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Background: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes.

Purpose: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis.

Methods: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate  analyses, logistic regression, and content analysis were used for analysis. (more…)

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Objectives: Research shows advanced practice registered nurses (APRNs) embedded in nursing homes (NHs) reduce resident hospitalizations. However, the specific APRN activities that reduce hospitalizations have not been adequately investigated. This study aims to identify the causal links between APRN activities and NHs resident  hospitalization. The study also examined relationships among other variables, including advanced directives, clinical diagnosis, and length of hospitalization.

Design: Secondary data analysis.

Setting and Participants: Residents of NHs participating in the Missouri Quality Initiative for Nursing Homes, 2016e2019.

Methods: We performed a secondary analysis of data from the Missouri Quality Initiative for Nursing Homes Intervention using causal discovery analysis, a machine learning, data-driven technique to determine causal relationships across data. The resident roster and INTERACT resident hospitalization datasets were combined to create the final dataset. Variables in the analysis model were divided into before and after hospitalization. Expert consensus was used to validate and interpret the outcomes.

Results: The research team analyzed 1161 hospitalization events and their associated NH activities. APRNs evaluated NH residents before a transfer, expedited follow-up nursing assessments, and authorized hospitalization when necessary. No significant causal relationships were found between APRN activities and the clinical diagnosis of a resident. The analysis also showed multifaceted relationships related to having advanced directives and duration of hospitalization.

Conclusions and Implications: This study demonstrated the importance of APRNs embedded in NHs to improve resident outcomes. APRNs in NHs can facilitate communication and collaboration among the nursing team, leading to early identification and treatment for resident status changes. APRNs can also initiate more timely transfers by reducing the need for physician authorization. These findings emphasize the crucial role of APRNs in NHs and suggest that budgeting for APRN services may be an effective strategy to reduce hospitalizations. Additional findings regarding advance directives are discussed.

Knoo, L., Kummerfeld, E., Robinson, E., Anderson, L., & Rantz, M. (2023). Data-driven analytics to discover APRNs impact on nursing home hospitalization: causal discovery analysis. Journal of the American Medical Directors Association, 24(11), 1746-1754.

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Injuries, infections, behavioral incidents and family insistence often drive hospital admissions among nursing home residents, and a new study finds many of those transfers may be unavoidable.

Researchers: More hospital admissions are ‘unavoidable’ than previously thought – McKnight’s Long-Term Care News

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Context: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

Methods: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

Findings: Three key components were necessary for successful implementation of the Initiative—staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

Conclusions: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations.Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve

Tyler, D.A., Feng, Z., Grabowski, D.C., Bercaw, L., Segelman, M., Khatutsky, G., Wang, J., Gasdaska, A., & Ingber, M.J. (2022). CMS initiative to reduce potentially avoidable hospitalizations among long‐stay nursing facility residents: lessons learnedThe Milbank Quarterly, 100(4), 1243-1278.

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Study also found those with ‘full-code’ status regarding end-of-life care more likely to have repeat transfers than those with ‘do-not-resuscitate’ status.

Nursing homes transfer roughly 25% of their residents to the hospital at least once, at a cost of $14.3 billion to Medicare, according to a federal report by the Office of Inspector General.

But a new study by the University of Missouri discovered the number of repeat transfers are much higher for Black nursing home residents and those under age 65.

In one of the few studies to analyze the demographics of nursing home residents who get repeatedly transferred to the hospital, Amy Vogelsmeier, an associate professor in the MU Sinclair School of Nursing, found that Black nursing home residents, those under age 65 and those with “full-code” status were significantly more likely to be transferred to the hospital, at least four times or more in a given year.

“Black Nursing Home Residents, Those under Age 65 More Likely to Have Repeat Transfers to Hospital, MU Study Finds.” ShowMeMizzou, 1 July 2022, https://showme.missouri.edu/2022/black-nursing-home-residents-those-under-age-65-more-likely-to-have-repeat-transfers-to-hospital-mu-study-finds/. Accessed 5 July 2022.

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Background: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers.

Methods: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described.

Results: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable.

Conclusions: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Vogelsmeier, A., Popejoy, L., Fritz, E., Canada, K., Ge, B., Brandt, L., & Rantz, M. (2022). Repeat hospital transfers among long stay nursing home residents: A mixed methods analysis of age, race, code status, and clinical complexity. BMC Health Services Research, 22(1), 626-638.

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The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff

The Committee on the Quality of Care in Nursing Homes began their work in the fall of 2020 at a pivotal time when a bright light had been cast on care delivered in nursing homes because of the COVID-19 pandemic. While much of society previously had little awareness of the care delivered in nursing homes, the evening news channels and social media projected daily images of the pandemic’s impact and of the inadequate care that put the safety of both residents and staff at risk while distraught family members watched from afar as their frail older loved ones were kept in isolation. The committee worked to describe the care being delivered in nursing homes before the pandemic, now made manifest by the crisis.

Read the full report HERE! Or check out the highlights (summary document) HERE!

Press regarding the report release: Associated Press | McKnights Long-Term Care News | STAT | Modern Healthcare | ABC 17 (KMIZ) News

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Marilyn Rantz, a Curators’ professor emerita at the MU Sinclair School of Nursing, is a member of the Committee on the Quality of Care in Nursing Homes. The panel was organized by the National Academies of Sciences, Engineering and Medicine and first met in the fall of 2020, according to a news release.

Read the full article about the committee’s report HERE!

KOMU News, April 18, 2022. Written by Hannah Norton.

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The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and workforce development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery.

Alexander, G.L., Galambos, C., Rantz, M., Shumate, S., Vogelsmeier, A., Popejoy, L., & Crecelius, C. (2022). Value propositions for health information exchange toward improving nursing home hospital readmission rates. Journal of Gerontological Nursing, 48(1), 15-20.

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Background: US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff.

Problem: For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services.

Approach: It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed.

Conclusions: Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Popejoy, L.L., Vogelsmeier, A.A., Canada, K.E., Kist, S., Miller, S.J., Galambos, C., Alexander, G.L., Crecelius, C., & Rantz, M. (2021). A call to address RN, social work, and advanced practice registered nurses in nursing homes. Journal of Nursing Care Quality, 37(1), 21-27.

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Marilyn Rantz on “Brad’s Bites”, Inside Mizzou Athletics interview regarding reducing hospitalizations.

Click HERE for the 10-minute interview!

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Amy Vogelsmeier and Sue Shumate talk with Mason Rothert (Mediprocity) about NewPath Health Solutions.

Click HERE to listen to the episode!

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OBJECTIVES: To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending.

DESIGN: A four group comparative analysis of longitudinal data from September 2013 thru December 2019.

SETTING: NHs in the interventions of both Phases 1 (2012-2016) and 2 (2016-2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406).

PARTICIPANTS: NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only.

MEASUREMENTS: Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups.

RESULTS: The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) out-performed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state.

CONCLUSION: These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.

