IU, Regenstrief initiative aims to decrease hospitalization of nursing home residents

October 24, 2013

INDIANAPOLIS -- The OPTIMISTIC study, an innovative initiative developed by research-clinicians from Indiana University and the Regenstrief Institute to improve health care, reduce avoidable hospitalizations and increase access to palliative care, is now underway in 19 nursing facilities throughout Central Indiana. The program is supported by a $13.4 million 2012 award from the Centers for Medicare & Medicaid Services (CMS).

Emergency room visits and hospitalizations are common but extremely stressful to nursing home residents -- many of whom are physically frail and/or cognitively impaired -- and to their families. Total costs for these potentially avoidable hospitalizations for Medicare-Medicaid enrollees for 2011 have been estimated by CMS to be an estimated $3 billion.

The goal of OPTIMISTIC -- Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care -- is to improve care and communication within nursing facilities and between these facilities and acute care institutions so problems can be caught and dealt with before it becomes necessary to transport a resident to the hospital.

"We chose the acronym OPTIMISTIC to set a tone for how we feel about the potential to improve care for this vulnerable population," said OPTIMISTIC project co-director Kathleen T. Unroe, M.D., MHA, Regenstrief Institute investigator, assistant professor of medicine at the IU School of Medicine and IU Center for Aging Research center scientist. "Working with the IU School of Nursing and the University of Indianapolis, and community partners including nursing homes, we are providing education and training in real-world environments to develop a new model of care, putting increased resources into nursing homes, which we hope will result in system change in Indiana and across the nation."

For example, nursing aides working in the 19 nursing homes are trained to recognize warning signs to identify a change in a resident early -- for example, that a resident's swollen feet may be an indication of heart failure. They and the nursing staff are also educated to communicate rapidly and effectively with the resident's medical team so appropriate treatment can begin before the problem escalates to a level requiring hospitalization.

"Long-stay nursing facility residents are high-need and high-risk individuals who have gotten little attention in the research arena and have been neglected previously to a great extent by health care reform," said Regenstrief investigator Greg A. Sachs, M.D., OPTIMISTIC project director and director of the IU School of Medicine's Division of General Internal Medicine and Geriatrics. Dr. Sachs is also a professor of medicine and an IU Center for Aging Research center scientist. "With OPTIMISTIC, we are working with the residents where they live to improve many aspects of their lives including chronic disease management -- especially for dementia, which affects more than half of long-stay residents -- as well as improve the care they receive during the transition process to and from a hospital, when that transfer is necessary."

In addition to Drs. Unroe and Sachs, OPTIMISTIC is led by Arif Nazir, M.D., IU School of Medicine (medical director); Susan E. Hickman, Ph.D., IU School of Nursing (leader of the palliative care component); Ellen Miller, P.T., Ph.D., Center for Aging and Community, University of Indianapolis (leader of the education/training component); Greg Arling, Ph.D., Regenstrief Institute and IU School of Medicine (leader of the data and evaluation component); and Michael LaMantia, M.D., Regenstrief Institute and IU School of Medicine (leader of the transitions of care component). Laura Holtz, B.S.; Helen Maurer, M.A.; Merih Bennett, M.A. and Ravan Carter, B.S. of the Regenstrief Institute and IU Center for Aging Research manage the project.

OPTIMISTIC is supported by a project team of IU and Regenstrief geriatrics and palliative care experts along with their nursing facility partners. Specially trained nurses are stationed on site at the 19 Central Indiana nursing facilities to provide direct support to long-stay residents as well as education and training to the staff.

OPTIMISTIC nurses also lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications and clarify care goals. Nurse practitioners cover "pods" of geographically related facilities providing additional resources and expertise to the onsite nurses.

Nursing homes participating in OPTIMISTIC are:"OPTIMISTIC benefits our long term residents. An experienced and highly trained RN conducts assessments and evaluations. This work supplements, complements and informs the care that our nursing center staff provide," said Pamela Zanes, RN, BSN, Ed.M., senior director of care transitions, Kindred Heathcare. "The OPTIMISTIC nurse's findings are reviewed and discussed with the physician and nurse practitioner caring for the patient as well as the other members of the interdisciplinary care team. OPTIMISTIC also provides educational sessions for our staff which enhances their ability to care for our residents."

OPTIMISTIC is supported by one of only seven cooperative agreement awards nationwide to implement CMS' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. In addition to Indiana, programs are underway in Alabama, Missouri, Nebraska, New York, Nevada and Pennsylvania.

According to CMS, research has found that approximately 45 percent of hospitalizations among Medicare-Medicaid enrollees receiving either Medicare skilled nursing facility services or Medicaid nursing facility services are potentially avoidable.
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Indiana University

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