A University of Missouri project is reducing avoidable hospitalizations by shifting the culture, processes, and systems at 16 unique facilities. It's benefitting hospitals and health systems as well as nursing facilities.
Forrest Gump was right when he said, "Life is like a box of chocolates. You never know what you're gonna get."
That was certainly my experience during my brief foray into hospice nursing. I'm not referring to the types of patients or their individual situations, but rather, the way care was delivered in different settings and organizations.
I could walk into one nursing home and it would be outfitted with electronic medical records. Two hours later, I'd be at different facility that was still using paper charts and a Kardex for medication scheduling.
In hospitals, the types of EMRs varied from facility to facility as did workflows and chains of command.
Who to page, how-to-page them, where to put the progress note, all differed. Processes and systems, at both acute and post-acute care facilities, varied so widely it was overwhelming.
This experience played through my mind as I talked with University of Missouri researchers Colleen Galambos, PhD, ACSW, LCSW, LCSWC, professor in the College of Human Environmental Sciences' School of Social Work and Gregory L. Alexander, RN, PhD, FAAN, professor in the Sinclair School of Nursing about a project they are involved with called the Missouri Quality Initiative for Nursing Homes.
MOQI, which was launched in 2012 under the leadership of the university's Marilyn Rantz, RN, PhD, FAAN, curators' professor emerita, is a partnership among MU, the Centers for Medicare & Medicaid Services, and state Medicaid programs to improve care at 16 nursing facilities in St. Louis.
As one can imagine, this no small project. Shifting the culture, processes, and systems at one facility can be a challenge. But 16 unique facilities?
"Everybody's starting in a different place," Galambos told me. "We have 16 different facilities with 16 various capabilities, and 16 cultures."
Factor in all the other stakeholders involved in nursing home resident's care—hospitals that admit and transfer residents, primary care providers, labs, hospice—and it truly becomes an enormous undertaking. But it's one that seems to be working.
Decreasing Avoidable Hospitalizations
Don't be fooled by the name of the program, the project doesn't just benefit nursing homes. It addresses issues of importance to hospitals and health systems as well.
The four main goals of MOQI, which is a four-year project slated to wrap up in September 2016, are to:
- Reduce potentially avoidable hospital transfers
- Decrease polypharmacy and antipsychotic medication use among nursing home residents
- Increase discussions on goals of care and completion of advance directives
- Introduce secure communications for electronic transfer of health information among healthcare providers, nursing homes, and hospitals
Thus far, the project appears to be on track to meet these goals. Data released in January 2016 in CMS's year three report on the project shows that compared to 2012 there has been a 21% decrease in nursing home residents' all-cause hospitalizations, a 34.5% decrease in potentially avoidable hospitalizations, and a 27% decrease in all-cause ED visits.
"Essentially what we've done is we've saved a lot of Medicare dollars by taking care of people in the nursing home versus transferring them back and forth," Alexander says. "That's been a good thing for the residents and it's a good thing for the facilities because they get to keep better continuity of care for the residents."
Raising the Bar Through Feedback
Though the project is finding success, that doesn't mean that the intervention is simple. There's not one magic bullet that providers can implement to ensure improvement.
Rather, MOQI is built upon four major components:
- An APRN in each nursing home to provide direct services to residents and to mentor and educate nursing staff about early symptom and illness recognition, assessment, and management of conditions commonly to nursing home residents
- Early recognition, assessment, and management of residents' conditions. Positive, collaborative relationships with SNF residents' primary care providers
- Proactive discussions about end-of-life decision making. Development and implementation of end-of-life decision making and communication systems
- Improvement of hospital transitions and communication, and reduction of polypharmacy
"What the people we had working for us in the field did was identify those [stakeholders] and then bring them together into the stakeholder group to be able to communicate and talk about the way they did things," Alexander says. "It created this sort of understanding about how each worked, and how we could bring that together to be more seamless."
The 16 APRNs, who work full-time in each SNF, round on the residents and provide direct care, are also supported by other MOQI team members, Galambos points out. This includes a health information technology coordinator, social work care transitions coach, database Coordinator, INTERACT coach, and project supervisor.
Feedback is also an essential part of the project.
"We've provided lots of different feedback mechanisms and reports that enable them to see the progress that they're making," Alexander says. "If there are issues, then we can address those issues immediately and do the root cause analysis about what the systems problems are with readmissions. Then we send teams to those facilities that have the most problems to problem solve and troubleshoot the issues."
While there are many moving many moving parts, Alexander says the complexity of the project is worth it if it means improving quality of care.
"We're putting it at the forefront of their work so they are starting to recognize things early, and getting something done for these residents up front so we can avoid the hospital readmission in the long run," he says.
"We're introducing new measures—some very valid measures and reliable measures—but we also have some that are a little less studied in nursing homes. But that's okay because we're raising the bar."
Pages
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.