Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care: The OPTIMISTIC Project
Faculty/Project leadership: Greg A. Sachs, MD and Kathleen T. Unroe, MD, MHA
About OPTIMISTIC: The Indiana University Center for Aging Research (IUCAR) and Division of General Internal Medicine and Geriatrics has been awarded, in response to a CMS Innovations Center call, a comprehensive program, building on evidence-based strategies, to collaborate with 19 central Indiana nursing facilities to improve the quality of care of long stay nursing facility residents and reduce hospitalizations. This is a 4 year long initiative. These goals will be achieved through:
- improving medical care,
- enhancing transitional care and
- access to palliative care.
Supported by a project team with geriatrics and palliative care expertise, the program, with specially trained registered nurses (RNs) stationed on-site at each of the nursing facilities, will provide direct support, education and training to the staff at each facility and lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications, and clarify goals of care.
The advanced practice nurses (APNs), will support program RNs, respond to urgent resident care needs, with evening and weekend availability for in-person evaluation, and become site champions for training and leadership development.
Outcomes will be achieved through proactive management of chronic conditions, especially dementia, through structured care management reviews; increased capacity to respond to changes in medical condition through availability of additional RN and APN resources, as well as training in INTERACT tools; optimized transitional care protocols; a comprehensive advance care planning process; and improved access to palliative care.
IUCAR and the Division of General Internal Medicine and Geriatrics have been at the forefront nationally in developing, implementing and evaluating interventions to improve care and quality of life for vulnerable elders. Our faculty and staff have expertise in training providers to deliver geriatrics and palliative care interventions. Together with our local partners, including the University of Indianapolis Center for Aging and Community, we are well positioned to lead a demonstration and evaluation initiative aimed at avoiding inappropriate or unnecessary hospitalizations of long stay nursing facility residents.
We will be hiring 6 nurse practitioners and 18 RNs for this project starting in October 2012.
Partnering Nursing Facilities Include:
For more information, please contact:
American Senior Communities: Allisonville Meadows, American Village, Brownsburg Meadows, Forest Creek Village, Greenwood Meadows, Harrison Terrace, North Capitol Nursing and Rehabilitation Center, Riverwalk Village, Rosewalk Village, Washington Health Care Center
Kindred Healthcare: Greenwood, Wildwood
Miller's Merry Manor: Castleton, Indianapolis East
CarDon: University Heights Health and Living Community
Golden Living: Indianapolis
Hooverwood, Northwest Manor and Health Care Center, Westpark Healthcare Center
Laura Holtz, CCRP
OPTIMISTIC Project Coordinator
Regenstrief Institute, Inc.
410 W. 10th Street, Suite 2000
Indianapolis, IN 46202