Hickman, S. E., Unroe, K. T., Ersek, M. T., Buente, B., Nazir, A., & Sachs, G. A. (2016). An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting. Journal of the American Geriatrics Society, n/a-n/a. doi: 10.1111/jgs.14463

Abstract: Objectives: To describe processes and preliminary outcomes from the implementation of a systematic advance care planning (ACP) intervention in the nursing home setting. Design: Specially trained project nurses were embedded in 19 nursing homes and engaged in ACP as part of larger demonstration project to reduce potentially avoidable hospitalizations. Setting: Nursing homes. Participants: Residents enrolled in the demonstration project for a minimum of 30 days between August 2013 and December 2014 (n = 2,709) and residents currently enrolled in March 2015 (n = 1,591). Measurements: ACP conversations were conducted with residents, families, and the legal representatives of incapacitated residents using a structured ACP interview guide with the goal of offering ACP to all residents. Project nurses reviewed their roster of currently enrolled residents in March 2015 to capture barriers to engaging in ACP. Results: During the initial implementation phase, 27% (731/2,709) of residents had participated in one or more ACP conversations with a project nurse, resulting in a change in documented treatment preferences for 69% (504/731). The most common change (87%) was the generation of a Physician Orders for Scope of Treatment form. The most frequently reported barrier to ACP was lack of time. Conclusion: The time- and resource-intensive nature of robust ACP must be anticipated when systematically implementing ACP in the nursing home setting. The fact that these conversations resulted in changes over 2/3 of the time reinforces the importance of deliberate, systematic ACP to ensure that current treatment preferences are known and documented so that these preferences can be honored.

Abstract: Transitions to and from hospitals and nursing facilities (NFs) expose patients to lapses in care due to miscommunication. Potential consequences of these breakdowns in communication include medication errors, poor follow-up care after transitions, and rehospitalization. In 2012, the Centers for Medicare & Medicaid Services decided to fund an initiative made up of seven projects to re- duce potentially avoidable hospital transfers. One of the these projects, the Op- timizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project, implements registered nurs- es and nurse practitioners to assist with and close gaps in transitions of care for NF patients. The authors provide an overview of the transition visit model and a preliminary analysis of the outcomes of their interventions.


Unroe, K. T., Nazir, A., Holtz, L. R., Maurer, H., Miller, E., Hickman, S. E., . . . Sachs, G. A. (2015). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project. Journal of the American Geriatrics Society, 63(1), 165-169. doi: 10.1111/jgs.13141

Abstract: The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project aims to reduce avoidable hospitalizations of long-stay residents enrolled in 19 central Indiana nursing facilities. This clinical demonstration project, funded by the Centers for Medicare and Medicaid Services Innovations Center, places a registered nurse in each nursing facility to implement an evidence-based quality improvement program with clinical support from nurse practitioners. A description of the model is presented, and early implementation experiences during the first year of the project are reported. Important elements include better medical care through implementation of Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. There were 4,035 long-stay residents in 19 facilities enrolled in OPTIMISTIC between February 2013 and January 2014. Root-cause analyses were performed for all 910 acute transfers of these long stay residents. Of these transfers, the project RN evaluated 29% as avoidable (57% were not avoidable and 15% were missing), and opportunities for quality improvement were identified in 54% of transfers. Lessons learned in early implementation included defining new clinical roles, integrating into nursing facility culture, managing competing facility priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. The success of the overall initiative will be measured primarily according to reduction in avoidable hospitalizations of long-stay nursing facility residents.


Holtz, L. R., Maurer, H., Nazir, A., Sachs, G. A., & Unroe, K. T. (2015). OPTIMISTIC: A Program to Improve Nursing Home Care and Reduce Avoidable Hospitalizations. In M. L. Malone, E. A. Capezuti & R. M. Palmer (Eds.), Geriatrics Models of Care: Bringing 'Best Practice' to an Aging America (pp. 287-292). Cham: Springer International Publishing.

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.