For many nursing home residents, a trip to the hospital can be a jarring experience — one that leaves them confused and stressed. Yet avoidable transfers happen far too often, not only disrupting a resident’s routine but also costing the U.S. healthcare system $2.6 billion annually.

When researchers at the University of Missouri recently looked at the decision-making process for whether or not to transfer nursing home residents to the hospital, they quickly discovered that it’s complicated — particularly for residents with cognitive impairment who may not be able to communicate their preferences.