(L to R) Debbie Pool, BSN, RN, LNHA, and Wendy Boren, BSN, RN

It was late afternoon on Jan. 30, 2020. A nurse from the Quality Improvement Program for Missouri (QIPMO) was leading a standard table top influenza pandemic exercise in Poplar Bluff when a call came through that would forever change the way healthcare would operate. The words were ominous and foreboding. “Folks, the CDC just confirmed the first case of coronavirus in the United States. This is no longer a drill.” 

Missouri is the only state in the nation with a dedicated “help system” for long-term care. This is primarily done through the QIPMO program. The QIPMO program began in the 1990s, after Marilyn Rantz, Ph.D., RN, FAAN, curators’ professor emerita of the Sinclair School of Nursing at the University of Missouri, saw the need for improved quality of care outcomes and a reduction in overall care costs in long-term care. 1,2,3, 4

The QIPMO team currently consists of five registered nurses and three licensed administrator coaches employed to assist in nursing home consultations throughout Missouri. Nurses and coaches field calls, provide educational in-services, and do on-site visits, creating connections that go beyond regulatory compliance while also serving as colleagues and experts in long-term nursing care. In 2019, the QIPMO program provided over 750 site visits to over 400 skilled nursing facilities in the state and made over 600 different facility contacts.

Additionally, a grant was awarded in 2012 to the University of Missouri Sinclair School of Nursing by CMS for the Missouri Quality Initiative (MOQI) with the goal of reducing avoidable hospitalizations of nursing home residents and improving the quality of care for long-stay residents nationwide. Advanced practice nurses were placed in select homes to assess residents and treat common conditions that often lead to rehospitalizations. These efforts have shown a 50% reduction in potentially avoidable hospitalizations and a 32% all-cause emergency department visits.⁵ It was the collaborative effort of these “second responders” that helped Missouri’s long-term care face down the COVID crisis.

When the sparks began flying about nursing home lockdowns, the QIPMO and MOQI teams responded immediately by creating a baseline. QIPMO used video conferencing to assist in creating COVID-19 units, cross-training staff, and guiding administrators and DONs through the hoards of guidance. MOQI APRNs taught proper donning and doffing of personal protective equipment, implemented new infection control systems, led shift huddles, and educated staff about cohorting. One MOQI nurse stated, “It was very stressful but our motto was stay calm and don’t overreact, staff will feed off of us, I am proud we were able to do this. It made for a less stressful environment and happier co-workers.”

The QIPMO team held weekly statewide virtual support group meetings and created a special COVID-19 segment on their website providing homes 24-hour access to information. They produced several simple go-to COVID documents for nurses and administrators, such as the COVID-SBAR assessment tool, guidelines for resident documentation, staffing, facility surge and more. The documents are located on the QIPMO website, www.nursinghomehelp.org, and free to use.

With the widespread shortage of PPE adding to the emotional strain, QIPMO/MOQI also reached out to the community as advocates for supplies and community support. The team contacted local community healthcare partners such as home health and hospice, EMTs, hospitals, community clinics and local health departments to get gowns, gloves and N95 masks. Diapers and bleach donated by a local food pantry helped alleviate stress to staff working long hours. Other donations included homemade masks, gowns, hand sanitizer and  many meals donated by local area businesses, church groups, and the farmer’s market.

QIPMO/MOQI also teamed up with the Columbia STEM Alliance group to get over 5,000 face shields made and donated to nursing homes in Missouri. The QIPMO team delivered these face shields, getting their first glimpses of colleagues in the field since March 2020. They also saw firsthand what life was like, at least from the exterior of the building, for nursing homes with COVID.

Late-night calls, weekend texts, countless emails and endless virtual hugs all became the norm. One QIPMO nurse lost a former coworker who became infected with COVID, a second had to close their family business, a MOQI nurse became infected with COVID-19 herself. Everyone was touched in some way. 

As COVID-19 continues to surge, there are multiple new challenges ahead. As regulatory compliance and accountability increases, so does the need for hands-on physical and emotional support. The nurses and coaches of the QIPMO team, along with the advanced practice nurses of MOQI, will serve as Missouri’s second responders. When Missouri homes call, they know that help is always on the other side.


1 Popejoy, L.L., Rantz, M.J., Conn, V., Wipke-Tevis, D., Grando, V., & Porter, R. (2000). Improving quality of care in nursing facilities: The gerontological clinical nurse specialist as research nurse consultant. Journal of Gerontological Nursing, 26(4), 6-13.

2 Rantz, M.J., Popejoy, L, Petroski, G.F., Madsen, R.W., Mehr, D.R., Zwygart-Stauffacher, M., Hicks, L.L., Grando, V., Wipke-Tevis, D.D., Bostick, J., Porter, R., Conn, V.S., & Maas, M. (2001). Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontologist, 41(4): 525-538.          

3 Rantz, M.J., Vogelsmeier, A., Manion, P., Minner, D., Markway, B., Conn, V., Aud, M.A., & Mehr, D.R. (2003). A statewide strategy to improve quality of care in nursing facilities. The Gerontologist, 43(2): 248-258.

4 Rantz, M.J., Cheshire, D., Flesner, M., Petroski, G.F., Hicks, L., Alexander, G., Aud, M.A., Siem, C., Nguyen, K., Boland, C., & Thomas, S. (2009). Helping nursing homes “at risk” for quality problems: a statewide evaluation. Geriatric Nursing, 30(4), 238-249.* PMID: 19665666.

⁵ Ingber, M.J., Feng, Z., Khatutsky, G., et al. (September, 2017) Evaluation of the initiative to reduce avoidable hospitalizations among nursing facility residents: Final Report. Retrieved December 5, 2017 from https://innovation.cms.gov/files/reports/irahnfr-finalevalrpt.pdf.

Debbie Pool, BSN, RN, LNHA, has over 30 years as a seasoned healthcare professional. She currently serves as a clinical nurse educator in the St. Louis region with the Quality Improvement Program for Missouri (QIPMO) through the University of Missouri-Columbia Sinclair School of Nursing. Wendy Boren, BSN, RN, has over 10 years of experience in long-term care nursing. She currently serves as a clinical educator in the southeast region with the QIPMO through the University of Missouri-Columbia Sinclair School of Nursing.