INQRI Director Receives Award for Leadership in Gerontological Field

The Gerontological Society of America (GSA) chose INQRI Director Mary Naylor as the 2015 recipient of the Doris Schwartz Gerontological Nursing Research Award.

This honor, presented by GSA's Health Sciences Section, is given to a member of the Society in recognition of outstanding and sustained contribution to gerontological nursing research. Naylor will receive the award at GSA's 68th Annual Scientific Meeting in November.

Among her accomplishments, Naylor developed the Transitional Care Model, which utilizes nurses to reduce hospital readmissions among elderly patients after they have been discharged. As many as one-third of re-hospitalizations are considered preventable, so reducing readmissions not only improves patients’ quality of life, but reduces health care costs.

In addition to her work with INQRI, Naylor is the Marian S. Ware Professor in Gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Naylor leads an interdisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations, and reduce health care costs for vulnerable community-based elders.

Naylor was also the 2012 recipient of GSA's Maxwell A. Pollack Award for Productive Aging.

INQRI Brief: Non-Physicians Can Address Primary Care Shortage

A pending primary care shortage may be best addressed by implementing promising strategies that fully utilize non-physician health care professionals in new systems of care, according to a new research brief co-authored by INQRI Co-Directors Mary Naylor and Mark Pauly with Janet Weiner.

With approximately 30 million people expected to gain coverage through the Affordable Care Act (ACA), demands on primary care services will no doubt grow. The brief, Primary Care Shortages: It’s More Than Just a Head Count, examines how the ACA will affect the delivery of primary care, and reviews recent research on the primary care shortage and possible strategies to address it.

The brief outlines several strategies that show promise for addressing these demands. Among them is ACA’s investments in health professional education and training to increase the number of primary care providers, including nurse practitioners and physician assistants. Other models, like retail clinics could ensure that more people can access primary care services, particularly in rural areas.

Ultimately, allowing health care providers to practice to the full extent of their education and training is central to increasing access to primary care, the authors write.

An article on the brief from RWJF’s December 2014 Sharing Nursing’s Knowledge is available here.

Nurses Lead Innovations in Geriatrics and Gerontology

This story originally appeared in the July 2014 issue of Sharing Nursing's Knowledge, a monthly email newsletter from the Robert Wood Johnson Foundation.

Nurse-led initiatives are intended to help the nation’s health care system prepare for a crush of elderly people with multiple chronic conditions.

Nurses have been leading health care innovations since the dawn of the profession. They have ushered in broad-scale changes in areas ranging from better hygiene practices for wounded soldiers to public health visits to overcrowded urban homes to reproductive health services for women.

In more recent decades, nurses have begun developing innovations in geriatric care to help meet the massive health care needs of an aging population. They are finding new ways to improve the quality of care for older adults and ensure that it takes family and community considerations into account; improve access to highly skilled health care providers with training in geriatrics; narrow disparities that disproportionately affect older minorities; avoid preventable hospital readmissions; and more.

Their work answers the call from a groundbreaking report on the future of nursing that was released in 2010 by the Institute of Medicine (IOM). It urges nurses to continue their long legacy of innovation “as the health care needs of the population change from acute and infectious disease to that of an aging population with chronic disease.”

The country is, indeed, undergoing dramatic demographic changes. As Baby Boomers age and immigration patterns change, America is becoming older and more diverse. By 2050, the number of Americans age 65 and older will hit 40 million, about 20 percent of the population, according to the U.S. Census Bureau. These changes will strain the health care system and the nursing profession, the largest segment of the health care workforce.

Experts say the nursing workforce is not adequately prepared for a crush of elderly patients who are living longer, and sicker, with more chronic and complex health conditions. To meet these growing health care demands and bridge gaps in services for older Americans, the IOM said nurses “must continue to develop innovative care models based on current successes” in rural aging and other areas.

Fortunately, many nurses are already leading efforts to meet current and future health care needs. “Nurses are beginning to home in on the chronicity and the larger number of older people coming down the pike,” said Jennie Chin Hansen, RN, MS, FAAN, CEO of the American Geriatrics Society and a member of the study committee supported by the Robert Wood Johnson Foundation (RWJF) that drafted the IOM’s nursing report.

She pointed to the Transitional Care Model, developed by Mary Naylor, RN, PhD, FAAN, national program director for RWJF’s Interdisciplinary Nursing Quality Research Initiative (INQRI). The model utilizes nurses to reduce hospital readmissions among elderly patients after they have been discharged from the hospital. As many as one-third of re-hospitalizations are considered preventable, so reducing readmissions not only improves patients’ quality of life, but reduces health care costs.

