Q: How do you describe your CMS-funded project to reduce avoidable hospitalizations, which just recorded a successful first year?
A: It’s an ambitious project at 19 Indiana nursing homes. We created a new clinical infrastructure, placing specially trained nurses in the facilities. A lot of the time over the first months has been at the facility-level, building relationships, learning the culture.
Q: What are you most excited by?
A: I’d like to highlight advanced care planning. We’ve had over 1,000 advance care planning conversations with residents and families. There are hospitalizations that can be considered avoidable because they are unwanted. We as providers aren’t proactive enough in understanding the care that residents want and need.
Q: Not all nursing homes have the resources of your project. What can they do to reduce hospitalizations?
A: Advance care planning is a cornerstone. But we need more people dedicated to addressing care issues that lead to avoidable hospitalizations. I hope there will be more opportunities like this project, leading to awareness that additional resources will move the needle. And those resources need to be supported by payers. We’re exploring dissemination of our model.
From the February 01, 2015 Issue of McKnight's Long-Term Care News
