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.

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.”

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.

Interdisciplinary Study Indicates Poor Communication During Hospital to Nursing Home Transition Can Harm Patient Health

Transitional care has garnered significant attention since INQRI's own Mary Naylor conducted her ground-breaking research into the care older patients with multiple chronic conditions received during the transition from acute care to home or another care setting and developed the Transitional Care Model. Now, a study led by nurse researcher Barbara King and geriatrician Amy Kind reveals that the transition from hospital to nursing home is often difficult because of poor communication between staff at those institutions.

The study, published in the Journal of the American Geriatrics Society, reveals that nurses in skilled nursing facilities report that difficult transitions are the norm because they receive little information about their incoming patients. Adverse consequences that were a result of this poor communication included: increased risk of medication errors, delayed efforts to mobilize patients, and time wasted trying to obtain information that should have been shared. The nurses who participated in focus groups and surveys for this study reported that they felt their credibility and the credibility of the nursing home were undermined because of communications failures.

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.

Read more about the King/Kind study here.

Coordinated Care Still Needs Some Work

While coordinated care is widely considered the best way to keep costs down and provide better patient care and is a centerpiece of the Affordable Care Act, too often care coordination isn't really happening according to a story produced by Kaiser Health News in collaboration with the Washington Post.

Kaiser Health News quotes leading health policy analyst Lucian Leape: "nobody is responsible for coordinating care." According to the story, lack of coordination is resulting in an estimated 44,000 to 98,000 deaths from medical errors annually. This, despite health care's strong response to the landmark Institute of Medicine report, To Err Is Human, published in 1999. That study was the subject of an INQRI blog carnival in 2010, featuring posts from several INQRI-funded researchers.

There is good news, however -- an article HealthLeadersMedia, published earlier this week indicates that nurses have the skills and experience provide effective and successful coordinated care. According to sources in the article, nurses' experience at the bedside - caring for multiple patients and handling their varying needs - makes them uniquely suited to understand and provide coordinated care.

Several INQRI teams have investigated how nurses' contribute to improved care coordination, especially in times of transition from hospital to home.

Scores Predict Readmission Likelihood

Through a simple risk score, a team from Brigham and Women's Hospital in Boston, collaborating with a team in Bern, Switzerland, say they can identify roughly one-fourth of a hospital's patient population with the highest likelihood of being readmitted, and then within that group the 18% whose readmissions were potentially avoidable, for whom more expensive, intensive efforts might be worth the money.  Continue reading the article.

Readmissions is an area of interest to INQRI.  Grantees Dr. Marianne Weiss and Dr. Olga Yakusheva have conducted research on the discharge process and it's relationship to readmissions.  Learn more about their work:

View "Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization."
View "Age-related differences in perception of quality of discharge teaching and readiness for hospital discharge."
View "Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization."

Webinar: Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness

If you missed last week's excellent webinar on the translation of a transitional care nursing intervention for people with serious mental illness, check it out right here:

A Continuing Collaboration

Randall Krakauer, MD 

Five years ago there was considerably less attention paid to the issue of readmissions than is the case today. Mary Naylor, Mark Pauly and the University of Pennsylvania team had already demonstrated the potential to reduce 90 day readmissions through better management of the discharge process, including the period immediately after discharge. Our team at Aetna was busy building Medicare care management infrastructure to impact chronic illness and Advanced Illness at the intersection of quality and cost - and had already seen a reduction in avoidable admissions and readmissions through telephonic case management. We needed to know whether there was incremental opportunity with on-site and home care management. So began a very productive collaboration that continues. Our program began with collaboration with Mary, Mark, and their team on Aetna Medicare Advantage members in metropolitan Philadelphia, with a Transitional Care program, measured against a clinically matched group in another region. With the demonstration of a 20% reduction in 90-day readmissions (publication 1), and considerable cost savings (impact at the intersection of quality and cost) we began building Transitional Care programs that are now nationwide. With the increased importance of Star Rating measures for Medicare programs, this experience has served us well. Such programs are still being expanded, but they are part of comprehensive care management programs everywhere - it is no longer necessary to demonstrate their value.

My collaboration with Mary, Mark, and their team has also led me to another venture: my role on the National Advisory Committee (NAC) for the Interdisciplinary Nursing Quality Research Initiative (INQRI) program. Since joining the NAC in 2006, I have been pleased to review research proposals, advise funded grantees on their project plans, and offer advice and support to Mary and Mark as they lead this impressive program. Like Aetna’s work with the Penn team, INQRI teams have continually shown the value of nurse-led interventions.

