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The overall aim of the present thesis was to study factors related to transfers of older people between nursing homes, emergency department and hospital care.

The thesis was based on four studies and used three methods: focus group discussions, structured review of electronic healthcare records, semi-structured interviews with registered nurses and general practitioners.

Study I: nursing home nurses found it difficult to decide whether older residents should be referred to hospital from the nursing home. Hospital registered nurses reported often trying to stop premature discharges or having to carry out the discharge although it had not been fully prepared. Study II: transfer rate to ED was 594 over 9 months among a total of 431 residents (M 1.37 each). 25% were caused by falls and/or injuries, 63% resulted in hospitalization (M 7.12 days). The transfer rate was 0.00-1.03 transfers/bed; it was higher for private for-profit providers than for public/private non-profit providers. Study III: nursing homes with high transfer rates had fewer updated advance care plans than did nursing homes with lower transfer rates. More nurses from nursing homes with low transfer rates had a specialist education and training in dementia care and had worked longer in eldercare. Study IV: general practitioners perceived registered nurses’ continuity, competence and collaboration with family members as important to quality of care in nursing homes; inadequate staffing, lack of medical equipment and less-than-optimal IT systems for electronic healthcare records are impediments to patient safety.

The findings indicate that organizational factors could explain differences in transfer rates between nursing homes. The studies highlight the importance of advance care planning together with residents and family members in facilitating future medical decisions. Registered nurses’ continuity and competence are perceived as crucial to quality of care. To meet increasing demands for more complex medical treatment at nursing homes and to provide high-quality palliative care several changes should be made: Nursing homes should be equipped with suitable medical equipment and registered nurse staff should be matched accordingly; importantly, registered nurses and general practitioners should be able to access each other’s healthcare record systems.