Nurses Play Key Roles in OPTIMISTIC Project

By Tracy Denninger

Specialized training under the OPTIMISTIC project includes educating nursing facility staff on communication tools and care related to common clinical conditions.

Prompted by a call for proposals from the Centers for Medicare & Medicaid Services (CMS) Innovations Center, researchers from Indiana University and the Regenstrief Institute created the OPTIMISTIC project, aiming to improve care, reduce avoidable hospitalizations, and increase access to palliative care for nursing home residents.

The OPTIMISTIC project (Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care) builds on evidence-based strategies, according to Kathleen Unroe, MD, MHA, of the Regenstrief Institute and Indiana University Center for Aging, and is a collaboration with 19 nursing facilities in central Indiana.

Project Aims
As part of the project, specially trained registered nurses, supported by a project team with geriatrics and palliative care expertise, are stationed at each participating nursing facility. They provide support, education, and training to facility staff and lead care management reviews on long-stay patients. The aim is to optimize chronic disease management, reduce unnecessary medication usage, and clarify care goals for patients, Unroe explains.

For example, as part of their training, nursing aides may learn to recognize changes such as swollen feet that indicate a resident could be suffering from heart failure. The aides and nursing staff also learn to communicate rapidly and effectively, using standardized forms and tools, with residents’ medical teams to provide early intervention for any potential health issues.

Additionally, nurse practitioners support registered nurses in responding to urgent resident care needs. They also provide evening and weekend availability to conduct in-person evaluations and become site champions for training and leadership development, according to Unroe.

“This project relies on partnerships among many different stakeholders—clearly the nursing facility leadership and staff but also all of the physician groups and health systems in the region who treat this patient population,” Unroe says.

Training occurs on several levels: large in-services, small groups, and one-on-one mentoring. “The staff have been receptive to the trainings, especially in smaller groups and one-on-one,” Unroe says. “Residents and their families/caregivers have appreciated the additional layer of support from OPTIMISTIC.”

A Participating Facility’s Experience
Ten nursing facilities began participating in the OPTIMISTIC project in February 2013, with the remaining nine beginning in April 2013. “Early efforts have focused on implementation of the INTERACT tools and advance care planning using the Indiana Physician Orders for Scope of Treatment program,” Unroe explains. “Early successes have included hospitalizations avoided through early recognition of problems and through clarification of patient goals, leading to supporting and treating residents at the facility.”

The INTERACT tools are part of the Intervention to Reduce Acute Care Transfers quality improvement program that focuses on managing acute care changes in resident conditions. “Our OPTIMISTIC staff are training the nursing facility staff on INTERACT tools, which include communication tools and care pathways for common clinical conditions,” Unroe says.

Rosewalk Village at Indianapolis, an American Senior Communities facility, was asked to participate in the OPTIMISTIC project because it’s one of the largest providers of short-term senior rehabilitation, long term care, and memory care in the state of Indiana. Additionally, many of its facilities are located in central Indiana and admit IU Health patients, according to Executive Director Tony Link.

As part of the study, “Our long term care residents are receiving the benefits of an additional full-time registered nurse and part-time nurse practitioner, both being IU Health employees,” Link explains. “These two staff members spend their time educating and training staff, performing comprehensive care reviews, and interacting with residents and family members regarding code status and any associated questions or concerns.”

For instance, at Rosewalk Village, the OPTIMISTIC project nurse participates in daily grand rounds, where nurse managers check in with clinically at-risk residents or those who have experienced changes in health status. The nurse then follows up throughout the day, contacting a patient’s family if necessary and coordinating care with the facility’s medical director.

As a result of the nurses’ work, Link says the facility has seen “improved communication and better clinical and psychosocial outcomes due to OPTIMISTIC staff being embedded with our staff. The residents and families have greatly enjoyed and appreciated the availability of additional staff to answer their questions, thoroughly research their clinical history through the use of comprehensive care reviews, and share this information with the facility staff,” he explains.

Link says that facility staff members see the OPTIMISTIC study team as a resource, often involving them in addressing residents’ care and concerns. “The facility medical director and nurse practitioner also collaborate with the OPTIMISTIC staff and have asked them to track and trend lab values and comorbidities to long term care residents,” he notes.

Next Step
According to Unroe, the OPTIMISTIC project’s success will be measured by a reduction in hospitalizations among nursing home residents and meeting other quality benchmarks. Additional steps as part of the project depend on the CMS’ eventual evaluation.

— Tracy Denninger is the senior production editor at Today’s Geriatric Medicine.