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Objectives: The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states “develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations.” The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used.

Design: A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care.

Setting and Participants: All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020–2022.
Methods QM data were drawn from CMS’s publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity.

Results:All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with “worse” overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity.

Conclusions and Implications: This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and “initiate fundamental change” for better care for our nation’s older adults.

Rantz, M.J., Martin, C., Zaniletti, I., Mueller, J., Galambos, C., Vogelsmeier, A., Popejoy, L., Thompson, R.A., & Crecelius, C. (2024). Longitudinal evaluation of a statewide Quality Improvement Program for Nursing Homes. Journal of the American Medical Directors Association. Published online January 31, 2024.

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November 2023

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August 2023

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  • A Time for Celebration
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May 2023

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  • Introducing…
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  • Thanks to NARCAN

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February 2023

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The way the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, inequitable, fragmented, and unsustainable. The failings of the US healthcare system regarding nursing homes are reflected in poor resident outcomes, substantial government spending, pervasive inequities, and an underpaid and demoralized workforce (Konetzka, Yan, & Werner, 2021; Sloane et al., 2021; Travers, Agarwal, et al., 2021; Travers, Teitelman, et al., 2020; Yang, Yong, & Scott, 2022). Between the years of 2013 and 2017, 82% of nursing homes were cited for an infection prevention and control deficiency (U.S. Government Accountability Office, 2020). Consequently, it is no surprise residents and those working in the nursing home sector suffered greatly under the weight of the coronavirus disease 2019 (COVID-19) pandemic. Images of isolated residents languishing day after day, reports of infections fomented by lack of personal protective equipment, the deaths of over 150,000 residents, and stories of underpaid staff working in unsafe conditions with little respite, recognition, or support, have plagued news feeds for over 2 years. And yet, many underlying problems related to how the United States finances and regulates nursing home care have existed for decades in nursing homes without timely and critical legislative intervention. Four reports produced by the Institute of Medicine, now the National Academies of Sciences, Engineering, and Medicine (NASEM), proposed solutions for improving care delivery in nursing homes (Instituteof Medicine [IOM] Committee on Nursing Home Regulation, 1986; IOM Committee on Improving Quality in Long-Term Care, Wunderlich, & Kohler, 2001; IOM Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes, Wunderlich, Sloan, & Davis, 1996; IOM Committee on the Future Health Care Workforce for Older Americans, 2008). Some led to significant changes, such as the passage of OBRA 1987, and promulgation of new standards; however, none have resulted in change that eradicated these fundamental problems. Immediate action to initiate meaningful change is necessary.

Travers, J.L., Alexander, G., Bergh, M., Bonner, A., Degenholtz, H.B., Ersek, M., Ferrell, B., Grabowski, D.C., Longobardi, I., McMullen, T., Mueller, C., Rantz, M., Saliba, D., Sloane, P., & Stevenson, D.G. (2023). 2022 NASEM quality of nursing home report: moving recommendations to action. Public Policy & Aging Report. 33(S1), S1-S4.

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The National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on the Quality of Care in Nursing Homes had a broad mandate: to examine how the United States“delivers, finances, measures, and regulates the quality of nursing home care”(National Academies of Sciences, Engineering, and Medicine,2022,p. xvii). The resultant goals and associated recommendations encompass a broad array of strategies and actors needed to improve the quality of care. At their core are a vision and guiding principles that, if enacted, the Committee asserts will transform the day-to-day delivery of care: “nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses benefits and risks of care and treatments”(NationalAcademies of Sciences, Engineering, and Medicine,2022,p. 498i). Care delivery must be person-centered: that is, care that meets the unique needs, goals, values, and preferences of residents

Rantz, M. & Ersek, M. (2023). Care delivery, quality measurement, and quality improvement in nursing homes: Issues and recommendations from the National Academies’ report on the quality of care in nursing homes. Journal of the American Geriatrics Society, 71(2), 329-334.

Rantz, M. & Ersek, M. (2023). Care delivery, quality measurement, and quality improvement in nursing homes: Issues and recommendations from the National Academies’ report on the quality of care in nursing homes. Public Policy & Aging Report, 33(S1), S11-S15.

