Pilot Prevents Unnecessary Hospitalizations by Optimizing Transfers of Nursing Facility Residents

Designed to prevent unnecessary hospitalizations of nursing facility patients, a new study focuses on how to optimize transfers of these patients between facilities and acute-care institutions by improving care and communication, according to research from Indiana University (IU) and Regenstrief Institute.

The paper, “The OPTIMISTIC approach: preliminary data of the implementation of a CMS nursing facility demonstration project,” is published in the Journal of the American Geriatrics Society. It describes the program, which is called OPTIMISTIC, an acronym for Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care, and is supported by a four-year, 2012 award of $13.4 million from the CMS.

The goal of OPTIMISTIC is to improve care and communication within nursing facilities, and between these facilities and acute-care institutions, so problems can be caught and solved before it becomes necessary to transport a resident to the hospital. According to the report, nationally estimated rates of potentially avoidable hospitalizations of nursing home residents range as high as 50 percent.

Throughout the project, nurses provide direct support to long-stay nursing home residents and their families, and offer education and training to the staff. OPTIMISTIC nurses lead care management reviews to optimize chronic disease management, reduce unnecessary medications and clarify care goals. Earlier detection and prevention are key to the program’s success. If not addressed and prevented, problems such as medication errors, lack of advance directives and lack of recognition of changes in medical status could result in hospitalization of the nursing facility resident.

Researchers say they chose the acronym because they are optimistic about the care they can provide frail, older adults. Working with their colleagues and community partners, they are providing education and training in real-world environments to develop a new model of care and putting increased resources into nursing homes, which they hope will result in system change regionally and across the nation.

Source: Indiana University School of Medicine, January 8, 2015

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Guide to Care Transition Management delivers a comprehensive set of 2013 transitional care management benchmarks from 86 companies as well as select metrics from related interventions influencing the quality of care transitions: Medication Adherence, Reducing Readmissions, Case Management, Patient-Centered Medical Home and Health Coaching.

This entry was posted in Avoidable Hospitalization, Care Coordination, Care Transitions, Case Managers, Case Managers and the Patient Experience, Disease Management, Elderly Care, Hospital Readmissions, Hospital Services, Hospital Training, Improving Patient Care and tagged , , , . Bookmark the permalink.
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