Rantz, M., Petroski, G.F., Popejoy, L.L., Vogelsmeier, A.A., Canada, K.E., Galambos, C.L., Alexander, G.L., & Crecelius, C. (2021). Longitudinal impact of APRNs on nursing home quality measures in the Missouri Quality Initiative. Journal of Nutrition, Health, & Aging, 25, 1124–1130.

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Eleven nursing homes, that participated in the Missouri Quality Initiative (MOQI) reduced potentially preventable hospitalizations for short- and long-stay residents by 58%, which saved payers more than $32 million from 2014 through 2019. The reduction in potentially preventable hospitalizations also improved revenue for the 11 nursing homes.

Hacker, T. (September 9, 2021). “Missouri Nursing Homes Participating In A Quality Initiative Cut Potentially Preventable Hospitalizations By 58%, Which Saved Payers $32 Million Over Six Years”, OPEN MINDS – Weekly News Wire, openminds.com/market-intelligence/news/.

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Researchers say employing more fully trained staff members can also save lives and money.

Maynard, C. (August 17, 2021). “Detecting illnesses early in nursing homes helps prevent hospitalizations, study finds”, Consumer Affairs.

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Skilled nursing operators can reduce costs and increase revenues, potentially by millions, by having staff members focus on detecting illnesses earlier to avoid hospitalization, according to a new study.

Brown, D. (August 18, 2021). “Nursing homes recapture $32 million after reducing hospitalizations: study”, McKnight’s Long-Term Care News.

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MU study examines financial, clinical benefits of early illness detection.

Click HERE for the press release!

Consiglio, B. (August 17, 2021). “Missouri nursing homes saved $32 million by reducing avoidable hospitalizations”, MU News Bureau.

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The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Read the article HERE!!

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Objectives: 1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes.

Design: A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012–2020).

Setting and Participants: Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region.

Methods: Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis.

Results: There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015–2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014–2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes.

Conclusions: Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization.

Implications: Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Rantz, M., Vogelsmeier, A., Popejoy, L., Canada, K., Galambos, C., Crecelius, C., & Alexander, G.L. (2021). Financial and work-flow benefits of reducing avoidable hospitalizations of nursing home residents. Journal of Nutrition, Health, & Aging, 25, 971–978.

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Social network analysis (SNA) uses quantitative methods to analyze relationships between people. In the current study, SNA was applied in two nursing homes (NHs) to describe how health care teams interact via text messages. Two data sources were used: (a) a Qualtrics® survey completed by advanced practice RNs containing resident transfer data, and (b) text messages from a secure platform called Mediprocity™. SNA software was used to generate a visual representation of the social networks and calculate quantitative measures of network structure, including density, clustering coefficient, hierarchy, and centralization. Differences were found in the low and high transfer rate NHs for all SNA measures. Staff in the NH with low transfer rate had greater decision-making interactions, higher information exchange rates, and more individuals communicating with each other compared to the high transfer rate NH. SNA can be applied to examine communication patterns found in text messages occurring around the time of NH resident transfers.

Powell, K.R., Popescu, M., & Alexander, G.L. (2021). Examining social networks in text messages about nursing home resident health status. Journal of Gerontological Nursing, 47(7), 16-22.

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Click HERE to access the 10-page MOQI report

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Click HERE to access the a 3-page brief on MOQI

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Click HERE to access the final MOQI Phase 1 report

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MU Nursing Home Research – radio interview with David Lile, KFRU

MOQI project, APRN regulations, reducing avoidable hospitalizations in LTC/nursing homes, systems change and sustaining change, quality improvement,

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MU study examines effectiveness of $35 million program designed to improve quality of care in nursing homes.

Marilyn Rantz still remembers the day she got the call that her mother, whose health had been declining, had fallen and fractured her shoulder. After rushing to the hospital, her mother told her she didn’t understand how she ended up on a helicopter pad after the traumatic incident. A nearby nurse told Rantz the noise from the MRI scanning tube had caused her frightened mother to mistakenly believe she had been airlifted to the hospital on a helicopter.

Determined to prevent avoidable hospitalizations, as well as the stress and panic that often comes along with the ambulance ride, Rantz, now a Curators’ professor emerita at the University of Missouri’s Sinclair School of Nursing, dedicated her career to improving the quality of care in nursing homes. In a recent study, Rantz and her team evaluated the effectiveness of the Missouri Quality Improvement Initiative, a $35 million program funded by the Centers for Medicare and Medicaid that implemented advanced practice registered nurses (APRNs) full time into 16 Missouri nursing homes. They recently evaluated the program over a six-year period and found the APRNs improved the quality of care for nursing home residents, which resulted in reduced avoidable hospitalizations and emergency room visits, leading to better overall health and more than $31 million in savings.

Consiglio, Brian. “Advanced practice registered nurses help reduce hospitalizations from nursing home residents,” Show Me Mizzou News, University of Missouri, 3 Mar. 2021.

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Medicare should scrap billing restrictions for direct care services provided by advanced practice nurses in nursing homes, researchers say.

Their new study followed a six-year Missouri quality improvement program that put full-time advanced practice nurses in 16 nursing homes. The program allowed staff to preempt hospital transfers by providing preventive care onsite, resulting in better health outcomes for residents and $31 million in savings over six years, the investigators reported.

Read the full article HERE.

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Advance care planning involves a meaningful conversation about residents’ end of life goals with the health-care team and documenting these wishes in advance directives; however, these conversations are not taking place early enough or with strategies that allow nursing home residents’ preferences to be meaningfully integrated into care plans. This article outlines a new model that nursing home social workers can use to initiate advance care planning discussions called Take it to the Resident. This model was tested with 11 long-term stay nursing home residents. Data were collected through structured memos and field notes. Summative content analysis was utilized to analyze the data. Take it to the Resident facilitated a discussion about advance care planning and allowed residents to consider their wishes before engaging family members. Although discussions took place, some residents were hesitant to document their wishes formally through advance directives. The results of this study support the utility of continued testing of this model. Having empirically supported tools for nursing home social workers is critical to increasing advance care planning conversations and empowering residents to document their wishes.

Pritchett, A., Canada, K.E., Galambos, C., Rollin, L., & Rantz, M. (2021). Take it to the resident: A model for engaging long-term stay residents in advance care planning. Social Work in Health Care, 60(3), 272-281.

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Early illness recognition is central to managing resident condition change and reducing potentially avoidable hospitalizations. Every staff member, provider and family play a role in identifying when a resident has a condition change.

Coletti, M.R. & Kist, S. (2021, February 1). Improve early illness recognition with two simple tools. McKnight’s Long-Term Care News.