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Mueller, C.A., Alexander, G., Ersek, M., Ferrell, B., Rantz, M., & Travers, J. (2023). Calling all Nurses – Now is the time to take action on improving the quality of care in nursing homes. Nursing Outlook. Published online: January 6, 2023.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee’s vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

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Purpose: To identify leadership styles and staffing strategies in Missouri long-term care (LTC) facilities that stood out among their peers as “positive deviants” with regard to COVID-19 infections and staffing shortages.

Methods: Statewide survey of all LTC facilities to identify exemplar facilities with stable staffing and low rates of COVID-19. Interviews with senior leaders were conducted in 10 facilities in the state to understand the strategies employed that led to these “positive outliers.” A result-based educational program was designed to describe their actions and staff reactions.

Results: Exemplar leaders used transformational leadership style. Top reasons for their success were as follows: (1) trusting and supportive staff relationships; (2) positive presence and communication; and (3) use of consistent staffing assignments. Strong statewide participation was noted in the educational programs.

Martin, N., Frank, B., Farrell, D., Brady, C., Dixon-Hall, J., Mueller, J., & Rantz, M. (2022). Sharing lessons from successes – long-term care facilities that weathered the storm of COVID-19 and staffing crises. Journal of Nursing Care Quality, 38(1), 19-25.

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The National Academies of Sciences, Engineering, and Medicine (NASEM) convened a committee in Fall 2020 to address the quality of nursing home care with three specific tasks: (1) examine how our nation delivers, regulates, finances, and measures the quality of nursing home care; (2) delineate a framework and general principles for improving the quality of care in nursing homes; and (3) consider the impact of the coronavirus disease 2019 (COVID-19) pandemic on nursing home care. The Committee comprised 17 members, including six nurses. Over a period of 18 months, the Committee held numerous meetings, including public forums with key stakeholders, conducted extensive reviews of the evidence, and produced a report with seven goals along with recommendations specific to those goals. The complete report is available in print and online (NASEM, 2022). The following discussion describes the seven goals, which address Tasks 1 and 2. With regard to Task 3, the Committee’s conclusion was that the COVID-19 pandemic made evident the long-standing deficiencies in nursing home care in the United States. As a family caregiver stated in her testimony to the committee, “The pandemic has lifted the veil on what has been an invisible social ill for decades.” The pandemic resulted in high rates of mortality for residents and staff and shed light on each area described in the Committee’s recommendations.

Alexander, G.L., Travers, J., Galambos, C., Rantz, M., Ferrell, B., & Stevenson, D. (2022). Strategic recommendations for higher quality nursing home care in the United States: The NASEM report. Journal of Gerontological Nursing, 48(11), 3-6.

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November 2022

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  • Another Gem Added
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August 2022

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Over five decades in nursing, Marilyn Rantz has done it all. She’s gone from working one-on-one with patients and serving as an administrator to spending the last 30 years working as a professor and researcher. She’s quite the grant writer, too, having generated more than $100 million for the University of Missouri.

Read the full story HERE.

American Heart Association News, May 6, 2022. Written by Tate Gunnerson.

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  • Addressing your Residents’ Psychosocial Needs
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May 2022

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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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  • How Does the Vaccine Work?
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February 2022

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  • 5-Star Staff
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November 2021

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MU Sinclair School of Nursing was well represented by two members of the QIPMO team in a June 2021 public webinar sponsored by the National Academies of Science, Engineering, and Medicine to inform the national study currently being conducted by the Academies about the Quality of Care in Nursing Homes: www.nationalacademies.org/our-work/the-quality-of-care-in-nursing-homes.

QIPMO was invited to present about the statewide service provided to all the nursing homes in Missouri. It is a program funded by the MO Department of Health and Senior Services that was developed by research conducted by faculty of the Sinclair School of Nursing. The program began in 1999 and continues today to improve the quality of care of nursing home residents in Missouri.

View the presentation HERE!

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  • This Is Your Legacy
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August 2021

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When Marilyn Rantz hung up the phone, she knew she had to do something. A director of nursing at a long-term care facility in St. Louis had just told Rantz that she was making masks out of rubber bands and paper towels. “That rocked my world,” says the curators professor emerita of the Sinclair School of Nursing. A long-term care researcher known nationally for her work improving care in nursing homes, Rantz gathered a team for an urgent strategy session — on Zoom, of course. “How do we help these homes and residents survive?”

