Problem Addressed

Researchers estimate that as many as 67% of nursing home hospitalizations are avoidable.¹ Hospitalizations among residents can disrupt resident plans of care, impact quality of life, and lead to functional decline.¹ In addition to the impact on resident care and status, avoidable hospitalizations are a substantial expense to the system.¹ Therefore, this innovation sought to reduce these avoidable hospitalizations by facilitating earlier identification of residents at risk of hospitalization due to functional decline.

Federal requirements for nursing home staffing include having a registered nurse (RN) on duty for at least eight consecutive hours, seven days a week, with an RN or a licensed practical nurse on duty for the remaining shifts. Additionally, at least one RN or charge nurse (depending on the number of residents) must serve as a full-time director of nursing five days per week.² However, experts recommend nursing homes go beyond these minimum standards to ensure that the needs of residents are being met, noting the clear link between nursing home staffing ratios and resident outcomes.²

Description of the Innovative Activity

The Missouri Quality Initiative (MOQI) expands upon standard staffing models and offers a multipronged approach to improving the safety of nursing home care. The primary intervention of the innovation is the inclusion of an advanced practice registered nurse (APRN) among the full-time essential staff within each nursing home. The role of the APRN is to focus on fundamental components of resident care delivery, with a specific focus on early illness detection, acute illness management, reduction of polypharmacy through medication reviews, and quality improvement (QI) to support systems change. QI efforts may vary at each nursing home depending on opportunities for improvement.³ For example, QI may focus on improving advance directive completion or conducting medication reviews.^4,5

In addition to the incorporation of an APRN, each nursing home implements the Interventions to Reduce Acute Care Transfers (INTERACT®) program and its associated tools.³ INTERACT is a QI program intended to manage acute changes in residents’ status. Included within INTERACT are educational trainings for providers as well as clinical and education tools, such as a medication reconciliation worksheet, a “stop and watch” early warning tool, and templates for progress notes and documenting acute changes in condition.

The MOQI also emphasizes resident and family involvement⁶ in end-of-life care and resident choice in the type of care desired at the end of life. Residents are encouraged to enact advance directives,⁴ and these advance directive documents are reviewed periodically to ensure that they reflect residents’ wishes.⁴ Staff are also trained on advance care planning and advance directives, and the MOQI project emphasizes developing facility policies on end-of-life care and advance directives. The APRN assists the facilities in organizing charts and records so that there are designated sections in the chart for advance directives.⁷ Residents who have advance directives are less likely to be transferred to hospitals unnecessarily.⁴

During implementation under the CMS grant, the MOQI team provided monthly feedback reports to the nursing homes on resident outcome measures associated with hospital transfer. Health information technology and available health information exchanges (HIEs) facilitates communication between nursing home staff and providers in the program to foster shared lessons learned.³

Context of the Innovation

The MOQI was developed based on research conducted by the Quality Improvement Program for Missouri (QIPMO). QIPMO is a cooperative service between the University of Missouri Sinclair School of Nursing and the Missouri Department of Health and Senior Services that offers nurse consultations and technical assistance for nursing home QI efforts. Given this role, QIPMO has participated in numerous research efforts attempting to better understand how to effectively enhance nursing home care to improve patient outcomes. Lessons learned from other initiatives have helped to inform the approach for the MOQI.

The MOQI was initially funded by a CMS grant as a demonstration project. Phase 1 was implemented from 2012 to 2016 with the goal of transforming 16 nursing homes in Missouri. These nursing homes were within the St. Louis area and were identified as having a history of high-quality care and good results on satisfaction surveys, but with high rates of hospitalizations and admission/discharging relationships with hospitals that also had a high rate of readmissions. The objective was to lower the rates of avoidable hospitalizations in these facilities with the intention that this would improve resident outcomes and reduce costs. Additionally, when hospitalization was necessary, the MOQI sought to improve transitional care between hospitals and the nursing homes to prevent hospital readmission.

Phase 2 was implemented from 2016 to 2020 with the goal of expanding to include provider- and facility-enhanced reimbursement, while sustaining the successes of Phase 1. The enhanced billing component of the innovation sponsored by CMS included a focus on six conditions (pneumonia, dehydration, congestive heart failure, urinary tract infection, skin ulcers or cellulitis, and chronic obstructive pulmonary disease or asthma), equalizing financial incentives for practitioners between treating beneficiaries in a nursing home vs. a hospital, and incentive payments to increase practitioner engagement in care planning activities.

Since the conclusion of the CMS grant, the care components of the initiative piloted in Phase 1 have been transferred to NewPath Health Solutions, LLC, to ensure continued dissemination of this successful intervention.