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Recently, there have been numerous policy and program responses to reducing potentially avoidable hospitalizations from skilled nursing facilities (SNFs). It is estimated that approximately 25% of resident discharges to SNFs are readmitted within 30 days of discharge. Medicare spends more than $14 billion annually on both short- and long-stay SNF resident hospitalizations, many of which are preventable and unnecessary. Models have been proposed that focus on the relationships between nursing home (NH) physicians and staff of SNFs to reduce rehospitalizations. Other models applying complexity science principles of building relationships create the capacity for delivering better care.6 Evidence examining the level of physician engagement in SNFs suggests that rehospitalizations can be reduced with higher physician engagement. In addition, there is growing evidence supporting the importance of the use of specialty staff, such as nurse practitioners and physicians, with a variety of clinical expertise to augment resident care provided by traditional or standard NH staff. One such model was developed using advanced practice registered nurses (APRNs), a clinical support team, and a medical director with a specialty in geriatrics to augment NH staff to reduce potentially avoidable hospitalizations.

Galambos, C., Vogelsmeier, A., Popejoy, L., Crecelius, C., Canada, K., Alexander, G., Rollin, L., & Rantz, M. (2021). Enhancing physician relationships, communication, and engagement to reduce nursing home residents hospitalizations. Journal of Nursing Care Quality, 36(2), 99-104.

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Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF’s). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF’s. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p<.001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an AD and occurrence of transfer to a hospital was tested on a sample of 1,563 residents with length of stays more than 30 days. Residents who did not have an AD were 29% more likely to be transferred. A logistic regression was conducted, and the results were statistically significant (p<.02).

Galambos, C., Rantz, M., Popejoy, L., Ge, B., & Petroski, G. (2021). Advance directives in the nursing home setting: an initiative to increase completion and reduce potentially avoidable hospitalizations. Journal of Social Work in End-of-Life & Palliative Care, 17(1), 19-34. doi: 10.1080/15524256.2020.1863895.

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Objectives: The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents.

Design: A CMS funded demonstration project analyzed over 6-years using a single group design. Setting and Participants: The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019.

Measures: Resident data were analyzed using descriptive methods of aggregate facilities’ hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described.

Intervention: Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents.

Results: Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified.

Conclusions/Implications: The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN’s daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations’ support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Vogelsmeier, A., Popejoy, L., Canada, K., Galambos, C., Petroski, G., Crecelius, C., Alexander, GL, & Rantz, M. (2021). Results of the Missouri Quality Initiative: six-year trends of reducing unnecessary hospitalizations. Journal of Nutrition, Health, and Aging, 25(1), 5-12.

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Texting is ubiquitous with a text frequency of 145 billion/day worldwide. This paper provides partial results of the national demonstration project called the Missouri Quality Improvement Initiative (MOQI). MOQI goals were to reduce avoidable hospitalizations using APRNs to infuse evidence-based practices, model appropriate decisions and improve communication among workers responsible for nursing home resident care. This is a retrospective content analysis of text messages sent and received via a secure, password protected, encrypted mobile text message platform called Mediprocity. Text messages were created by 15 APRNs and a PhD-RN project supervisor working in 16 nursing homes over 6 months (January 1-June 30 2018). During the 6 months of data collection 8,946 text messages were captured, coded and analyzed. Data included 1,018 sent messages and 7,928 received messages. The most common messages sent (n=324) and received (n=2319) were about patient updates. The second most common texts included messages confirming information (n=1312).

Alexander G.L., Harrell, R., Shumate, S., Rothert, M., Vogelsmeier, A., Popejoy, L., Crecelius, C., & Rantz, M. (2020). To Text or Not to Text? That is the Question. Proceedings from the American Medical Informatics Association (AMIA), Virtual Conference, November 2020. National. (Refereed)

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Hospitalization for nursing home residents is a national concern. Studies suggest the majority of hospital transfers are avoidable, often resulting from poor care processes such as lack of early illness detection, adverse event occurrences, and poor communication between nursing home staff, providers, and residents/families about goals of care. Efforts supported by the Centers for Medicare and Medicaid Services are underway in the United States to reduce avoidable hospitalizations for nursing home residents. In 2012, the University of Missouri Sinclair School of Nursing was one of 7 sites across the United States selected for their evidence-based model called the Missouri Quality Initiative (MOQI), based on the nationally recognized Quality Improvement Program of Missouri (QIPMO). The goal of the MOQI was to work with 16 nursing homes in the Midwestern United States who had higher than national averages of hospitalization rates to change their systems of care delivery so that reduced hospital transfers could be achieved. Since 2012, the MOQI has achieved a 30% reduction in all-cause admissions following full implementation.

The MOQI method of reducing hospitalizations embeds a full-time advanced practice registered nurse (APRN) in each nursing home to implement early illness identification strategies including using Interventions to Reduce Acute Care Transitions (INTERACT) tools,8 managing acute and chronic conditions, initiating advance directives/advance health care planning, and facilitating the use of health information technology. APRNs use data to drive systems-level change including the use of monthly feedback reports showing the number of hospital transfers and changes of condition that provide longitudinal performance data to the APRN and nursing home team. Additionally, APRNs complete root cause analyses of all hospital transfers to help identify underlying causes. These root cause analyses are reviewed monthly with the project supervisor who is a member of the multidisciplinary intervention team.

The multidisciplinary intervention team has expertise in nursing home practice, geriatric medicine, advance care planning, end-of-life care, health information technology, and systems/quality improvement (QI). This team provides support to each MOQI APRN, hereafter referred to as APRN, to ensure achievement of successful outcomes. The APRN and the intervention team work closely with nursing home leaders and staff to facilitate system-level change to sustain lower hospital transfer rates. The purpose of this article is to describe the critical role of the multidisciplinary intervention team of clinical experts in supporting improved processes and sustained outcomes.

Vogelsmeier, A., Popejoy, L., Kist, S., Shumate, S., Pritchett, A., Mueller, J., & Rantz, M. (2020). Reducing avoidable hospitalizations for nursing home residents: role of the Missouri Quality Initiative intervention support team. Journal of Nursing Care Quality, 35(1), 1-5.

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Across studies, the risk of hospital transfer for nursing home residents is highest for people without documented advance directives and for people with chronic health conditions (eg, diabetes and congestive heart failure), mental health conditions (eg, depression), and limited functional abilities. Care transitions can be disruptive, distressing, and potentially harmful for residents particularly when continuity of care is impacted by ineffective communication, medication errors, and lack of awareness of advance directives. Although family engagement in care transitions is important, nursing home staff report feeling pressured by family members to transfer their resident to the hospital, which can result in unnecessary hospital transfers. Similarly, although having a written advance directive is associated with fewer hospital transfers and subsequent admissions, this alone does not guarantee the directive will be honored when needed. Health care staff may be unaware of the presence of advance directives during medical emergencies. Previous research highlights that care transitions can be improved by involving residents and their family in decision-making, discussing advance care plans before medical emergencies, and improving communication between providers, family members, and residents.

While previous studies investigated care transitions between nursing facilities and hospitals, only one examined transitions from the nursing home to the hospital and back, and none examined the latter experience exclusively from the resident perspective. This study contributes to what is known about resident perspectives of care transitions from the nursing home to the hospital and back by exploring resident perspectives of communication prior to hospital transfer, whether choices for care were honored, family engagement during and after the transfer, and their overall experience with the hospital transfer.