Historically underfunded and understaffed, nursing homes are not designed for a pandemic: Residents reside in close, often shared, living arrangements. They share caregivers. Many are especially vulnerable to the effects of respiratory-borne illnesses. And staff, visitors and other health care workers are frequently coming and going. “Nursing homes were unprepared for this sort of event,” says Lori Popejoy, an associate professor in the School of Nursing. “They didn’t have the people who were skilled to help them. And the community and public health industry was not prepared to support nursing homes — or, I believe, they overestimated what nursing homes could do on their own.”

Read the full article about the amazing joint effort between QIPMO and MOQI HERE (page 8)!

Mizzou Nursing Magazine, Spring, May 2021. Written by Kelsey Allen.

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  • Embracing Diversity in Our Homes
  • Can You See the Light??
  • Just for You: QIPMO Infection Control Manual
  • No-Nose Gang
  • OSHA in tha’ House!
  • Maintaining Life Safety Code Compliance
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May 2021

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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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  • To Vaccinate or Not to Vaccinate
  • During These Depressive Times
  • The Role of the Charge Nurse
  • Infection Control Assessment and Response
  • Housekeepers: Another Important Team Member
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  • No More BUTS!

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February 2021

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  • Bringing Back Visitation
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  • The New Cats in Town
  • Staffing Problems in a Pandemic
  • A Living Legend
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  • Don’t Burst Our Bubble

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November 2020

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Dr. Marilyn Rantz has been selected as a “Living Legend” by the American Academy of Nursing

Rantz, a Curators’ Professor Emerita from the MU Sinclair School of Nursing, has been a nurse for 50 years and is considered by the Academy to be the “premier expert in quality measurement in nursing homes and research programs to improve elder care,” according to a news release announcing the honor.

The announcement humbled Rantz, who called it “very affirming” in a telephone interview. After years of watching colleagues with significant contributions to healthcare be recognized, the level of the award left an overwhelming impression on her.

“In some ways, it makes me feel old,” Rantz said. “I finally have lived long enough and the body of work is large enough that it could be recognized in this way.”

The award is the highest honor the Academy gives and is awarded annually to leaders who have “made a lasting impression on the trajectory of the profession and the well-being of individuals globally,” the release said.

“It is vital that we recognize the profession’s leaders who have worked tirelessly throughout their careers to promote better health outcomes, increase health equity, advance education and improve conditions for vulnerable populations, all while mentoring the next generation to follow in their footsteps,” said Academy President Eileen Sullivan-Marx in the news release.

Rantz is the executive director for the Aging in Place Project, which allows seniors to “age in place” through Sinclair Home Care. Rantz also directs the Quality Improvement Program for Missouri, which has “transformed the care Missouri nursing home residents receive,” the release said.

Rantz will be officially designated a “Living Legend” at the Academy’s “Transforming Health, Driving Policy” conference, to be held virtually Oct. 29-31.

Columbia Missourian, by Janae McKenzie, 9/1/20.

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It was late afternoon on Jan. 30, 2020. A nurse from the Quality Improvement Program for Missouri (QIPMO) was leading a standard table top influenza pandemic exercise in Poplar Bluff when a call came through that would forever change the way healthcare would operate. The words were ominous and foreboding. “Folks, the CDC just confirmed the first case of coronavirus in the United States. This is no longer a drill.”

Click HERE to view the full-text article!

Pool, D. & Boren, W. (2020). Second responders: Answering the call for help in long-term care. McKnight’s Long-Term Care News, accessed online August 27, 2020.

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  • Through the Looking Glass
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August 2020

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In the United States, the first case of the novel coronavirus 2019 (COVID-19) was detected in January 2020 in the state of Washington. By February 2020, COVID-19 was linked to 167 confirmed cases of staff and residents within a single nursing home in that same state, resulting in 34 deaths. As of March 21, the Kaiser Family Foundation reported that 7732 long-term facilities in 43 state had known COVID-19–positive residents. In the 38 states that reported nursing home mortality data, COVID-19 is responsible for 42% of the deaths. Residents in long-term care facilities are especially vulnerable to the effects of respiratory-borne illness (e.g. influenza), which now includes COVID-19. However, the vulnerability of nursing home residents goes beyond age, physical condition, and frailty and includes their physical environment. Nursing home residents share common caregivers and reside in close, often shared, living arrangements. In addition, pathogenic spread can occur through exposure during transfers to/from the hospital as well as exposure to staff, visitors, and other health care workers who go in and out of the facility.

