Preventing Unnecessary Hospitalizations of Frail Older Adults

By Sondra Forsyth

A study from Indiana University and Regenstrief Institute researcher-clinicians reports on the first year of the implementation of OPTIMISTIC, an acronym for Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care. The team developed and implemented this innovative program to prevent unnecessary hospitalizations of nursing facility residents.

Their paper, “The OPTIMISTIC approach: preliminary data of the implementation of a CMS nursing facility demonstration project,” was published in the January 2015 issue of Journal of the American Geriatrics Society. OPTIMISTIC is supported by a four-year, 2012 award of $13.4 million from the Centers for Medicare & Medicaid Services.

A release from the university explains that the goal of OPTIMISTIC is to improve care and communication within nursing facilities and between these facilities and acute-care institutions so problems can be caught and solved before transporting a resident to the hospital becomes necessary.

The release quotes project co-director Kathleen T. Unroe, M.D., MHA., a Regenstrief Institute investigator, assistant professor of medicine at the IU School of Medicine and IU Center for Aging Research center scientist, as saying, “OPTIMISTIC is about systems change. We are working with 19 Central Indiana nursing facilities that simply by participating in the project are indicating that they value improving quality of care and reducing unnecessary hospital transfers. Nationally estimated rates of potentially avoidable hospitalizations of nursing home residents range as high as 50 percent. Through this project, our specially trained RNs are doing in-depth reviews of all hospital transfers and are able to identify areas for quality improvement. Working with the IU School of Nursing, the University of Indianapolis and our nursing home partners, we are developing and testing a new model of care.”

Throughout the four-year OPTIMISTIC project, nurses are stationed at the participating nursing facilities to provide direct support to long-stay residents and their families as well as education and training to the staff. OPTIMISTIC nurses lead care management reviews to optimize chronic disease management, reduce unnecessary medications and clarify goals of care.

“Long-stay nursing home residents — whose numbers are growing as our population ages — need more attention from both researchers and clinicians,” said Regenstrief investigator Greg A. Sachs, M.D., OPTIMISTIC project director and director of the IU School of Medicine’s Division of General Internal Medicine and Geriatrics. Dr. Sachs is also a professor of medicine and an IU Center for Aging Research center scientist. “With OPTIMISTIC, we are working with the residents where they live to improve many aspects of their lives including chronic disease management — especially for dementia, which affects more than half of long-stay residents — as well as to improve the care they receive during the transition process to and from a hospital, when that transfer is necessary.”

Earlier detection and prevention are key to OPTIMISTIC. If not addressed and prevented, problems such as medication errors, lack of advance directives and lack of recognition of changes in medical status could result in hospitalization of the nursing facility resident.

“Nursing facilities [participating in OPTIMISTIC] have demonstrated commitment to the project, participating in seminars, meeting with project leadership and staff on a regular basis, and engaging in discussions to address issues as needed,” the study authors report. “Early experiences of clinical staff have yielded multiple stories of nursing facility staff, residents and families impacted by improved care.”

They also wrote that “savings from reduction in these [preventable] hospitalizations, as well as associated post acute care stays, should offset the substantial up front investment in improving quality of care with additional personnel and resources.”

The IU Center for Aging Research and Regenstrief Institute researcher-clinicians chose the acronym OPTIMISTIC to set a tone for how they feel about the potential to improve care for frail older adults. Working with their colleagues and community partners, they are providing education and training in real-world environments to develop a new model of care and putting increased resources into nursing homes, which they hope will result in system change regionally and across the nation.