Canada, K. E., Galambos, C., Pritchett, A., Rollin, L., Popejoy, L., Vogelsmeier, A., & Rantz, M. (2020). Transitions of care: Perspectives of patients living in long term care. Journal of Nursing Care Quality, 35(3), 189-94.

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In 2011, the Office of Inspector General (OIG) of the Department of Health and Human Services released the report Medicare Atypical Antipsychotics Drug Claims for Elderly Nursing Homes Residents. This report was prompted by a legislator’s concern about the extent that elderly nursing home residents were receiving antipsychotic medications for off-label conditions. OIG staff evaluated Medicare claims data from Part B and Part D and the Minimum Data Set (MDS) to identify Medicare payments for atypical antipsychotic drugs for elderly (65 years and older) nursing home residents from January 1, 2007, to June 30, 2007. The OIG report revealed a clear picture of overuse of atypical antipsychotic medication for elderly nursing home residents in the United States and that the cost of the overuse had financial implications for the Medicare program. Importantly, antipsychotic medications reportedly were placing elderly nursing home residents at risk for medical complications and increased risk of early death. In 2007 and 2011, the Agency for Healthcare Research and Quality confirmed these findings in comparative effective reviews. Adverse events reported for atypical antipsychotic use among elderly nursing home residents were urinary symptoms, extrapyramidal symptoms, and increased risk of death.

Flesner, M., Lueckenotte, A., Vogelsmeier, A., Popejoy, L., Canada, K., Minner, D., Galambos, C., & Rantz, M. (2019). Advanced practice registered nurses’ quality improvement efforts to reduce antipsychotic use in nursing homes. Journal of Nursing Care Quality, 34(1), 4-8.

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OBJECTIVES: We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI).

DESIGN: Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers.

SETTING: Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city.

PARTICIPANTS: A total of 5168 residents with a median age of 82 years.

MEASUREMENTS: Data from 3946 MOQI-adapted ACTs.

RESULTS: A total of 54%of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38-3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33-3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17-7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9-25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46-.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54-.91; P = .007), and resident/family preference for hospitalization (OR= .79; 95%CI = .68-.93; P = .003).

CONCLUSION: Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change.

Popejoy, L.L., Vogelsmeier, A.A., Alexander, G.L., Galambos, C.M., Crecelius, C.A., Ge, B., Flesner, M., Canada, K., & Rantz, M. (2019). Analyzing hospital transfers using INTERACT acute care transfer tools: lessons from MOQI. Journal of the American Geriatrics Society, 67(9), 1954-1959.

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Studies describing avoidable hospital transfers for nursing home (NH) residents suggest rates vary between 30% and 70%, often citing poor communication, limited resources,patient/family preference, and adverse events as underlying causes. Adverse events, defined as harm resulting from the delivery of care, are particularly concerning because by definition they are often preventable events. The Office of the Inspector General identified harm related to adverse events affected one-third of Medicare skilled nursing facility residents, including events resulting in $2.8 billion in hospitalization costs.

Vogelsmeier, A., Popejoy, L., Kist, S., Harrell, R., Alexander, G., & Rantz, M. (2019). Avoiding nursing home to hospital transfers: rethinking avoidability. Journal of Nursing Care Quality, 34(3), 541-550.

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Quality Transitions Boost Value-Based Services

Streamlining transitions of care, along with reducing hospitalizations and re-hospitalizations, is a priority in any value-based payment model. Here is a look at 2 nursing-intensive initiatives that are leading the way.

As value-based care becomes more common, post-acute and long-term services and supports providers will need to become more adept at preventing hospital admissions and emergency department visits, and nurses appear to play a key role in the success of those organizations that have made this a priority.

Wood, Debra. (2019). Quality Transitions Boost Value-Based Services. LeadingAge e-magazine. March/April 2019.

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In 2011, the Office of Inspector General (OIG) of the Department of Health and Human Services released the report Medicare Atypical Antipsychotics Drug Claims for Elderly Nursing Homes Residents. This report was prompted by a legislator’s concern about the extent that elderly nursing home residents were receiving antipsychotic medications for off-label conditions. OIG staff evaluated Medicare claims data from Part B and Part D and the Minimum Data Set (MDS) to identify Medicare payments for atypical antipsychotic drugs for elderly (65 years and older) nursing home residents from January 1, 2007, to June 30, 2007. The OIG report revealed a clear picture of overuse of atypical antipsychotic medication for elderly nursing home residents in the United States and that the cost of the overuse had financial implications for the Medicare program. Importantly, antipsychotic medications reportedly were placing elderly nursing home residents at risk for medical complications and increased risk of early death. In 2007 and 2011, the Agency for Healthcare Research and Quality confirmed these findings in comparative effective reviews. Adverse events reported for atypical antipsychotic use among elderly nursing home residents were urinary symptoms, extrapyramidal symptoms, and increased risk of death.

The findings from these reports prompted the Centers for Medicare & Medicaid (CMS) in 2012 to establish a National Partnership to Improve Dementia Care in Nursing Homes.4,5 This private-public partnership developed a multidimensional strategy to address the public health issue affecting 14% of the nursing home population and health care costs. According to the 2011 OIG report, the costs of overuse of antipsychotic medication toMedicare was $309 million during the 6 months preparing the report.

The purpose of this article is to share the quality improvement (QI) efforts to reduce antipsychotic medication use in nursing home residents in a federally funded initiative that used full-time advanced practice registered nurses (APRNs). These APRNs were embedded in 16 nursing homes in Missouri from 2014 to 2016.

Flesner, M., Lueckenotte, A., Vogelsmeier, A., Popejoy, L., Canada, K., Minner, D., Galambos, C., & Rantz, M. (2019). Advanced practice registered nurses’ quality improvement efforts to reduce antipsychotic use in nursing homes. Journal of Nursing Care Quality, 34(1), 4-8.

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MOQI, a program of the Sinclair School of Nursing, works with nursing homes to implement improvements in care to avoid unnecessary hospitalizations, improve resident care and reduce health care costs. MOQI is a pilot project sponsored by the Centers for Medicaid & Medicare Innovations Center and Medicare-Medicaid Coordination Office.

The Missouri Quality Initiative (MOQI) works to improve the quality of care for residents of the state’s nursing homes – University Assets

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Over twenty years ago, the University of Missouri formed a broad interdisciplinary team to revolutionize older adult care. Over the years, this team consisted of engineering, nursing, and social work researchers, among other valuable members. From this team came two unique and successful interventions. The first is the development of in-home sensor technology to help older adults age in place. This system captures sleep, gait, and activity patterns non-invasively recognizes when patterns change, and automatically generates alerts to signal possible impending health problems days or weeks earlier than people are typically aware, allowing them to seek early treatment. The second intervention is the Mobilizing Options for Quality Improvement in Post-Acute Care (MOQI-PAC) project. Full-time Advanced Practice Registered Nurses (APRNs) and a multidisciplinary clinical support team in sixteen nursing homes promote early interventions for residents with declining health conditions. This team has been able to reduce potentially avoidable hospitalizations by 50% and all-cause hospitalizations by 32%. Together, these two interventions can result in even more improvements in avoidable hospitalizations, improved overall function, better chronic illness management, and better overall quality of life for older adults.

