OPTIMISTIC: A Program to Improve Nursing Home Care and Reduce Avoidable Hospitalizations

Abstract

“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.