(National Institutes of Health)
A new project at University of Missouri school of nursing aims to cut avoidable hospitalizations among nursing home residents. The study, led by nursing professor Marilyn Rantz is funded by a four-year $15 million grant from the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
The university cites CMS data that show the majority of nursing home residents are enrolled in Medicaid and most also participate in Medicare, with nearly half of the hospitalizations by nursing home residents in Medicare or Medicaid considered avoidable. CMS says these avoidable hospitalizations cost more than $7 billion in 2011.
The project plans to target 16 nursing facilities in St. Louis, where the project team will recruit and place one advanced practice registered nurse at each of the nursing homes. The advanced practice registered nurses, who receive specialized post-graduate education in nursing, are expected to coordinate patient care with nursing facility staff and residents’ health providers to improve the recognition, assessment, and management of conditions that are common causes of hospitalizations for aging adults.
Another part of the project brings in INTERACT, a quality improvement program designed to monitor and improve aging adults’ health. INTERACT — now in it’s second version known as INTERACT II — is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.
This part of the project will be implemented by a traveling team of social worker, an information technology specialist, a medical director, and an advanced practice registered nurse knowledgeable in INTERACT. The traveling team will work with the advanced practice registered nurses at each facility.
“Transitioning between hospitals and nursing homes is a complicated process because the exchange of accurate, complete and timely information often is convoluted,” says Rantz. “The interdisciplinary team will put the infrastructure in place to support good communication, which will help improve the patients’ care.”
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