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A new study finds that nursing facilities were able to reduce hospitalizations among residents without increasing their mortality risk. RTI International tracked 143 nursing facilities participating in the Centers for Medicare and Medicaid Services’ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The results of the study were published in the October issue of Health Affairs.

New study finds that nursing facilities can reduce avoidable hospitalizations without increasing mortality risk, RTI International, October 2, 2018.

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Implementation of the Centers for Medicare and Medicaid Services’ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents reflected recognition of the adverse impacts of excess hospitalizations on the cost of care and the well-being of long-stay residents. Prior studies of the initiative have found favorable effects on reducing hospitalizations and costs, but were these accompanied by unintended consequences for well-being? We tracked all-cause mortality rates in each year for the period 2014–16 among long-stay residents at nursing facilities in seven states that participated in the initiative, and we found no evidence of excess mortality. The initiative’s effects on mortality rates were small—ranging from a reduction of 0.8 percentage points to an increase of 1.5 percentage points, relative to changes in mortality rates at comparison-group facilities—and none of the effects was significant. This suggests that efforts to reduce unnecessary hospitalizations among nursing facility residents can succeed without increasing mortality rates.

Nursing Facilities Can Reduce Avoidable Hospitalizations Without Increasing Mortality Risk For Residents, Health Affairs, 37(10), 2018.

Appendix

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An Introduction to Health Information Technology in LTPAC Care Settings (HIMSS Book Series) by Gregory L. Alexander, PhD, RN, FAAN; Derr F. John, RPh, FASCP;‎ Lorren Pettit, MS, MBA

Purchase the book here!!

A multiplicity of factors converging together suggest the LTPAC provider community (e.g. nursing homes, behavioral health facilities, home health agencies, etc.) will elevate in importance within the healthcare ecosystem during the next few years. The challenge for many LTPAC providers in this emerging environment will be to advance their clinical health IT capabilities in order to “play” with other providers in the healthcare “sandbox.” This book is designed to assist LTPAC leaders in identifying and exploring the array of critical issues one needs to consider in order to operate within an advanced clinical health IT ecosystem.

This book surveys key issues surrounding the use of clinical health information technologies (health IT) in long-term/post-acute care (LTPAC) settings. It also will provide the reader with a suggested strategic plan and roadmap to be a valued provider partner in care coordination in the new healthcare care and payment environment. It provides the reader with options in a strategic roadmap or plan to be a valued partner in the person-centric spectrum of care.

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Improving nursing home care has easy solution – hire advanced nursesMU News Bureau

By Sheena Rice | July 10, 2018

New research from the University of Missouri provides substantial evidence that full-time APRNs have a significant impact on improved outcomes

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A remarkable transformation is occur-ring in the nation’s use of health information technology (HIT). Health information technology adoption has been spurred on by federal legislation in the past few years, which provided financial incentives for HIT adoption, mostly in acute care. Federal strategies continue to promote goals that support research, scientific knowledge, and innovations that show how HIT improves health and health care delivery across all sectors. A growing area of evidence concerns the widening gap of HIT adoption across health care organizations, such as varied trend rates of electronic health record adoption in long-term care facilities (LTC). Despite recognized values HIT provides to LTC providers, such as error reduction, clinical efficiencies, cost savings, and improved patient outcomes, some LTC providers continue to lag behind in their choice to adopt HIT. Furthermore, there is scant evidence focused on HIT adoption and trends in quality measures (QMs). Quality measures, which LTC leaders have collected nationally for years, are used in few studies reporting associations with technology adoption trends. Research reported in this article was undertaken to explore this evidence gap by answering the following research questions: (1) What are the trends in information technology (IT) adoption in US nursing home facilities over 2 years? (2) How are 2-year trends in IT adoption in US nursing homes related to nationally reported QM

Alexander, G. & Madsen, R. (2018). A national report of nursing home quality and information technology: two-year trends. Journal of Nursing Care Quality, 33(3), 200-207.

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Purpose: The purpose of this article is to review the impact of advanced practice registered nurses(APRNs) on the quality measure (QM) scores of the 16 participating nursing homes of the Missouri Quality Initiative (MOQI) intervention. The MOQI was one of 7 program sites in the US, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services Innovations Center. While the goals of the MOQI for long-stay nursing home residents did not specifically include improvement of the QM scores, it was anticipated that improvement most likely would occur. Primary goals of the MOQI were to reduce the frequency of avoidable hospital admissions and readmissions;improve resident health outcomes; improve the process of transitioning between inpatient hospitals and nursing facilities; and reduce overall healthcare spending without restricting access to care or choice of providers.

Methods: A 2-group comparison analysis was conducted using statewide QMs; a matched comparison group was selected from facilities in the same counties as the intervention homes, similar baseline QM scores, similar size and ownership. MOQI nursing homes each had an APRN embedded full-time to improve care and help the facility achieve MOQI goals. Part of their clinical work with residents and staff was to focus on quality improvement strategies with potential to influence healthcare outcomes. Trajectories of QM scores for the MOQI intervention nursing homes and matched comparison group homes were tested with non parametric tests to examine for change in the desired direction between the 2 groups from baseline to 36 months. A composite QM score for each facility was constructed, and baseline to 36-month average change scores were examined using non parametric tests. Then, adjusting for baseline, a repeated measures analysis using analysis of covariance as conducted.

Results: Composite QM scores of the APRN intervention group were significantly better (P¼.025) than the comparison group. The repeated measures analysis identified statistically significant group by time interaction (P¼.012). Then group comparisons were made at each of the 6-month intervals and statistically significant differences were found at 24 months (P¼.042) and 36 months (P¼.002), and nearly significant at 30 months (P¼.11).

Implications: APRNs working full time in nursing homes can positively influence quality of care, and their impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs. Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes,indicating budgeting for APRN services can be a successful strategy.

Rantz, M.J., Popejoy, L., Vogelsmeier, A., Galambos, C., Alexander, G., Flesner, M., Murray, C., Crecelius, C., Ge, B., & Petroski, G. (2018). Impact of advanced practice registered nurses on Quality Measures: the Missouri Quality Initiative experience. Journal of the American Medical Directors Association, 19(6), 541-550.

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UTIs Can Leave Elderly Confused

Interview with JoAnn Franklin (APRN, NHC Healthcare, Desloge) in Daily Journal Online

May 2018 | by Kevin Jenkins

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The increasing demand for healthcare services is placing great strain on healthcare systems throughout the world. Although the older population is increasing worldwide, there is a marked deficit in the number of persons trained in geriatrics. It is now recognized that early detection and treatment of geriatric conditions (e.g., frailty, sarcopenia, falls, anorexia of aging, and cognitive decline) will delay or avert the development of disability. At the same time, recent years have seen an increased interest and use of advanced practice nurses (APN). Models of best practices of supervision and collaboration have been promulgated by many organizations. APN’s roles and scope of practice have been expanded in many countries and the quality and cost-effectiveness of healthcare systems have improved. Nevertheless, in older people, evidence of advanced practice roles remains scattered, and there is little synthesis of evidence, and therefore it is not easy to visualize the different practice models and their components. The aim of this paper is to explain the need for advanced practice nurses to manage geriatric conditions.

