OPTIMISTIC: A Program to Improve Nursing Home Care and Reduce Avoidable Hospitalizations
“Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care” (OPTIMISTIC) is a multi-component model of care which provides enhanced services and opportunities for quality improvement for long-stay nursing home residents, with a primary goal of reducing avoidable hospitalizations. Registered Nurses (RNs) placed full-time in nursing facilities, supported by Nurse Practitioners (NPs), deliver interventions including championing INTERACT quality improvement tools, comprehensive advance care planning, facilitating collaborative chronic care, and improving transitions of care for residents who do transfer out of the facility.
This model is being tested as a 4-year demonstration project funded by the Centers for Medicare and Medicaid Services Innovations Center. The specially trained OPTIMISTIC RNs provide direct clinical support, education and training to the staff, review medications, and clarify goals of care. NPs respond to urgent resident care needs, with evening and weekend availability for in-person visits, evaluate residents returning to the facility after a hospitalization, lead care management reviews, and work collaboratively with primary care providers to optimize chronic disease management. The clinical staff is supported by a project team with extensive expertise in geriatrics and palliative care.
There have been many “lessons learned” in the implementation of this project, particularly around communication with stakeholders and careful role definition for added staff. Scaling up and disseminating this model will be facilitated by consideration of these key elements, as well as by attention to how financial incentives support delivery of high-quality care in the nursing home.
Key wordsNursing home Implementation science Hospitalization Medicare Dual eligible Transitions of care Collaborative care Advance care planning Quality improvement CMS Innovations Center
- 2.Kramer A, Eilertsen T, Goodrich G, Min S. Understanding temporal changes in and factors associated with SNF rates of community discharge and rehospitalization. Washington, DC: Medicare Payment Advisory Commission; 2007.Google Scholar
- 3.Ouslander JG, Lamb G, Perloe M, Givens JH, Kluge L, Rutland T, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761]. J Am Geriatr Soc. 2010;58(4):627–35.CrossRefPubMedGoogle Scholar
- 5.Walsh EG, Freiman M, Haber S, Bragg A, Ouslander J, Wiener J M. Cost drivers for dually eligible beneficiaries: potentially avoidable hospitalizations for nursing facility, skilled nursing facility, and home and community-based services waiver programs: centers for medicare and medicaid services; 2010. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/costdriverstask2.pdf. Accessed 23 Feb 2014.
- 6.Polniaszek S WE, Wiener JM. Hospitalizations for Nursing Home Residents: Background and Options: Health and Human Services; June 2011 http://aspe.hhs.gov/daltcp/reports/2011/NHResHosp.pdf. Accessed 12 Sept 2014.
- 7.Center for Medicare and Medicaid Services. Initiative to reduce avoidable hospitalization among nursing facility residents 2014. http://innovation.cms.gov/initiatives/rahnfr/. Accessed 7 Feb 2014.
- 11.Gundersen Health System. Respecting choices: advance care planning. 2014.Google Scholar