Hospital Transfer Decision-Making for Residents with Dementia in Long-Term Care: A Qualitative Study of Interprofessional Perspectives

Background: Hospital transfers of residents with dementia may provide them with access to acute diagnosis and treatment but also disrupt their continuity of care, which is essential for residents’ stability, safety, and quality of care. The aim of this study was to examine how transfer decisions are produced within the organizational context of long-term dementia care and how they may affect continuity of care. Methods: A qualitative descriptive design was used, supplemented by retrospective referral data. The study was conducted in a 200-bed dementia-specialist long-term care facility. Referral records over three years were reviewed to describe transfer patterns, reasons, and outcomes. Semi-structured interviews were conducted with 15 nurses and 2 physicians. Referral data were analyzed descriptively, and interviews were analyzed using Reflexive Thematic Analysis (RTA). Results: A total of 578 referrals to hospital emergency departments were identified; 34.9% resulted in hospitalization. Three themes were identified: (1) From recognition to authorization, describing interprofessional hierarchy in referral decision-making; (2) When uncertainty becomes risk, describing how limited diagnostic and treatment capacity shifted decisions toward transfer; and (3) Protecting continuity, describing staff concerns about the disruptive effects of transfer. Overall, decisions were shaped by clinical uncertainty, organizational conditions, and continuity-of-care concerns. Conclusions: Transfer decisions for residents with dementia are context-dependent organizational judgments, not solely responses to acute clinical deterioration. Strengthening institutional capacity, decision-support tools, staff training, and advance care planning may help preserve continuity of care, reduce avoidable disruption, and improve resident safety and quality of care.