Nursing Home Quality

The MOQI Intervention Model3 illustrates the key components of the intervention. An APRN guides the intervention delivering care to the residents and training the facility staff to improve their skills. An MOQI intervention team assists with medical care, care transitions, health information technology, and evidence-based INTERACT (Interventions to Reduce Acute Care Transfers) II assessment tools. The project promotes the use of INTERACT, which is a set of evidence-based clinical practice tools and strategies developed with funding from the CMS to reduce hospitalizations from nursing homes.5 The tools and strategies assist the nursing home staff in early identification, assessment, communication, and documentation about changes of condition in nursing home residents.

The APRN works collaboratively with the facility staff on assessing and managing chronic and acute conditions, recognizing early illness, using the INTERACT II tools, enhancing goals of care and end-of-life (EOL) discussions and advance directive (AD) decision making, and increasing the use of health information technology for improved communication.

Rantz, M.J., Flesner, M.K., Franklin, J., Galambos, C., Pudlowski, J., Pritchett, A., Alexander, G., & Lueckenotte, A. (2015). Better care, better quality: reducing avoidable hospitalizations of nursing home residents. Journal of Nursing Care Quality, 30(4), 290-297.

THERE are nearly 1.5 million older adults residing in nursing homes (NH) across the United States. Reducing avoidable hospitalizations among vulnerable NH residents has become a national priority. Estimates suggest more than $14 billion of Medicare funding is spent annually on hospitalizations for this vulnerable population. The most common causes of avoidable hospitalizations are conditions of septicemia, pneumonia, congestive heart failure, and urinary tract infections. Experts identify that NHs have limited capacity for early illness detection and/or prevention to avoid the need for hospitalization. As such,
it is vital that NHs improve their capacity to identify and treat acute illness in their residents to avoid hospitalization. Evidence suggests that advanced practice registered nurses (APRNs) improve NH outcomes including reducing avoidable hospitalizations. Moreover, major health care cost savings have been measured when APRNs work in NHs. This improvement appears to be related to the APRNs expertise in clinical management of health conditions, early detection of illness, and problem solving with NH staff to provide the needed care to manage clinical conditions within the NH. Despite evidence that APRNs improve resident outcomes, little evidence exists to describe how APRNs actually integrate their advanced practice role into NHs to influence care delivery. This article reports on a series of 3 focus groups held with APRNs who were embedded full-time in 16 Missouri NHs. The purpose of the focus groups was to describe the integration of APRNs into the NH setting including their their perceived challenges and successes.

Vogelsmeier, A., Popejoy, L., Rantz, M., Flesner, M., Lueckenotte, A., & Alexander, G. (2015). Integrating advanced practice registered nurses into nursing homes: The Missouri Quality Initiative experience. Journal of Nursing Care Quality, 30(2), 93-98.

This exploratory qualitative study examined staff perceptions of social work student contributions to client services, family and client communication, and staff workload in an independent living setting for older adults. Ten employees who had contact with the students, clients and family were interviewed using a semi-structured interview method. The findings suggest a positive response to the presence of social work students in the enhancement of home healthcare and in this independent living environment. In particular, their contributions were viewed as helpful in client quality of life, quality of care, communication with clients and families, and work performance.

Galambos, C., Starr, J., Musterman, K., & Rantz, M. (2015). Staff perceptions of social work student contributions to home health care services at an independent living facility. Home Healthcare Nurse, 33(4), 206-214.

Purpose: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed.

Design and Methods: Nursing facilities (n=113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group.

Results: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents).

Implications: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Rantz, M.J., Popejoy, L, Petroski, G.F., Madsen, R.W., Mehr, D.R., Zwygart-Stauffacher, M., Hicks, L.L., Grando, V., Wipke-Tevis, D.D., Bostick, J., Porter, R., Conn, V.S., & Maas, M. (2001). Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontologist, 41(4), 525-538.

Strengthening healthcare overall is essential to the health of our nation and promoting access to healthcare as well as controlling healthcare costs in a quality cost-effective manner. Nurse practitioners have demonstrated in prior research to be effective and cost-effective providers; however, many states restrict their practice. We examined for a statistically significant relationship between level of APRN practice (full, reduced, or restricted) allowed and results of recent nation-wide, state level analyses of Medicare or Medicare-Medicaid beneficiaries of potentially avoidable hospitalizations, readmission rates after inpatient rehabilitation, and nursing home resident hospitalizations; then compared with state health outcome rankings. States with full practice of nurse practitioners have lower hospitalization rates in multiple populations of Medicare or Medicare-Medicaid beneficiaries and improved health outcomes in their communities. Results indicate that obstacles to full scope of APRN practice have the potential to negatively impact our nation's health. Action should be taken to remove barriers to APRN practice.

Oliver, G.M., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook, 62(6), 440-447.

AgingMO is Copyrighted by the Sinclair School of Nursing

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