The Program for All-Inclusive Care for the Elderly (PACE) is an example of a nurse-driven innovation in geriatric care. A replication of a program spearheaded many years ago by Chin Hansen, PACE is a now a federally legislated program in which interdisciplinary teams of providers give frail elders coordinated health, medical, and social services support by a one-stop system, a process that enables many to live in their own homes for longer periods of time.

Another nurse-led innovation, Nurses Improving Care for Healthsystem Elders (NICHE), was developed to better meet the needs of older adults in a health care system that, in general, lacked access to gerontology-trained providers and to care coordination services. The NICHE program is helping hospitals and, increasingly, community health systems, provide older Americans with “sensitive and exemplary care.” Under the program, “nurses are empowered by knowledge to provide high-quality care for older adults and, in doing so, teach others about the uniqueness of caring for older adults,” said Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing in New York and an alumna of the RWJF Executive Nurse Fellows program (1999-2002).

And that’s just the beginning:

Promoting cancer screening among older African American women

Nurses all over the country are studying ways to improve care for older Americans. In North Carolina, for example, Dee Baldwin, PhD, RN, FAAN, a nurse educator at the University of North Carolina-Charlotte and an RWJF Executive Nurse Fellows program alumna (2000-2003), has spent decades exploring ways to prevent cancer in older African American women, who are more likely to die from the disease than other groups.

In 1992, Baldwin launched Project Breast Health, a culturally sensitive educational program to encourage more African American women to take advantage of cancer screening services. She also led an effort to hire lay navigators to raise awareness about breast and cervical cancer among older women in African American communities and developed electronic computer messaging to target the population. “We tried to look at different ways to reach people.”

Improving the quality of care in assisted-living facilities

Anna Beeber, PhD, RN, an RWJF Nurse Faculty Scholar (2011-2014) also from North Carolina, is exploring ways to improve the quality of care in assisted-living facilities. She is conducting research that examines staffing, service delivery, and resident outcomes in order to help assisted-living communities better match services with resident needs. “We really don’t know in assisted-living communities what, if any, influence nurses have on quality of care,” she says. And that is a critical piece of information that has the potential to improve care for the roughly 1 million Americans who currently live in the country’s 22,000 assisted-living facilities.

Increasing the number of geriatrics-trained nurses

In North Dakota, Jane Strommen, PhD, project coordinator of the North Dakota Gerontology Consortium, an initiative supported by Partners Investing in Nursing’s Future (PIN), is working to ensure that older people have more access to geriatrics-trained nurses. She and her team are promoting gerontology nursing via marketing materials, nursing conferences, nursing-themed summer camps, and stipends for nurses and nurse educators who study gerontology and geriatric nursing. “We have a growing population of older adults in our state, and we know the need for nurses who have the skills and training to care for them is just going to increase,” she says.

Creating safer homes

And in Maryland, Sarah Szanton, PhD, ANP, an RWJF Nurse Faculty Scholar (2011-2014) and associate professor of nursing at Johns Hopkins University, has come up with an innovative program to use “handymen” to turn older people’s homes into safe environments. Her goal is to enable elderly people to continue living in their homes as long as they are willing and able—and to stay out of nursing homes, which create considerable taxpayer expense. Read more about Szanton’s work here.

These projects are among the many nurse-led efforts under way across the nation to improve care for older Americans—a natural outgrowth, Chin Hansen says, of nurses’ skills, abilities, and population focus. “One of the things that nurses have always done is advocate for the patient and the family,” she says. They will continue to do that as their patients get older, and they will likely have a greater ability to transform health care as more earn master’s and doctoral degrees and assume positions of leadership in health care and society. Says Chin Hansen: “More nurses are being sought out for their leadership and their ability to change the current culture of medical care towards health and health care in an aging America.”

Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy

By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of INQRI. This commentary originally appeared on the Institute of Medicine website.

The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.

This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.

More than 3.1 million strong, nurses represent the largest segment of the health care professional workforce in the United States and are the professionals who provide the most direct patient care. But, until the launch of the INQRI program, there was little rigorous research linking nursing’s contributions to patient outcomes. INQRI has served to advance the science of health care by investigating those linkages and providing evidence to inform policies and practices that improve patient care and outcomes, thereby improving our health care system overall.

Since INQRI’s launch, the program has encouraged researchers to develop new strategies to improve health care value and demonstrate nursing’s role in accomplishing that aim. To date, INQRI has supported 48 multidisciplinary teams of scholars whose studies have dramatically increased the evidence linking nursing to quality of care. These teams not only examine the nursing practices and processes that affect the patients’ experience with care and outcome, but also design and implement nurse-led interventions to improve patient outcomes. Equally important, findings from INQRI teams have helped to distinguish effective ideas from solutions that are often popular, yet ineffective.