Fougère, B., Lagourdette, C., Abele, P., Resnick, B., Rantz, M., Kam Yuk Lai, C., Chen, Q., Moyle, W., Vellas, B., & Morley, J.E. (2018). Involvement of Advanced Practice Nurse in the management of geriatric conditions: examples from different countries. The Journal of Nutrition, Health and Aging, 22(4), 463-470.

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Fougère, B., Lagourdette, C., Abele, P., Resnick, B., Rantz, M., Kam Yuk Lai, C., Chen, Q., Moyle, W., Vellas, B., & Morley, J.E. (2018). Involvement of Advanced Practice Nurse in the management of geriatric conditions: examples from different countries. The Journal of Nutrition, Health and Aging, 22(4), 463-470.

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One of Health Affairs Top 10 Most Read Articles of 2017!!!

Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results” by Melvin J. Ingber, Zhanlian Feng, Galina Khatutsky, Joyce M. Wang, Lawren E. Bercaw, Nan Tracy Zheng, Alison Vadnais, Nicole M. Coomer, and Micah Segelman | March 2017

Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2–9.3 percentage points in the probability of an all-cause hospitalization and 1.4–7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60–$2,248 for all-cause hospitalizations and by $98–$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

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Alexander G.L. & Madsen, R.W. (2017). A report of information technology and health deficiencies in US nursing homes. Journal of Patient Safety. Published online 6/5/17.

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Purpose: The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health out-comes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center.

Design and methods: A prospective, single group intervention design, the MOQI included an advanced practice registered nurse (APRN) embedded full-time within each nursing home (NH) to influence resident care outcomes. Data were collected continuously for more than 3 years from an average of 1750 long-stay Medicare, Medicaid, and private pay residents living each day in 16 participating nursing homes in urban, metro, and rural communities within 80 miles of a major Midwestern city in Missouri.Performance feedback reports were provided to each facility summarizing their all-cause hospitalizations and potentially avoidable hospitalizations as well as a support team of social work, health information technology, and INTERACT/Quality Improvement Coaches.

Results: The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents.

Implications: As the population of older people explodes in upcoming decades, it is critical to find good solutions to deal with increasing costs of health care. APRNs, working with multidisciplinary support teams, are a good solution to improving care and reducing costs if all nursing home residents have access to APRNs nationwide.

Rantz, M., J., Popejoy, L., Vogelsmeier, A., Galambos, C., Alexander, G., Flesner, M., Crecelius, C., Ge, B., & Petroski, G. (2017). Successfully reducing hospitalizations of nursing home residents: results of the Missouri Quality Initiative. Journal of the American Medical Directors Association, 18(11), 960-966.

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Reducing in avoidable hospitalizations of nursing home residents is a major concern to health care providers as well as payers. Not only are hospitalizations costly but also hospitalized nursing home residents experience functional and physical decline as a result of hospital transitions that can result in worsening health conditions or death. In 2012, the Missouri Quality Initiative (MOQI)was funded by the Centers for Medicare &Medicaid Services (CMS) Innovations Center and Medicare-Medicaid Coordination Office as a part of a national demonstration, Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. While avoiding hospitalizations is important for both short- and long-stay nursing home residents,the CMS initiative focuses on long-stay residents. The CMS funded 7 sites across the United States with the purpose for each site to test the effectiveness of evidence-based clinical and educational interventions in reducing potentially avoidable hospitalizations for long-stay residents—an important aspect of improving care and quality of life.

Rantz, M., Popejoy, L., Vogelsmeier, A., Galambos, C., Alexander, G., Flesner, M., Murray, C., & Crecelius, C. (2017). Reducing avoidable hospitalizations and improving quality in nursing homes with APRNs and interdisciplinary support: lessons learned. Journal of Nursing Care Quality, 33(1), 5-9.

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Objective: As part of the Missouri Quality Initiative (MOQI) to reduce hospitalizations for long-stay nursing home residents, this article describes reasons MOQI advanced practice registered nurses(APRNs) recommended medication order changes as part of their medication review process as well as the outcomes of their recommendations.Design:Cross-sectional descriptive study of MOQI APRN-conducted medication reviews.Setting:Long-stay nursing homes participating in the MOQI project.

Participants: Seventeen MOQI APRNs recorded medication reviews for 3314 long-stay residents residing in 16 Midwestern nursing homes over a 2-year period.

Intervention: APRNs conducted medication reviews and made recommendations for medication order changes to residents’medical providers.

Measurements: The MOQI medication review database was used to abstract data.

Results: There were 19,629 medication reviews recorded for 3314 residents during the 2-year period. Of the 19,629 reviews, 50% (n¼9841) resulted in recommended order changes of which 82% (n¼8037) of order changes occurred. More than two-thirds of recommendations were because of changes in the residents’ plans of care. Other recommendations included adjusting and/or discontinuing medications that had the potential for harm.

Conclusion: Resident care needs are dynamic, resulting in the need for frequent medication order changes. MOQI APRNs, because of their advanced pharmacological education and daily presence in the nursing home, are uniquely positioned to ensure residents’medications aligned with their overall goals of care while minimizing risk of harm.

Vogelsmeier, A., Popejoy, L., Crecelius, C., Orique, S., Alexander, G. & Rantz, M. (2018). APRN-conducted medication reviews for long-stay nursing home residents. Journal of the American Medical Directors Association, 19(1), 83-85.

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Background: Centers for Medicare and Medicaid Innovation Center sponsored the initiative to reduce avoidable hospitalizations among nursing facility residents.Purpose:Missouri Quality Initiative (MOQI) designed inter-professional model in nursing homes with advanced practice registered nurses (APRNs).

Method: MOQI APRN model was implemented for 4 years in 16 nursing homes in a metro area of the Midwest. Hospitalizations were reduced (40% all-cause, 58%potentially avoidable), emergency room visits (54% all-cause, 65% potentially avoidable), Medicare expenditures for hospitalizations (34% all-cause, 45%potentially avoidable), and Medicare expenditures for emergency room visits (50% all-cause, 60% potentially avoidable) for long-stay nursing home residents.

Discussion: Success of the MOQI model reinforces decades of research demonstrating that care provided by APRNs is cost-effective, safe, and associated with positive health outcomes and patient satisfaction.Conclusion:Nursing homes can implement and benefit by hiring APRNs. However,changes in the Code of Federal Regulation (CFR 483.40) are necessary to improve patient access to care and encourage hiring APRNs in US nursing homes.

