Q: Why do hospital readmissions continue to be such a big problem?

A: There is not, unfortunately, a single, quick fix. Avoidable hospital transfers from the hospital occur for a variety of reasons: a lack of access to timely medical assessments, communication breakdowns among stakeholders and failure to elicit and honor resident and family preferences for treatments.

Q: How did you find success with OPTIMISTIC?

A: They tested OPTIMISTIC intervention centers on an embedded specially trained RN who is skilled at identifying a clinical change in status, assessment of sick patients, communicating these assessments in a standardized way and supporting acute illness management plans. OPTIMISTIC RNs facilitate advance care planning conversations and record goals of care, and conduct root cause analyses on transfers that do occur. Care Revolution was founded to disseminate the OPTIMISTIC clinical model into nursing homes.

Q: Why are nurses important in reducing readmissions?

A: OPTIMISTIC and other similar programs demonstrate the impact that nurse-delivered interventions can have on hospital re-admissions and quality of care. They lead communication with providers, families and residents.