assessment tools such as the criteria of Fried’s phenotype criteria.
The SARC-F (12) is a simple five-items questionnaire based on the cardinal characteristics or consequences of sarcopenia: Strength, Aids for walking, ability to Rise from a chair, and Climb stairs, and risk of Falls. The score ranges from 0 to 10. Subjects are considered sarcopenic if the score is ≥4 and the subject is considered non-sarcopenic if the score is 0 to 3 (12).
The Mini-GDS consists of 4 questions and has demonstrated excellent reliability for detecting depressive symptoms in older adults compared to the well validated 30 items GDS scale (11).
All information was provided anonymously and on a voluntary basis. This investigation has been validated by the Toulouse University-Hospital according to the French ethic and regulatory law (Registration number: RC31/17/0068).



A total of 29 residential homes in Toulouse and the suburbs of Toulouse volunteered, 18 residential homes (with 3 establishments run by private commercial or associative groups), and 11 intergenerational facilities (i.e. apartments suitable for seniors). The admission period was more than 1 year for 83.6% of residents and more than 5 years for 31.01%. 44.1% of residents participate in prevention activities proposed by the facilities. These residents participate in balance and physical activity workshops (28.8%), memory workshops (29.5%), nutrition workshops (4.9%) and other workshops (2.8%).

Table 1
Characteristics of the Population living in Residential facilities (n=807)

Notes. FiND, Frail Non-Disabled» [FiND] instrument; ADL, Activity of Daily Living; IADL Instrumental Activity of Daily Living; SARC-F Questionnaire that assessed Strength, Assistance walking, Rise from a chair, Climb stairs and Falls; GDS, Geriatric Depression Scale; BMI, Body Mass Index=Weight/Height².


A total of 1,274 older people received the questionnaire. It was completed by 807 people (63.3%). The response rate per residence varies from 29% to 100%. Resident characteristics are reported in Table 1. In our survey, the typical profile of an older adult living in a residential home is a 83.0-year-old woman, living alone, autonomous for the basic activities of daily life but having difficulties in 2 to 3 instrumental activities of daily life. More than once in two resident is frail. They are rarely robust. In this population, about 4 out of 10 people were positively screened for sarcopenia, 15% are malnourished (BMI<21) and 19% are obese (BMI≥30). Six out of 10 residents are afraid of falling and this fear reduces their involvement in activities in a quarter of cases. A memory complaint is reported by 41.6% of respondents, 24.7% have sleep problems. About one in two people have depressive symptoms and one-third of people complain of loneliness. 6.3 to 31.3% residents have sensory disorders (sight, hearing) that affect their daily life.



In residential home, 53.7% of older adults are frail according to the FiND questionnaire. Prevalence of frailty has been reported to be between 3 to 20% in middle-aged and older community-dwelling Europeans (13). Frail older adults are exposed to various adverse events such as falls, hospitalizations (14) and to a rapid functional decline especially when the uncoordinated and fragmented care are provided (15). This makes the frail older population a target group for the organization of integrated care (16). Our survey shows that seniors living in residential homes are a target group for the organization of preventive measures. The various geriatric areas explored in our survey allow us to consider strategies for preventing functional decline. The lack of coordination of care by a team of caregivers, as it exists in LTCFs, should lead to consider relevant innovative models for primary care.
A care model that could be tested in such a frail, non-disabled population is the WHO Integrated Care for Older People (ICOPE) program for primary care and social services. This community approach initiates a personalized and integrated approach to maintaining the intrinsic abilities of older adults to prevent disability (17). ICOPE offers pre-established models for assessing, responding to and monitoring intrinsic capacities (mobility, vision, hearing, cognition, mood, nutrition) that complement traditional care for chronic diseases, with the aim of preventing dependency (Table 2). The screening test can be carried out by a health professional but also by self-assessment of the patient (or aid of a family caregiver) using a mobile application (App) or BOTFRAIL (conversational robot on the Internet) (18,19). We believe this approach would be particularly relevant in the context of residential facilities. Only 30% of residents participated in physical activity and balance or nutrition programs.
Our study presents the methodological limitations of a self-reported cross-sectional survey. The lack of data on comorbidities and the use of care services (such as hospitalizations or emergency room transfers) and the number of non-responder residents (36.7%) are limits of this research. However, there is currently little information to describe the population living in residential homes in France and our results support the data of the international literature (2, 3).

Table 2
Screening Tool for the “Integrated Care for Older Persons” (ICOPE)


In conclusion, the elderly living in residential homes are mostly frail patients. Our work opens up opportunities for preventive strategies against functional decline on this population. In light of these results, future research should evaluate the implementation of the ICOPE program in residential homes.

Conflict of interest: All the authors declare no conflict of interest.


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