Specially trained nurse practitioners help nursing homes improve the resident transfer process and reduce errors, recently published research shows.
The findings come from the OPTIMISTIC project at Indiana University, a program that embeds nurses and nurse practitioners at skilled nursing facilities in an effort to improve care quality and communication between providers, and reduce avoidable hospital readmissions.
The nurse practitioners employed through the OPTIMISTIC study visited with long-stay nursing home residents within 48 hours of returning to the facility from a hospital. The visits covered the resident’s hospital discharge summary, medication reconciliation, advance care planning, follow-up care and education for the residents’ family.
The visits, which lasted an average of 102 minutes, allowed the nurse practitioners to address residents’ potential care issues. The issues’ origins were split fairly evenly, with 33% of the issues traced back to a nursing home, 32% to the facility’s physicians and 29% to discharging hospitals. Identifying potential care issues helped OPTIMISTIC cut hospitalizations by 21% in the early stages of the program, researchers said.
“These specially trained nurse practitioners got in touch with the hospital discharge teams and worked with the nursing facility staff and providers to improve access to critical, complex information — not an easy task,” said OPTIMISTIC Director Kathleen Unroe, M.D., MHA, in a news release Monday.
The OPTIMISTIC program will continue its analysis of nurse practitioner visits to see if they present an opportunity to cut costs, and if they could be replicated in healthcare systems outside the project’s home state of Indiana, researchers said.
“Telling nursing homes to do a better job isn’t the only answer,” said lead researcher Arif Nazir, M.D. “It’s the entire healthcare system — not just the nursing home, discharging hospital or the physician seeing the patient post-hospitalization. All three need to work on the problem and to commit more resources to patient transitions.”
Results of the study appear online in The Annals of Long-Term Care. The OPTIMISTIC program, which began in 2013, received an additional $16.9 million in funding from the Centers for Medicare & Medicaid Services earlier this year. The second phase of the so-far successful project kicks off this month.