Results

The MOQI achieved statistically significant results during Phase 1 of implementation. Transitions from the nursing home to a hospital setting decreased across numerous metrics:

• Reduction of 32% in all-cause hospitalizations and statistically significant reductions in four single quarters of the 2.75 years of Phase 1 implementation of the intervention for long-stay nursing home residents⁸
• Reduction of 49.9% in potentially avoidable hospitalizations⁸
• Reduction of 41.7% in all-cause emergency department (ED) visits⁸
• Reduction of 56.0% in potentially avoidable ED visits⁸  

These results translated into decreases in expenditures, as measured per resident per year. These savings offset the expense associated with a full-time APRN:

• Reduction of $1,241 (6.3%) for total cost of all Medicare services⁸
• Reduction of $1,153 (28.6%) for all-cause hospitalizations⁸
• Reduction of $514 (40.2%) for potentially avoidable hospitalizations⁸
• Reduction of $62 (36.3%) in spending for all-cause ED visits⁸
• Reduction of $21 (42.8%) for potentially avoidable ED visits⁸

On average, rates of hospital transfers continued to decline through Phase 2 implementation. Total hospital transfers for 2014–2019 were 6,913, and the average transfer rate per 1,000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019.³

Planning and Development Process

The commitment of corporate and facility leaders to this innovation, along with clear communication to their staff, is key to the success of this program. When preparing to implement this innovation, it is critical to establish a training and education rollout that will familiarize existing nursing staff not only with any new improvement tools and resources, but also with the new roles and responsibilities of the dedicated APRN. Additionally, the implementation planning team should determine how the new APRN role aligns with existing workflows or where processes are required to change. This will inform a plan to ensure that all nursing home staff understand any workflow adjustments. Periodic reinforcement of these new workflows and processes will help solidify them with staff and assist with compliance.

Resources Used and Skills Needed

When implementing this innovation, several key resources were critical to success:

• Funding is required to support the inclusion of a dedicated APRN on the clinical team.
• Ongoing engagement and commitment of leadership to ensuring an organization-wide focus are crucial.
• The APRNs and nursing home leaders were supported by a nurse project supervisor, an INTERACT/QI coach, a health information coordinator, a care transitions coach with a Master of Social Work, and a medical director. Support was also provided by researchers with expertise in QI, care coordination, advance care planning, informatics, and transitional care. Support included educational resources for staff and assistance with QI efforts.³
• Access to resources such as the INTERACT tools, education programs, and HIEs provide systematic approaches for nursing home staff.

Funding Sources

Initial funding for this innovation was provided by a demonstration grant from CMS. Interested nursing homes pay a consulting fee to NewPath Health Solutions, LLC, for support with implementation. NewPath Health Solutions, LCC, notes that this fee is based on the degree of support the nursing home will require and the expected savings from reduced hospitalizations.

Getting Started with This Innovation

When getting started with this innovation, organizations should ensure the following:

• The commitment of the nursing home leadership team, including the administrator/executive director and director of nursing, to engage in the change process
• The identification of a champion within the nursing home to promote change
• Completion by a majority of staff of appropriate training and understanding of all staff across the nursing home of roles and responsibilities
• The establishment and communication of a plan outlining how implementation will be monitored, what data will be collected, and the frequency of feedback reports

Sustaining This Innovation

The MOQI credits sustained engagement by the nursing homes to an approach that fosters improving communication, encouraging a diversity of ideas via input from all employees, and positive relationships across members of the nursing home care team. Moving forward, the cost savings associated with a reduction in avoidable hospitalizations provide a clear business case for an organization to continue to implement this initiative.

References/Related Articles

Publications associated with this innovation can be found here.

Footnotes

1. Rantz MJ, Popejoy L, Vogelsmeier A, et al. Successfully reducing hospitalizations of nursing home residents: results of the Missouri Quality Initiative. J Am Med Dir Assoc. 2017;18(11):960-966. doi:10.1016/j.jamda.2017.05.027
2. Harrington C, Dellefield ME, Halifax E, Fleming ML, Bakerjian D. Appropriate nurse staffing levels for U.S. nursing homes. Health Serv Insights. 2020;13:1178632920934785. Published 2020 Jun 29. doi:10.1177/1178632920934785
3. Vogelsmeier A, Popejoy L, Canada K, et al. Results of the Missouri Quality Initiative in sustaining changes in nursing home care: six-year trends of reducing unnecessary hospitalizations for nursing home residents. J Am Geriatr Soc. Forthcoming 2021.
4. Galambos C, Rantz M, Popejoy L, Ge B, Petroski G. Advance directives in the nursing home setting: an initiative to increase completion and reduce potentially avoidable hospitalizations [published online ahead of print, 2021 Jan 25]. J Soc Work End Life Palliat Care. 2021;1-15. doi:10.1080/15524256.2020.1863895
5. Vogelsmeier A, Popejoy L, Crecelius C, Orique S, Alexander G, Rantz M. APRN-conducted medication reviews for long-stay nursing home residents. J Am Med Dir Assoc. 2018;19(1):83-85. doi:10.1016/j.jamda.2017.10.012
6. Pritchett A, Canada KE, Galambos C, Rollin L, Rantz M. Take it to the resident: a model for engaging long-term stay residents in advance care planning [published online ahead of print, 2021 Feb 11]. Soc Work Health Care. 2021;1-10. doi:10.1080/00981389.2021.1878319
7. Galambos C, Starr J, Rantz MJ, Petroski GF. Analysis of advance directive documentation to support palliative care activities in nursing homes. Health Soc Work. 2016;41(4):228-234. doi:10.1093/hsw/hlw042
8. Ingber MJ, Feng Z, Khatutsky G, et al. Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Final Report. Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, US Dept of Health and Human Services; 2017. Accessed March 23, 2021. https://downloads.cms.gov/files/cmmi/irahnfr-finalevalrpt.pdf

Date Verified by Innovator

March 22, 2021