Popejoy, L., Vogelsmeier, A., Boren, W., Martin, N., Kist, S., Rantz, M., & Miller, S. (2020). A coordinated response to the COVID-19 pandemic in Missouri. Journal of Nursing Care Quality, 35(4), 287-292.

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  • Be a Nurse!
  • Your Role in Infection Prevention
  • Nursing Care to Manage Respiratory Distress/Illness
  • Environmental Cleaning and Disinfecting in a COVID-19 World
  • Staying Social while Social Distancing

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April 2020

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  • When to Re-evaluate PASRR
  • Our Changing Long-Term Care Population
  • A Skin Cornerstone: The Admission Skin Assessment
  • Infection Control Preventionist
  • Dialysis Doesn’t Just Affect the Kidneys

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February 2020

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  • Let’s Hire Great Employees
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  • That Ominous Dash
  • Foot Care
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November 2019

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  • Welcome to Mark Francis
  • Get with the Lingo
  • Developing Care Plans for Non-Verbal or Confused Residents
  • Documentation: Did I Remember to Chart it All?
  • Recognizing Hyponatremia in Older Adults
  • Staffing Budget
  • Adverse Behaviors: Are They a Sign of Undiagnosed Medical or Dental Conditions?

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August 2019

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Platinum research: MU nursing home improvement program celebrates 20th anniversary

As people age and their health needs change, nursing homes become a source of care and support, especially for those who can no longer live independently.

Since 1999, the Quality Improvement Program for Missouri has been providing clinical practice consultations and technical assistance to nursing homes throughout the state. Curators’ Professor Emerita Marilyn Rantz is the project director for the program, which is a cooperative between the MU Sinclair School of Nursing and the Missouri Department of Health and Senior Services.

Find the full press release here.

Written by Brian Consiglio | Mizzou News

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  • Hello…
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  • Anticoagulation Therapy
  • Employee Engagement
  • Medication Disposal
  • Nurse Manager: Delegation

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May 2019

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  • Fond Farewell
  • Section M: Skin Conditions
  • CMS Phase 3
  • Antipsychotics
  • Drug and Food Interactions
  • ABN, SNFABN, NOMNC, DENC

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February 2019

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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.

WebsEdgeHealth
MU News Bureau | MU News Bureau Twitter

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  • Resident Rights on Discharge
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  • Vaccinations
  • Gastronomy Tube and the Nursing Plan of Care
  • Alzheimer’s and Dementia

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November 2018

***SUPPLEMENT ARTICLE*** 11/28/18
Hard to Love – Addressing Sexuality in Long-Term Care: A Person-centered Approach to Intimacy and Dementia
Wendy Boren, BS, RN

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Due to their role overseeing administrative, operational, and clinical services in nursing homes (NHs), licensed nursing home administrators (LNHAs) are responsible for quality of care and correcting deficiencies identified during the annual certification and survey process. State regulations vary widely in educational and work experience requirements for LNHAs. As an adjunct to traditional education, the Quality Improvement Program for Missouri (QIPMO) offers on-site 2-day survey readiness training from experienced LNHA-consultants to better prepare current LNHAs.

Phillips, L.J., Oyewusi, C., Martin, N., Youse, E., & Rantz, M.J. (2018). Impact of Survey Readiness Training on Nursing Home Quality of Care. Innovation in Aging, 2(Suppl 1), 723.

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  • Wanted: RN Coverage
  • The Revolving Door of MO Nursing Home Administrators
  • CPR – Let’s Do It or NOT
  • Alzheimer’s and Dementia
  • Resources for Infection Control
  • Caring for a Resident with a Pacemaker
  • Committees? Tasks?

