Initiative to Test a Multidisciplinary Model With Advanced Practice Nurses to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

Rantz, Marilyn; Alexander, Gregory L.; Galambos, Colleen; Vogelsmeier, Amy; Popejoy, Lori; Flesner, Marcia; Lueckenotte, Annette; Crecelius, Charles; Zwygart-Stauffacher, Mary; Koopman, Richelle J.

doi:10.1097/ncq.0000000000000033

Cited by 37 publications

(23 citation statements)

References 20 publications

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“…The project promotes the use of Interventions to Reduce Acute Care Transfers (INTERACT), which is a set of evidence-based clinical practice tools and strategies developed with funding from CMS to reduce hospitalizations from nursing homes. The tools and strategies assist nursing home staff in early identification, assessment, communication, and documentation about changes of condition in nursing home residents (Rantz et al, 2014(Rantz et al, , 2015.…”

Section: The Missouri Quality Initiative Projectmentioning

confidence: 99%

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

et al. 2016

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As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

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Section: The Missouri Quality Initiative Projectmentioning

confidence: 99%

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

et al. 2016

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“…111-148) to implement this intervention. 3 The MOQI intervention is a 4-year demonstration of a care coordination effort using advanced practice registered nurses (APRNs) in 16 nursing homes in a region of Missouri where the transfer rates were one of the nation's highest for Medicare readmissions within 30 days of discharge (rates of 16.7%-18.9% for medical discharges). 4 The MOQI Intervention Model 3 illustrates the key components of the intervention.…”

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confidence: 99%

Better Care, Better Quality

Rantz

Flesner

Franklin

et al. 2015

Journal of Nursing Care Quality

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“…The use of HIE is a core component of the Missouri Quality Initiative for Nursing Homes (MOQI), funded by the Centers for Medicare and Medicaid Services (CMS) to reduce avoidable hospital readmission rates in 16 Missouri nursing homes using the MOQI for Nursing Homes Intervention Model [11]. The MOQI model has been described in detail elsewhere, but it involves (a) working with clinicians, health care providers, patients, and families to improve recognition and management of illness, (b) improve quality of care, (c) prepare facilities for implementation and use of HIE, (d) reduce polypharmacy, and (e) improve the use of advance healthcare directives.…”

Section: Missouri Quality Initiative For Nursing Homesmentioning

confidence: 99%

“…However, many NHs are participating in national initiatives in the United States and abroad to demonstrate the use of HIE to increase access to residents PHI and to transmit PHI securely [3,4,[8][9][10]]. HIE's facilitate greater communication pathways between internal and external stakeholders to reduce potentially avoidable hospitalizations, improve resident health outcomes, improve transitions of care between hospitals and NHs, and reduce healthcare spending [11]. Lessons learned from these initiatives are being incorporated into new care delivery models to visualize how HIE enhances access to PHI and to improve secure communication systems that will lead to better outcomes [12].…”

Section: Introductionmentioning

confidence: 99%

Preparing Nursing Homes for the Future of Health Information Exchange

Alexander¹,

Rantz²,

Galambos³

et al. 2015

Appl Clin Inform

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SummaryObjective: Our purpose was to describe how we prepared 16 nursing homes (NHs) for health information exchange (HIE) implementation. Background: NH HIE connecting internal and external stakeholders are in their infancy. U.S. initiatives are demonstrating HIE use to increase access and securely exchange personal health information to improve patient outcomes. Method: To achieve our objectives we conducted readiness assessments, performed 32 hours of clinical observation and developed 6 use cases, and conducted semi-structured interviews with 230 participants during 68 site visits to validate use cases and explore HIE. Results: All 16 NHs had technology available to support resident care. Resident care technologies were integrated much more with internal than external stakeholders. A wide range of technologies were accessible only during administrative office hours. Six non-emergent use cases most commonly communicated by NH staff were: 1) scheduling appointments, 2) laboratory specimen drawing, 3) pharmacy orders and reconciliation, 4) social work discharge planning, 5) admissions and pre-admissions, and 6) pharmacy-medication reconciliation. Emerging themes from semi-structured interviews about use cases included: availability of information technology in clinical settings, accessibility of HIE at the point of care, and policies/procedures for sending/receiving secure personal health information. Conclusion:We learned that every facility needed additional technological and human resources to build an HIE network. Also, use cases help clinical staff apply theoretical problems of HIE implementation and helps them think through the implications of using HIE to communicate about clinical care. BackgroundHealth care providers in over 16,000 nursing homes (NHs) across the United States play an important role in providing care for over 1.3 million residents [1]. Caring for this many residents requires significant amounts of health information exchange (HIE) between a variety of stakeholders including nurses, physicians, pharmacists, and others working both within and outside NHs. HealthIT.gov defines HIE as an information system that, "allows health care professionals and patients to appropriately access and securely share a patient's vital medical information electronically. " [2]. Internal and external stakeholders involved in the care of residents use HIE most frequently to monitor resident care tasks, authorize care plans, communicate with each other about patient care, and for financial and administrative activities [3]. Without proper HIEs, health care providers in NHs are at greater risk of breaks in vital communication about resident care, using incomplete clinical data resources, and experiencing limited capacity to make informed care decisions [3]. Additionally, patients are at greater risk for reduced responsiveness to care needs, medical errors, and increased costs from inadequate and fragmented care [4].Providing access and securely sharing NH resident's personal health information (PHI) through a H...

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Initiative to Test a Multidisciplinary Model With Advanced Practice Nurses to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

Cited by 37 publications

References 20 publications

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

Better Care, Better Quality

Preparing Nursing Homes for the Future of Health Information Exchange

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