We know that moving, even if it is a positive choice, can be a cause of stress and even depression and grief for any person. When symptoms like these exist, it may be referred to as transfer trauma or relocation stress syndrome (RSS).
NANDA (formerly the North American Nursing Diagnosis Association) lists “Relocation Stress Syndrome” as physiological and/or psychosocial disturbance following transfer from one environment to another. It describes defining characteristics, nursing outcome and intervention classifications (NIC and NOCs).
Nursing home residents being transferred between facilities are particularly vulnerable to transfer trauma/RSS, and such transitions are especially difficult for those who have cognitive or mental health issues and those with reduced physical function, who are dependent for their everyday and intimate care. The deleterious effects of transfer trauma have been recognized and defined in legal cases since the 1970s as “…the recognition that the transfer of geriatric patients to any unfamiliar surroundings produces an increased rate of mortality and morbidity.”
For long term care residents, the nursing facility is their home, and we would expect them to grieve the loss of their environment and community of both staff and residents. Feelings of security and safety are enhanced where people, surroundings and routines are familiar and predictable, and this becomes especially important to those with cognitive, emotional, and physical differences that reduce independence and make it harder for them to cope with change.
In the case of an involuntary relocation, such as the closure of a nursing facility, or where Medicare eligibility has ended, anticipatory grief, stress and anxiety begin when residents discover the potential of losing their home and being sent elsewhere. Research has shown that nursing home residents and their families perceive being disempowered, being left out of decision making and having less autonomy. Residents being discharged when their facility is closing have even less choice or control and are therefore more vulnerable to transfer trauma. The uncertainty for vulnerable individuals may cause psychological distress, with changes in habits, activities and behaviors leading to outcomes that include premature death, increased depression, cognitive decline, behavioral issues, and withdrawal from social activities.
Discharge Planning and Transfer Trauma
The impact of transfer trauma can be life-threatening, but its impact can be predicted and mitigated through proper relocation planning. Even where a transfer is not a choice, the effects of transfer trauma/RSS can be mitigated with resident-centered discharge planning involving the resident, their friends and family. Providing clear communication, setting expectations and preparing for the move by providing information about their new home (including for example, visits in-person or virtual, photos, written descriptions, public transport/parking options).
Efforts to minimize transfer trauma are mandated. The facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. 42 CFR §483.15(c)(7)). Staff should take steps to minimize transfer trauma with potential for unnecessary and avoidable anxiety or depression.
Individual discharge planning is mandated, and the resident and resident’s representative need to be treated as partners in planning the discharge, focusing on the resident’s discharge goals and treatment preferences. 42 CFR §483.21(c). Any new nursing home placement should be based on ensuring the facility can meet the resident’s care and treatment preferences. The facility must also share essential care information to the receiving facility before initiating a transfer or discharge. 42 CFR §§483.15(c)(2)(iii), 483.21(c)(2).
Transfer Trauma and Closure of Laguna Honda Hospital
In the context of Laguna Honda Hospital (LHH) announcing a closure plan following withdrawal of federal Medicare and Medi-Cal (Medicaid) funding, residents are at high risk of transfer trauma. LHH has a tradition of caring for San Francisco’s most vulnerable citizens. For many it is perceived as a place of last resort for those without social networks or families, financial resources or homes. NANDA state that people at risk for RSS are those with a “history of loss” and all nursing home residents have experienced loss. In our society it is already hard to place people who are Medi-Cal only eligible and so options are few. In San Francisco County it is not possible to be admitted to a nursing home if your only source of funding is Medi-Cal. For Medi-Cal recipients, their physical, emotional, and financial dependence means that the nursing home is more than a provider of nursing and medical services – it is their home, their community and for the many without any outside contact, their world. Fifty-seven residents were in the first phase of discharges. Within weeks (between 10 and 67 days) nine had died and at last count 12 in totali. Mandated discharges were halted and have not resumed as yet.
Indeed, this was the case with the closure of two long term care units (one of which was subacute) at St. Luke’s Hospital in San Francisco (now reopened as CPMC Mission Bernal campus). Fifty-three residents received notice of relocation in June 2017. Following protests, the 17 remaining residents from the sub-acute unit were finally relocated to a newly licensed sub-acute unit at CPMC Davies campus in August 2018. It was ultimately acknowledged that with the closure of St. Luke’s, there were zero sub-acute beds in county.
As with the closure of St. Luke’s long term care beds, one of the few certainties about where LHH residents will go is that they will certainly be moved out of county often at some distance and potentially out of state, removed not only from the familiar community and environment LHH provides, but from any social support and sense of belonging to the wider community of San Francisco.
The Center for Medicaid and Medicare Services (CMS) has given a series of deadlines to defund Laguna Honda Hospital because they consider current standards of care at there to be inadequate. Decertification will lead to a withdrawal of Medi-Cal and Medicare funds for residents at LHH and effectively lead to the closure of the facility. However due to the ineffective enforcement of nursing home regulations in general, especially failure to give deficiencies where chronic low staffing is evident, decertification becomes “…an ineffective means of enforcing minimum standards”. In other words, there are no guarantees that Laguna Honda Hospital residents will be relocated to facilities with better standards of care.
Dr. Liz Halifax is an Assistant Professor in the Social & Behavioral Sciences Department at UCSF.