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The optimizing patient transfers, impacting medical quality, and improving symptoms: Transforming institutional care approach: preliminary data from the implementation of a centers for medicare and medicaid services nursing facility demonstration project

Here is the PICO analysis for the twenty-first uploaded article: ✅ PICO Analysis Full Article Title: The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach (OPTIMISTIC): Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project Type of Study: Implementation evaluation – observational report of…

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Here is the PICO analysis for the twenty-first uploaded article:

✅ PICO Analysis

Full Article Title:

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach (OPTIMISTIC): Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project

Type of Study:

Implementation evaluation – observational report of a multi-component quality improvement intervention

Journal and Year:

Journal of the American Geriatrics Society (JAGS), 2015; 63(1):165–169

DOI: 10.1111/jgs.13141

P – Population

  • Setting:
    • 19 nursing facilities in central Indiana, USA
  • Participants:
    • Long-stay residents (N = 4,035 enrolled in year one)
    • Mean age 80; 65% female; 59% with dementia
    • Staff included nurses, nurse practitioners, primary care providers 

I – Intervention

  • Intervention Name: OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care)
  • Core Components:
    1. Medical Care Support
      • Facility-based RNs and mobile NPs for early recognition, chronic care, and acute management
      • Use of INTERACT tools and structured Collaborative Care Reviews (CCRs)
    2. Transitional Care Support
      • Medication reconciliation, care handoff documentation, use of root cause analysis after transfers
      • Use of Indiana Network for Patient Care (INPC) for cross-sector health information
    3. Palliative Care Support
      • Standardised advance care planning using POST (Physician Orders for Scope of Treatment)
      • ELNEC-Geriatric training for staff
    4. Data-Driven Quality Improvement
      • Real-time reporting of hospital transfers and feedback loops
      • Root cause analyses of transfers using a structured tool
    5. Education and Training
      • Staff “boot camp,” INTERACT training, ongoing QI and communication training 

C – Comparison

  • No formal control group in this preliminary implementation report
  • However, performance is compared against baseline data (e.g., hospitalisation rates, transfer patterns)
  • Evaluation focuses on preliminary outcomes and feasibility prior to formal comparative effectiveness assessment

O – Outcomes

Preliminary Outcomes Reported:

  • Hospital Transfers (N = 910):
    • 28% judged avoidable by RN-led root cause analysis
    • 54% had identifiable opportunities for quality improvement
    • Most frequent QI opportunities: missed early signs, lack of advance planning, and missing onsite diagnostics 
  • Resident Profile:
    • High dependency: 80%+ needed extensive help with ADLs (bed mobility, transfer, toilet use)
    • Frequent risk factors: CHF (29%), COPD (26%), dementia with behaviours (29%) 

Process Outcomes:

  • Facility engagement in training, INTERACT use, palliative planning
  • Implementation of structured care reviews, medication reconciliation, and documentation standards
  • Development of cross-sector partnerships for information continuity

Implementation Insights:

  • Critical role of embedded clinical staff
  • Challenges: staff turnover, survey disruptions, data management burdens
  • Enablers: facility “point person,” regular advisory meetings, flexible training formats

Outcome Classification

  • Person-centred outcomes: Advance care planning (POST), palliative symptom management, staff-family-resident communication improvements
  • Process outcomes: Use of INTERACT tools, CCRs, structured root cause analyses, improved transitions, increased ACP documentation
  • Health system outcomes: Primary focus is reduction in potentially avoidable hospitalisations and associated costs (formal results not yet presented) 

Summary Conclusion

The OPTIMISTIC model is a comprehensive, nurse-led, interdisciplinary intervention deployed across 19 Indiana nursing homes to reduce avoidable hospitalisations. Early implementation showed strong facility engagement, widespread identification of quality improvement opportunities, and successful training of staff in acute care management and advance care planning. Though the initial data are descriptive, the model’s structure and integration of medical, transitional, and palliative care suggest a scalable approach to improving long-stay nursing home care .

J_American_Geriatrics_Society___2014___Unroe___The_Optimizing_Patient_Transfers__Impacting_Medical_Quality__and_ImprovinDownload

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