Rantz, M.J., Birtley, N.M., Flesner, M., Crecelius, C., & Murray, C. (2017). Call to Action: APRNs in US nursing homes to improve care and reduce costs. Nursing Outlook, 65(6), 689-696.

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Centers for Medicare & Medicaid Innovations Centers partnered with 7 Enhanced Care and Coordination Provider (ECCP) sites across the United States with the goal to reduce potentially avoidable hospital transfers for nursing home residents. The University of Missouri Sinclair School of Nursing,1 of the 7 ECCP sites, developed the Missouri Quality Initiative (MOQI) for nursing homes. The MOQI partnered with 16 nursing homes in the St Louis region to reduce potentially avoidable hospital transfers by implementing key elements to improve health condition management through prevention and early illness detection and treatment; use Intervention to Reduce Acute Care Transfers(INTERACT) tools and processes to communicate about resident condition change; improve end-of-life care; and expand use of health information technology.

Popejoy, L.L., Vogelsmeier, A., Galambos, C., Flesner, M., Alexander, G., Lueckenotte, A., & Lyons, V. (2017). The APRN role in changing nursing home quality: The Missouri quality improvement initiative. Journal of Nursing Care Quality. 32(3), 196-201.

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Fewer nursing home patients are hospitalized with MU programKOMU News

By Jasmine Ramirez | December 11, 2017

One MU Nursing School program has reduced the number of nursing home patients from hospitalization by nearly 50 percent.

The Missouri Quality Initiative for Nursing Homes (MOQI) applies to advanced care, new technology and places Advanced Practice Registered Nurses in nursing homes.

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Advanced Practice Nurses Cut Hospitalizations from SNFs by Almost HalfSkilled Nursing News

By Maggie Flynn | December 11, 2017

If a nursing home wants fewer hospitalizations, it needs more nursing personnel.

This was the takeaway from a report released in October on an initiative supported by the Centers for Medicare & Medicaid Services (CMS). The initiative was meant to reduce avoidable hospitalizations among nursing facility residents, and was part of the Missouri Quality Initiative for Nursing Homes (MOQI). 

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The final independent evaluation report for the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, Phase One

Read the report here

The final independent evaluation report for Phase One was released on October 20, 2017.

The evaluation determined that all seven sites reduced hospitalizations, with six of the seven achieving statistically significant improvement in either all-cause hospitalizations, potentially avoidable hospitalizations, or both. Total Medicare expenditures were reduced in six of the seven sites, with statistical significance in four. If the intervention cost is taken into account, four of the seven sites achieved Medicare expenditure reductions in excess of costs, though overall the difference was not statistically significant.

The report found the strongest improvements in both cost and quality at the intervention sites with a full-time nurse at each facility providing direct care to residents. These models demonstrated greater changes in facility culture, greater support for the need to reduce avoidable hospitalizations, and greater overall buy-in to the Initiative from facility staff, resulting in stronger intervention effects. Intervention sites where nurses did not provide direct care, or where nurses rotated across multiple facilities, showed less consistent effects.

According to the report, “Overall, these findings provide persuasive evidence of the Initiative’s effectiveness in reducing hospital inpatient admissions, ED visits, and hospitalization-related Medicare expenditures.”

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Advanced practice nurses key to improving SNF care, researchers sayMcKnight’s Long-Term Care News

By Emily Mongan | August 24, 2017

Training an advanced practice nurse to lead a nursing home care team has shown promise for improving staff communication and the way facilities handle mobility, hydration and end-of-life care issues, a new study shows.

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Advanced Practice Nurses Improve Health Care for Nursing Home Residents, MU Study Finds – MU News Bureau

By Sheena Rice | August 23, 2017

The nation’s 65 and older population is projected to double in size by the year 2050, according to the U.S. Census. To improve health care for the nation’s aging population, researchers from the Sinclair School of Nursing at the University of Missouri are studying how advanced practice nurses (APRNs) can improve nursing home care by serving as leaders of health care teams in nursing homes. Findings suggest that APRN-led health care teams reduce hospitalizations related to falls, dehydration and other health issues.

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How Certain Nurses Can Lower Hospital Readmission Rates at SNFsSkilled Nursing News

By Tim Regan | August 15, 2017

For skilled nursing providers looking for ways to reduce unnecessary hospitalizations, taking on advanced practice registered nurses (APRNs) could be the way forward.

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MU study finds successful ways to reduce hospital admissions of St. Louis nursing home residentsSt. Louis Public Radio

By Kelly Moffitt | August 15, 2017

In 2011, one in four nursing home residents on Medicare was hospitalized. It’s an issue that impacts many facets of health care, from quality of life for nursing home residents to spending of taxpayer dollars, and on Tuesday’s St. Louis on the Air, host Don Marsh spoke with a University of Missouri Nursing School professor about ways to reduce avoidable hospital admissions.

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The Patient Self-determination Act requires that health care institutions inform patients of their right to make health care preferences known through advance directives. However, actual advance directive documentation remains low. This study’s purpose is to identify and analyze research studies incorporating clinical decision support to improve rates of advance directive documentation. In addition, variables impacting advance directive documentation are identified. Literature searches were performed in the Cumulative Index of Nursing and Allied Health Literature, PubMed, and Scopus between 1998 and 2015. Search criteria yielded more than 2000 results using various search engines, yielding 34 articles with 35 studies total. Articles included 17 studies describing electronic health record–based decision support interventions for advance directive documentation (Supplemental Digital Content 1). In addition, 18 studies assessed factors influencing advance directive documentation (Supplemental Digital Content 2). Findings suggest that decision support–based reminders are effective in improving advance directive documentation. Use of e-mail reminders for patients before patient visits through electronic health record portals provides a mechanism to improve advance directive documentation rates. Furthermore, major factors influencing advance directive documentation include inconsistencies in end-of-life preferences between patients and providers and inconsistencies in patients’ preferences over time.

Folarinde, B. & Alexander, G.L. (2017). An integrated review of research using clinical decision support to improve advanced directive documentation. Journal of Hospice and Palliative Care Nursing, 19(4), 332-338.

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APRNs in Nursing Homes Can Curb Avoidable HospitalizationsToday’s Geriatric Medicine

By Jamie Santa Cruz | June 22, 2017

APRNs’ ability to assess nursing home residents’ changes in health status early and implement appropriate treatments can reduce unnecessary hospital admissions.

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Objective: The aim of the study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publically reported health safety deficiency scores documented during standard inspections.

Methods: The sample included 807 NHs from every U.S. state. A total of 2187 health inspections were documented in these facilities. A national sophistication survey describing IT capabilities, extent of IT use, and degree of IT integration in resident care, clinical support, and administrative activities in U.S. NHs was used. The relationship between NH health deficiencies and IT sophistication survey scores was examined, using weighted regression.

Results: Controlling for registered nurse hours per resident day, deficiency scores decreased as total IT sophistication increased. Controlling for total IT sophistication score, deficiency scores decreased as registered nurse hours per resident day increased. Ownership status significantly influenced health deficiency scores.