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August 2018

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  • Survey Preparedness Guide
  • Under Pressure
  • CMS Clarification
  • Changes in the 5-STAR Report
  • Complementary and Alternative Medicine for PTSD
  • Staffing: It’s Everybody’s Problem

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May 2018

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  • CMS Errata Document
  • Text Communication S and C
  • Infection Control Practices
  • Having Fun with ADLs
  • Alphabet Soup (Help with Acronyms)
  • Oral Diabetic Agents

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February 2018

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  • Coming to Your Home November 28, 2017
  • Discharge and the Ombudsmen Offices
  • Florence Nightingale Black Market Viagra!
  • Medication Management Systems
  • F655 Baseline Care Plans and Baseline Summary
  • It’s All About Me!
  • Oral Diabetic Agents

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November 2017

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  • New LTC Survey Process – Highlights
  • Don’t Just Survive… Thrive!
  • Seriously, AGAIN?
  • What’s Coming Up for QRP
  • MDS Changes this Fall: Sect N and P
  • Medicare Short-Stay Assessments
  • Sepsis: What to Know and How to Manage

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August 2017

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  • Hello! Crystal Plank Intro
  • A Few Parting Thoughts
  • Communication, Delegation, Documentation Models for Nursing Staff
  • The PEPPER Reports
  • MDS-Focused Surveys
  • Emergency Preparedness Conditions of Participation

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May 2017

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  • And the Winner Is…
  • Poetry at Sunrise
  • Do YOU Have High Nursing Turnover?
  • What’s New in 2017?
  • Life Safety Code Updates and Reminders

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February 2017

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  • To Prevent Stroke: F.A.S.T. Take Charge!
  • Clinical CornerMDS Nook; Caption This!
  • It’s Time to Move It, Move It!
  • The Sleep Seminar

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October 2016

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  • Newbie Alert!
  • Farewell from Dave
  • Coding Anticoagulants
  • Infection Control F441
  • Prioritizing Individuals who will Benefit from Antipsych Reduction
  • Nobody to Call
  • Getting Ready for Bed
  • Sleep Interruptions

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July 2016

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  • Bullies in Long-Term Care
  • Pneumococcal Vaccines: Get This One Done!
  • Accidents and Supervision
  • Pain in the MDS!
  • ICD-10 Migraine: But is That right?

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May 2016

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  • Is Your Staff Prepared to Honor EOL Decisions?
  • Lightning Bugs, Lemon Meringue, and Love for Our Seniors
  • Why is F241 Dignity being Cited?
  • Post-Fall Huddle

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February 2016

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  • Who’s the New Kid?
  • CMS Proposed Rules
  • Significant Change MDS
  • Do You Know What’s Important to Your CNAs?
  • MDS Corner
  • Abuse Reporting Decision Tree (updated version of the tool here)

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October 2015

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  • Seriously?
  • What IS QIPMO?
  • ICD-10 is Coming!
  • Tips for Successful Transitions into LTC Living
  • The Beauty of Networking

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July 2015

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  • MDS Spotlight: Did You Know?
  • What People are Saying
  • Validation Reports
  • IMPACT Act
  • Questions from the Field: Abuse
  • Medication Errors: What is Your System?
  • Advance Care Planning

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April 2015

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  • MDS Spotlight: Common Questions and Mistakes
  • The 3-D Picture
  • Responsible Treatment of Urinary Tract Infections
  • Do You Know What’s Important to Your CNAs?
  • Questions from the Field: Resident Complaint Files
  • Let’s Hear it for Chapter Two!

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January 2015

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  • It’s Influenza Vaccination Time
  • QIPMO and Leadership Coaching Facts
  • Decisions for End of Life in Long-Term Care
  • October MDS Changes
  • Why Restorative Nursing Services are Important
  • Questions from the Field: Resident Complaint Files

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October 2014

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  • Little Known Facts about the MDS
  • Questions from the Field: Requirements for Emergency Preparedness and Fire Drills
  • Spotlight on Interesting Websites
  • MDS Coding Corner: Section G
  • The PEPPER Report

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July 2014

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  • AANAC Conference
  • Questions from the Field: Can extension cords be used in a long-term care facility?
  • MDS Coding Corner: Section Q
  • Spotlight on Interesting Websites

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May 2014

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IN THIS ISSUE

  • Multidrug-Resistant Organisms (MDROs): What are They and What is Your Role?
  • MDS Coding Corner: Sections I and O
  • Questions from the Field: Can an electric blanket or heating pad be used in a long-term care facility?

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January 2014

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IN THIS ISSUE

  • ICD-10: Are you ready?
  • MDS Coding Tip: Section M 1200
  • Questions from the Field: Can I charge my Medicaid/Medicare residents for oxygen?