A series of articles recently published in a special supplement of Medical Care revealed that, collectively, these studies have helped to improve the rigor of research methodology, built a solid base of evidence demonstrating linkages between nursing care and patient outcomes, and helped advance interdisciplinary research and practice. To a large extent, INQRI’s contributions to our knowledge are a function of the singular requirement that every INQRI research team include investigators from more than one discipline. As IOM’s Roundtable on Value & Science-Driven Health Care has drawn on the insights of a multidisciplinary community, so have INQRI teams. By requiring that researchers collaborate across disciplines, the program raises the bar for the level of rigor, ensuring that diverse perspectives contribute to the design of each study and are also brought to bear in the analysis of the findings.

The roundtable has sought to accelerate progress through six stakeholder Innovation Collaboratives: 1) Best Practices; 2) Clinical-Effectiveness Research; 3) Evidence Communication; 4) Digital Learning; 5) Systems Approaches for Health; and 6) Value Incentives. To make significant change, we must look at all aspects of the health care system. To that end, INQRI attempts to understand the nurses’ role in delivering high-quality care across a variety of patient populations and settings.

INQRI has funded several studies that examined nursing practices and tested interventions that can improve patient care and safety, including

• changes in nursing processes and the practice environment to facilitate nurses’ ability to intercept costly and dangerous medication errors;
• nurse-led innovations to reduce the incidence of facility-acquired
• pressure ulcers among residents in long-term care settings; and
• strategies to improve intensive care unit patients’ ability to communicate with nurses and other health team members regarding their care needs and preferences.

INQRI grantees have also applied rigorous research methods to examine a broad range of approaches to improving the value of health care—increasing quality while reducing health care costs associated with issues such as patient falls, hospital-acquired infections, and rehospitalizations. Studies aimed at reducing events that drive up health care costs have included

• an analysis of the factors that influence the quality of preparation of patients and family caregivers for the transition from hospitals to home and the impact of enhanced preparation on patients’ perceived readiness and rates of re-hospitalization;
• relationships between the level of professional nursing practice, adoption of evidence-based care strategies, and the number and kind of injuries from falls;
• effects on patients’ health of diabetes prevention information delivered by visiting nurses to residents in subsidized housing units; and
• linkages between nurse staffing levels in neonatal intensive care units and outcomes for very-low-birth-weight infants in those units.

In addition to contributing to continuous learning in our nation’s health care system, improving the rigor of research, and identifying the linkages between nursing and the quality of patient care, INQRI has helped to define what we mean by “quality” in the context of health care and to identify new metrics and measures that should be used in future health care research. As any research endeavor should, INQRI has proven to be greater than the sum of its parts.

Suggested citation: Naylor, M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary, Institute of Medicine, Washington, DC. http://iom.edu/interdisciplinaryresearch

Upcoming Webinar Highlights Transitional Care Model

The Institute for Professional Care Education is hosting a webinar on the Transitional Care Model (TCM), a tool developed by INQRI co-director Mary Naylor. TCM is designed to meet the needs of patients and family caregivers making the transition from an acute-care hospitalization to their home or a rehabilitative or skilled nursing facility. The webinar will be held Thursday, November 14 from 2:00pm-3:00pm EDT.

Topics will include:

•    Integrating patients' health goals into self-motivated, patient-specific care.
•    Avoiding emergency room transfer or preventing readmissions through provision of evidence-based care.
•    Trends in patient and family caregiver support and education.
•    Strategies for helping patients and family caregivers manage when end-of-life care becomes a priority.

This free webinar is approved for one CEU by the National Association of Long Term Care Administrators. Presenters include Brian Bixby, an advanced practice nurse with the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Mr. Bixby has extensive clinical experience in acute care, interventional cardiology and electrophysiology.

More information and registration for the webinar is available by clicking here.

Several INQRI studies have examined the ways nurses can improve transitional care, including a study by Cynthia Corbett and Stephen Setter exploring the role of the home health care nurse in medication management; and a translational study by Nancy Hanrahan and Phyllis Solomon adapting the Transitional Care Model for people with serious mental illness in public managed care.

Do Public Reporting Laws Affect Nurse Staffing, Patient Safety?

A new $214,000 grant from RWJF’s Future of Nursing National Research Agenda will fund a study to examine whether public reporting laws are effective in encouraging hospitals to improve nurse staffing levels and improving patient outcomes. The project is coordinated by INQRI and the team is led by Matthew D. McHugh, associate professor at the University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research. McHugh is also an RWJF Nurse Faculty Scholar.

The researchers will examine the impact of nurse staffing public reporting laws on staffing levels and patient outcomes in four states: Illinois, New Jersey, Rhode Island, and Vermont. They will look at the scope of nurse staffing public reporting laws, the process and context that supported their passage and implementation, the effects of the laws on registered nurse staffing levels, and the effects of the laws on patient mortality, readmissions, and failure-to-rescue.

