The overall aim of OPTIMISTIC is to reduce unnecessary hospitalization of nursing home patients. This is achieved by placing RNs and NPs in long-term care (LTC) facilities to extend clinical resources, implement evidence-based tools to improve care and communication, and lead efforts in advance care planning.

Working closely with facility staff, OPTIMISTIC team members align their efforts along
three primary goals:

Improving Medical Care

Early recognition and management of acute conditions

Resident-centered, evidence based chronic care management

Onsite training and mentorship for nursing home staff

Enhancing Transitional Care

Improving provider-to-provider communication 

Family and caregiver education of transition procedures 

Focus on follow-up with receiving physicians

Supporting Palliative Care

Systematic Advance Care Planning 

Improved support and education for palliative care 

Increased access to pain and symptom management