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October 2013

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Objectives: A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.

Design/Setting/Participants: Intervention facilities (N ¼ 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N ¼ 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.

Intervention: The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.

Rantz, M.J., Zwygart-Stauffacher, M., Hicks, L., Mehr, D., Flesner, M., Petroski, G.F., Madsen, R.W., & Scott-Cawiezell, J. (2012). Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvementJournal of the American Medical Directors Association, 13(1), 60-68.

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There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures.

Rantz, M.J., Hicks, L., Petroski, G.F., Madsen, R.W., Alexander, G., Galambos, C., Conn, V., Scott-Cawiezell, J., Zwygart-Stauffacher, M., & Greenwald, L. (2010). Cost, staffing, and quality impact of bedside electronic medical record (EMR) in nursing homes. Journal of the American Medical Directors Association, 11(7), 485-493.

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There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures.

Rantz, M.J., Hicks, L., Petroski, G.F., Madsen, R.W., Alexander, G., Galambos, C., Conn, V., Scott-Cawiezell, J., Zwygart-Stauffacher, M., & Greenwald, L. (2010). Cost, staffing, and quality impact of bedside electronic medical record (EMR) in nursing homesJournal of the American Medical Directors Association, 11(7), 485-493.

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There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures.

Rantz, M.J., Hicks, L., Petroski, G.F., Madsen, R.W., Alexander, G., Galambos, C., Conn, V., Scott-Cawiezell, J., Zwygart-Stauffacher, M., & Greenwald, L. (2010). Cost, staffing, and quality impact of bedside electronic medical record (EMR) in nursing homes. Journal of the American Medical Directors Association, 11(7), 485-493.

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Nearly everyone has some life experiences or opinions based on media about nursing homes and the need for quality improvement. States and federal agencies spend enormous amounts of time regulating and surveying nursing homes, but quality problems persist. In the past decade, federal initiatives have emphasized quality improvement, and researchers have tested a variety of ways to engage nursing home staff to embrace methods of quality improvement and best clinical practices. However, finding ways that are clinically effective, but not cost-prohibitive, to assist nursing homes most at risk for quality concerns eludes most states. This is a program report of the findings of 2 consecutive annual evaluations of the Quality Improvement Program of Missouri (QIPMO). This program is sponsored by the Department of Health and Senior Services (DHSS) in an effort to help facilities in the state develop quality-improvement programs and improve the quality of care to Missouri nursing home residents.

Rantz, M.J., Cheshire, D., Flesner, M., Petroski, G.F., Hicks, L., Alexander, G., Aud, M.A., Siem, C., Nguyen, K., Boland, C., & Thomas, S. (2009). Helping nursing homes “at risk” for quality problems: a statewide evaluationGeriatric Nursing, 30(4), 238-249.

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Marilyn Rantz, professor in the MU Sinclair School of Nursing completed a three-year analysis of the Quality Improvement Program of Missouri (QIPMO) and found significant improvements in overall care quality of residents in participating facilities.

Nursing homes save millions using care improvement program, MU researcher findsEurekAlert!

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Improvements in Missouri Nursing Homes Using QIPMO Services – Interdisciplinary Center on Aging (2008)

The Quality Improvement Program for Missouri (QIPMO) is a cooperative service of the University of Missouri Sinclair School of Nursing and the Missouri Department of Health and Senior Services

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Field test results are reported for the Observable Indicators of Nursing Home Care Quality Instrument-Assisted Living Version, an instrument designed to measure the quality of care in assisted living facilities after a brief 30-minute walk-through. The OIQ-AL was tested in 207 assisted living facilities in two states using Classical Test Theory, Generalizability Theory, and exploratory factor analysis.

Rantz, M.J., Aud, M.A., Zwygart-Stauffacher, M., Mehr, D.R., Petroski, G.F., Owen, S.V., Madsen, R.W., Flesner, M., Conn, V., & Maas, M. (2008). Field testing, refinement, and psychometric evaluation of a new measure of quality of care for assisted livingJournal of Nursing Measurement, 16(1), 16-30.

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The article discusses the initiative to measure the quality improvement efforts in assisted living facilities in the U.S. In 33,000 assisted living centers, there are roughly 800,000 residents who are under their care. However, there are continuing research to determine the efficient services offered in nursing homes to assist facilities in developing their care quality and to provide consumers with guidance.