“The studies funded through the Interdisciplinary Nursing Quality Research Initiative are establishing the links between nursing care and patient outcomes, and this new round of research takes that work one step further,” said INQRI Co-director Mary Naylor. “The National Research Agenda supports studies that will provide the evidence base for policies that will advance nursing, improve health care, and increase access to care.”

A news release on the new grant is here.

Free Webinar Highlighting Healthcare Transitions and Coordination

Next week, former INQRI grantee, Gerri Lamb, PhD, FAAN, RN, is the featured guest for a webinar focusing on how healthcare transitions and coordination affect early readmissions, care effectiveness and the economics associated with the two. This is the second webinar in this two part series that highlights the importance of care transitions.

To register for the upcoming webinar, click here.

To view the first webinar of the two part series, which featured INQRI director, Mary D. Naylor, PhD, RN, click here.

Reflections on INQRI's Work - A Video Presented At Last Week's 2012 National Conference

As many of you know, or may have attended, the INQRI Program held our National Conference last week in Washington, DC. We had the pleasure of engaging the 160+ participants with panels discussing the many facets of INQRI grantees' work. One of the most talked about sessions of the conference was the introductory section, which included a video reflecting on the work of INQRI since its inception 7 years ago. The video is embedded below.



If you are looking for more resources related to the INQRI program's work you can visit our BRAND NEW website that contains a variety of videos, documents, as well as general information about the INQRI program and the grantees we have served over the years.

INQRI Program Co-Director Interviewed for Last Month's Women's History Month

Yesterday, Stephanie Bouchard, Associate Editor for healthcarefinancenews.com, published her interview with INQRI's Co-Director Dr. Mary Naylor that discussed the role of women in healthcare. The interview provides great insight of Dr. Naylor's views on women leaders, decision makers and their continued role in improving the United States' health care system.

Click here to read the full interview.

Nurses' Role in the Future of Health Care

In today's New York Times, Pauline Chen, M.D., takes a look at Nurses' Role in the Future of Health Care by explaining the incredible impact that nurses can have... especially in the era of health reform.  Dr. Chen discusses the report generated by the Initiative on the Future of Nursing committee: "The Future of Nursing: Leading Change, Advancing Health."  Dr. Chen presents INQRI director, Mary Naylor's work on the transitional care model as an exemplar of successful nursing-led services.

Click here to read the article.

Transitional Care Cuts Hospital Re-Entry Rates, Costs

The NPR story featuring Mary Naylor's Transitional Care Model is now available online at NPR.org:

Here's a number that tells you a lot about what's wrong with the American health care system: When older patients get discharged from a hospital, 1 out of 5 of them will come right back within a month. Medicare pays $17 billion a year on these hospital readmissions. And in many cases, coming back should have been avoidable.

Mary Naylor is trying to change that. She started the Transitional Care Model at the University of Pennsylvania Health Care System in Philadelphia. A nurse with advanced training in geriatrics is assigned to an elderly patient while he is in the hospital and then follows the patient, with frequent visits and contact, over two or three months to help him manage his own care.

"Every time an older adult is hospitalized, it generally results in changes in their plan of care," says Naylor. Some of the instructions from a doctor can be hard to follow, like new prescriptions. "So they would go home and 24 hours after discharge have a set of prescriptions, drugs already in their cabinet and wonder, 'Should I be taking these plus these?'"

For the rest of the story and to hear the clip from Morning Edition, click here.

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The INQRI program is very invested in ensuring good patient care quality at each stage of the health care journey. An INQRI team at Marquette University has been working for the past two years on discharge preparation.

Hospital readmission and emergency department utilization within the first 30 days following hospital discharge represent adverse, potentially avoidable, and costly outcomes of hospitalization. For their project, "A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes," Marianne Weiss and Olga Yakusheva, worked on linking the unit-level nurse practice environment and nursing care processes with patient outcomes at discharge and post-hospitalization. Specifically, the study examined direct and indirect causal relationships between the nursing practice environment, the discharge teaching process and readiness for hospital discharge with hospital readmission and emergency department utilization.

Dr. Weiss has published extensively regarding discharge readiness. To read her article, "Patients' Perceptions of Hospital Discharge Informational Content," co-authored by Lynn Maloney, click here.

INQRI Program Director Mary Naylor on NPR

INQRI Program Director Mary Naylor’s Transitional Care Model is scheduled to be featured today on NPR’s Morning Edition.

Click here to find your local NPR affiliate. The piece will be available online, via live and archived streams from NPR, to your desktop.

The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management - all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient's physicians.

For more information on the Transitional Care Model, please click here.