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

“Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care,” or “OPTIMISTIC,” is a year demonstration project funded through the CMS Innovations Center conducted by IU Geriatrics.    The program targets long-stay (> 100 days) residents in 19 central Indiana nursing facilities. This multi-component program supports nursing facilities in redesigning care delivery processes and provides additional resources in order to reduce avoidable hospitalizations. OPTIMISTIC will station specially trained registered nurses on-site at each of the partner nursing facilities.

Project RNs:

  • represent additional resources for the facilities;
  •  provide direct support, education and training to the staff at each facility;
  • provide support for transitional care and palliative care;
  • lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications, and clarify goals of care; 
  • are supported by advanced practice nurses (NPs)

Project NPs:

  • span several facilities;
  • respond to urgent evaluation and care needs in collaboration with the RNs;
  • provide evening and weekend availability for in-person evaluation;
  • become site champions for training and leadership development. 

The proposed intervention integrates a suite of inter-related evidence-based practices targeting one or more causes of avoidable hospitalization.

OPTIMISTIC is comprised of three major care components:

  •  improving medical care,
  • enhancing transitional care and
  • access to palliative care.

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.  

Map of Participating Nursing Facilities (attach to map)

Project Website (http://www.optimistic-indy.com/)

For more information, please contact:
Laura Holtz, CCRP
OPTIMISTIC Project Coordinator
Regenstrief Institute, Inc.
410 W. 10th Street, Suite 2000
Indianapolis, IN 46202
tel: 317-423-5602
fax: 317-423-5695