Aud M., Rantz, M.J., Zwygart-Stauffacher M., Flesner M. (2007). Measuring quality of care in assisted living: A new tool for providers, consumers, and researchersJournal of Nursing Care Quality, 22(1), 4-7.

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This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Rantz, M., Mehr, D., Hicks, L., Scott-Cawiezell, J., Petroski, G.F., Madsen, R.W., Porter, R., & Zwygart-Stauffacher, M. (2006). Entrepreneurial program of research and service to improve nursing home careWestern Journal of Nursing Research, 28(8), 918-934.

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Funding from NINR enabled large-scale field testing of an instrument to measure the observable multidimensional components of the concept of nursing home care quality. Field testing in 3 states was directed by research teams at the University of Missouri-Columbia (MU) Sinclair School of Nursing (SSON) and the University of Wisconsin-Eau Claire College of Nursing. The instrument development was sparked by a cooperative venture between the Missouri Department of health and Senior Services and the MUSSON to improve the quality of care in Missouri nursing homes. The Observable Indicators of Nursing Home Care Quality Instrument (OIQ) has been under development by the MU MDS and Nursing Home Quality Research Team for more than 10 years and has undergone numerous changes on the basis of qualitative and quantitative multidisciplinary research projects. As the instrument name implies, each item refers to some directly observable aspect of quality of care in any nursing home. The instrument is designed to guide researchers, healthcare professionals, and consumers or regulators in appraising specific indicators of quality care during an approximate 30-minute inspection of a nursing home.

Rantz, M.J., & Zwygart-Stauffacher, M. (2006). A new reliable tool for nurse administrators, nursing staff, regulators, consumers, and researchers for measuring quality of care in nursing homesNursing Administration Quarterly, 30(2), 178-181.

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The article focuses on nursing homes costs and quality of care outcomes. Consumers are demanding mechanisms that will allow them to evaluate the quality of care provided in nursing homes. Policymakers, who are responsible for oversight of the public funding of more than 70% of patient days in nursing home care and approximately two-thirds of expenditures on nursing home care, want assurance that monies are contributing to better quality care. A number of studies attempted to assess the factors contributing to variations in the costs of care in nursing homes. An underlying assumption in these studies was the existence of a direct relationship between costs and the efficient provision of services appropriate to patient needs.

Hicks, L.L., Rantz, M.J., Petroski, G.F., & Mukamel, D.B. (2004). Nursing home costs and quality of care outcomesNursing Economics, 224, 178-192.

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The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes. In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.

Rantz, M.J., Hicks, L., Grando, V.T., Petroski, G.F., Madsen, R.W., Mehr, D.R., Conn, V., Zwygart-Stauffacher, M., Scott, J., Flesner, M., Bostick, J., Porter, R., & Maas, M. (2004). Nursing home quality, cost, staffing, and staff-mixThe Gerontologist, 44(1), 24-38.

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We describe the development of a statewide strategy to improve resident outcomes in nursing facilities, and we present some evaluative data from this strategy. Key components of the strategy include (a) a partnership between the state agency responsible for the nursing home survey and certification and the school of nursing in an academic health sciences center; and (b) on-site clinical expert technical assistance and support to facilities throughout the state.

Rantz, M.J., Vogelsmeier, A., Manion, P., Minner, D., Markway, B., Conn, V., Aud, M.A., & Mehr, D.R. (2003). A statewide strategy to improve quality of care in nursing facilitiesThe Gerontologist, 43(2): 248-258.

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We describe the development of a statewide strategy to improve resident outcomes in nursing facilities, and we present some evaluative data from this strategy. Key components of the strategy include (a) a partnership between the state agency responsible for the nursing home survey and certification and the school of nursing in an academic health sciences center; and (b) on-site clinical expert technical assistance and support to facilities throughout the state.

Rantz, M.J., Vogelsmeier, A., Manion, P., Minner, D., Markway, B., Conn, V., Aud, M.A., & Mehr, D.R. (2003). A statewide strategy to improve quality of care in nursing facilitiesThe Gerontologist, 43(2): 248-258.