Conclusions: These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety.

Alexander G.L. & Madsen, R.W. (2017). A report of information technology and health deficiencies in US nursing homes. Journal of Patient Safety. Published online 5/30/17.

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Advanced Practice Nurses are Lowering Hospitalization Rates, Saving Money in Nursing HomesMU News Bureau

By Sheena Rice | March 13, 2017

Five years into the Missouri Quality Initiative for Nursing Homes (MOQI), a program aimed at improving nursing home care, researchers at the Sinclair School of Nursing at the University of Missouri are seeing significant reductions in spending and potentially avoidable hospitalizations in participating nursing homes. The results were reported in the project’s annual report, released by the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services (CMS) and prepared by RTI International.

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Program shows advanced practice registered nurses better for nursing homesKOMU

By Lexi Larson | February 27, 2017

Results from the Missouri Quality Initiative for Nursing Homes (MOQI), show that advanced practice registered nurses, or APRNs, in nursing homes might help improve the health of nursing home residents with heart disease.

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The heart of the matter with advanced directives and why you need to push more for themMcKnight’s Long-Term Care News

By James Berklan | January 19, 2017

In their most crass interpretation, advance directives can save the healthcare system a lot of money. At their most heartfelt, they can reduce a lot of pain and suffering. They also are the essence of patient-centered care.

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As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative(14 percent), or spouse (13 percent). Financial power of attorney documents were some-times found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

Galambos, C., Starr, J., Rantz, M., & Petroski, G. (2016). Analysis of advance directive documentation to support palliative care activity in nursing homesHealth and Social Work, 41(4), 228-234.

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Objectives: Limited research exists on nursing home information technologies, such as health information exchange (HIE) systems. Capturing the experiences of early HIE adopters provides vital information about how these systems are used. In this study, we conduct a secondary analysis of qualitative data captured during interviews with 15 nursing home leaders representing 14 nursing homes in the midwestern United States that are part of the Missouri Quality Improvement Initiative (MOQI) national demonstration project.

Methods: The interviews were conducted as part of an external evaluation of the HIE vendor contracting with the MOQI initiative with the purpose of understanding the challenges and successes of HIE implementation, with a particular focus on Direct HIE services.

Results: Emerging themes included (1) incorporating HIE into existing work processes, (2) participation inside and outside the facility, (3) appropriate training and retraining, (4) getting others to use the HIE, (5) getting the HIE operational, and 6) putting policies for technology into place.

Discussion: Three essential areas should be considered for nursing homes considering HIE adoption: readiness to adopt technology, availability of technology resources, and matching of new clinical workflows.

Alexander, G., Popejoy, L., Lyons, V., Shumate, S., Mueller, J., Galambos, C., Vogelsmeier, A., Rantz, M., & Flesner, M. (2016). Exploring health information exchange implementation using qualitative assessments of nursing home leaders. Perspectives in Health Information Management, 13(Fall), 1-12. PMCID: PMC5075234, PMID: 27843423.

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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. A such, it is vital that NHs improve their capacity to identify and treat acute illness in their residents to avoid hospitalization

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.

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Objective: Our purpose was to describe how we prepared 16 nursing homes (NHs) for health information exchange (HIE) implementation. Background: NH HIE connecting internal and external stakeholders are in their infancy. U.S. initiatives are demonstrating HIE use to increase access and securely exchange personal health information to improve patient outcomes.

Method: To achieve our objectives we conducted readiness assessments, performed 32 hours of clinical observation and developed 6 use cases, and conducted semi-structured interviews with 230 participants during 68 site visits to validate use cases and explore HIE.

Results: All 16 NHs had technology available to support resident care. Resident care technologies were integrated much more with internal than external stakeholders. A wide range of technologies were accessible only during administrative office hours. Six non-emergent use cases most commonly communicated by NH staff were: 1) scheduling appointments, 2) laboratory specimen drawing, 3) pharmacy orders and reconciliation, 4) social work discharge planning, 5) admissions and pre-admissions, and 6) pharmacy-medication reconciliation. Emerging themes from semi-structured interviews about use cases included: availability of information technology in clinical settings, accessibility of HIE at the point of care, and policies/procedures for sending/receiving secure personal health information.

Conclusion: We learned that every facility needed additional technological and human resources to build an HIE network. Also, use cases help clinical staff apply theoretical problems of HIE implementation and helps them think through the implications of using HIE to communicate about clinical care.

Alexander, G.L., Rantz, M., Galambos, C. Vogelsmeier, A., Flesner, M., Popejoy, L.L., Mueller, J., Shumate, S., & Elvin, M. (2015). Preparing nursing homes for the future of health information exchange. Applied Clinical Informatics, 6, 248-266.

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The MOQI Intervention Model 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. 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 residentsJournal of Nursing Care Quality, 30(4), 290-297.

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Faculty at the Sinclair School of Nursing at the University of Missouri, with its 20-year history of partnering with Missouri nursing homes to improve quality of care, have assembled an extraordinary team of organizations to develop and implement the Missouri Quality Initiative for Nursing Homes (MOQI).This call to action was in response to the Centers for Medicare & Medicaid Services (CMS)funding opportunity announcement: Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. The team includes the Quality Improvement Program for Missouri (QIPMO), Primaris (the Missouri Quality Improvement Organization), Leading-Age Missouri, Missouri Health Care Association, Missouri Hospital Association, Missouri Health Connection, Missouri Association of Long Term Care Physicians, Missouri Nurses Association, the Alzheimer’s Association, and others.

Rantz, M., Alexander, G., Galambos, C., Vogelsmeier, A., Popejoy, L., Flesner, M., Lueckenotte, A., Crecelius, C., & Zwygart-Stauffacher, M. (2014). Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents. Journal of Nursing Care Quality, 29(1), 1-8.

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For many years, The Centers for Medicare and Medicaid Services (CMS) have had in place two (2) regulations (F 309 & 329) for long-term care facilities to assess, evaluate, and attempt gradual dose reductions in the use of antipsychotic, antianxiety, and hypnotic/sedative medications. In 2012, CMS challenged long-term and skilled care communities to reduce the use of these medications by 15%. The overall challenge from CMS was to improve dementia care, with one (1)focus being the reduction of antipsychotics in addition to implementation of other key principles in dementia care. These goals are challenging nursing facilities to develop new care approaches for residents and medication review processes.

Hampton, J.K., Reiter, T., Doerr, J., & Popejoy, L. (2014). Using FOCUS PDA to improve antipsychotic medication management. Journal of Nursing Care Quality, 29(4), 295-302.

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Heal Early, Heal Often: Marilyn Rantz keeps elders healthyMizzou Magazine

By Dale Smith | May 21, 2013

Researcher Marilyn Rantz has set out to counter the too-common idea and experience of aging as an inevitable decline into frailty and dependency. Her mission in life is to replace that defeatist outlook by developing and testing new ways of caring for elderly people so they can remain as independent as possible for as long as possible.

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