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

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

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

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

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

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

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

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

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

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

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It is becoming increasingly common for nursing facilities to use Quality Indicators (Ql) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review Ql reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Popejoy, L.L., Rantz, M.J., Conn, V., Wipke-Tevis, D., Grando, V., & Porter, R. (2000). Improving quality of care in nursing facilities: The gerontological clinical nurse specialist as research nurse consultant. Journal of Gerontological Nursing, 26(4), 6-13.

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It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problem areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Popejoy, L.L., Rantz, M.J., Conn, V., Wipke-Tevis, D., Grando, V., & Porter, R. (2000). Improving quality of care in nursing facilities: The gerontological clinical nurse specialist as research nurse consultant. Journal of Gerontological Nursing, 26(4), 6-13.

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This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

While much is written about the topic of nursing home care quality, little attention is paid to carefully defining it or developing a theoretical model of the dimensions of nursing home care quality. Rantz and colleagues proposed a multidimensional theoretical model of nursing home care quality based on research with experienced providers. This second exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the perspectives of consumers, to propose a conceptual model that integrates the views of both providers and consumers of nursing home care to guide nursing home quality research, and to develop instruments to measure nursing home care quality based on the integrated model.

Rantz, M. J., Zwygart-Stauffacher, M., Popejoy, L., Grando, V., Mehr, D., Hicks, L., Conn, V., Wipke-Tevis, D., Porter, R., Bostick, J., & Maas, M. (1999). Nursing home care quality: A multidimensional theoretical model integrating the views of consumers and providers. Journal of Nursing Care Quality, 14(1), 16-37.

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This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

Rantz, M. J., Mehr, D., Popejoy, L., Zwygart-Stauffacher, M., Hicks, L., Grando, V., Conn, V., Porter, R., Scott, J., & Maas, M. (1998). Nursing home care quality: A multidimensional theoretical model. Journal of Nursing Care Quality, 12(3), 30-46.

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An important area of inquiry in quality measurement when using quality indicators (QIs) lies in determining what thresholds indicate good and poor resident outcomes. In July 1996, a cross-section of 13 clinical care personnel from nursing homes participated on an expert panel for threshold setting of Qls derived from Minimum Data Set (MDS) assessment data. Panel members met as a group for a day, individually determined good and poor threshold scores for each QI, reviewed statewide distributions of MDS Qls, and completed a follow-up Delphi round of the final results. Reports of MDS scores that are sent to a group of nursing homes in Missouri now include thresholds established for good and poor scores so the facilities can easily see where they are performing well and where they need to concentrate quality improvement efforts. This article describes the efforts made to develop and disseminate the thresholds for MDS scores.

Rantz, M. J., Petroski, G.F., Madsen, R.W., Scott, J., Mehr, D., Popejoy, L., Hicks, L., Porter, R., Zwygart-Stauffacher, M., & Grando, V. (1997). Setting thresholds for MDS quality indicators for nursing home quality improvement reportsJoint Commission Journal on Quality Improvement, 23(11), 602-611.

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An important area of inquiry in quality measurement when using quality indicators (QIs) lies in determining what thresholds indicate good and poor resident outcomes. In July 1996, a cross-section of 13 clinical care personnel from nursing homes participated on an expert panel for threshold setting of Qls derived from Minimum Data Set (MDS) assessment data. Panel members met as a group for a day, individually determined good and poor threshold scores for each QI, reviewed statewide distributions of MDS Qls, and completed a follow-up Delphi round of the final results. Reports of MDS scores that are sent to a group of nursing homes in Missouri now include thresholds established for good and poor scores so the facilities can easily see where they are performing well and where they need to concentrate quality improvement efforts. This article describes the efforts made to develop and disseminate the thresholds for MDS scores.

Rantz, M. J., Petroski, G.F., Madsen, R.W., Scott, J., Mehr, D., Popejoy, L., Hicks, L., Porter, R., Zwygart-Stauffacher, M., & Grando, V. (1997). Setting thresholds for MDS quality indicators for nursing home quality improvement reportsJoint Commission Journal on Quality Improvement, 23(11), 602-611.

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In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their “more altruistic” mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data.

Hicks, L.L., Rantz, M. J., Petroski, G.F., Madsen, R.W., Conn, V.S., Mehr, D., & Porter, R. (1997). Assessing contributors to cost of care in nursing homesNursing Economics, 15(4), 205-212.

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