Our work and collaboration on reducing readmissions has been very productive and valuable. But since we don't actually achieve Nirvana in this world, this work and collaboration will continue, and we expect to continue pushing the limits of our potential. Similarly, I look forward to seeing the continued impact that I know INQRI teams will have on improving healthcare quality.

Dr. Krakauer is the National Medical Director for Aetna Medicare and a member of INQRI’s National Advisory Committee. 

1) Naylor, M; Bowles, K; McCauley, K; Maislin, G; Pauly, M; Krakauer, R: "High Value Transitional Care: Translation of Research into Practice." J. Eval. Clin. Practice. 16 March 2011, 1-7.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Upcoming Webinar: Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness

Don't forget: next Wednesday is our next webinar:

Please join for the sixth presentation in a series providing the study findings from INQRI's final cohort of grantees.  This session features Dr. Nancy Hanrahan presenting study findings regarding her team's work to translate the Transitional Care Model intervention to meet the complex needs of persons with serious mental illness in public managed care.

Information to join the webinar:

Topic: Webinar - Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness
Date: Wednesday, March 27, 2013
Time: 12:00 pm, Eastern Daylight Time (GMT -04:00, New York)
Event Number: 571 936 565
Event Password: tcm-smi

Register now.

Learn more about this INQRI team led by Dr. Phyllis Solomon and Dr. Nancy Hanrahan.

Care About Your Care Videos - Our Grantees Respond

Last month, we told you about an exciting event sponsored by the Robert Wood Johnson Foundation, "Care About Your Care," which focused on reducing hospital readmissions through improved transitions in care.

In addition to a live webcast, the event also featured the presentation of winners from a video contest featuring a series of videos submitted by care teams to demonstrate their successful strategies to improve transitions.

We continue to be impressed by this work and some of our INQRI grantees wanted to take the opportunity to comment on some of these fantastic contributions.

Northern Piedmont Community Care

"This approach to care makes so much sense to me that I have to ask myself why this isn't the prevailing model of healthcare delivery. Many chronic diseases can be managed and even prevented through a healthful lifestyle, but research shows that the majority of people do not know how to be healthy. Patient teaching and education is a core component of the nursing process, and the success of community clinics like the one featured in the video places nurses in the center of the healthcare reform and efforts to promote high-quality patient-centered cost-effective care." 
- INQRI Grantee Olga Yakusheva 

CARE Network - Transition to Better Care

"This video about care transitions tells the story so well. The patient's story is central in the video which says a lot about how the CARE Network hold their priories." 
 - INQRI Grantee Nancy Hanrahan 

U of U Health Care- Transitions Program

"A small investment in time at discharge can pay off in a big way. Ensuring that patients and their informal caregivers understand what is needed to be done upon discharge may well prevent a return to the hospital. Since hospital days are far more costly than is outpatient care, it behooves providers to devote a small amount of time and resources prior to release and just after discharge from the hospital to prevent an even greater investment due to an exacerbation of illness. This is an area where Ben Franklin's aphorism, 'Pennywise and pound foolish' is spot on." 
 - INQRI Grantee Phyllis Solomon

Webinar Next Week: Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness

The transition from a psychiatric hospitalization back into the community is a vulnerable period for individuals with serious mental illness. Cycling in and out of psychiatric hospitals and emergency services is harmful to this population and depletes scarce public resources. The Transitional Care Model for Persons with Serious Mental Illness (TCM-SMI) proposes to break this cycle by providing 90 days of intensive hospital-to-home services. An INQRI project led by Nancy Hanrahan and Phyllis Solomon was designed to translate the TCM intervention to meet the complex needs of SMI clients in public managed care.

Join us on Wednesday, March 27 from 12n-1pmET as Drs. Hanrahan and Solomon present the findings from this important study.

Register for this webinar.

Transitions of Care: The need for collaboration across entire care continuum

The Joint Commission enterprise is in the first year of a three-year initiative to define methods to achieve improvement in the effectiveness of the transitions of patients between health care organizations and provide for the continuation of safe, quality care for patients in all settings. All three components of The Joint Commission enterprise will offer various interventions and resources that are designed collectively to improve transitions of care. The interventions will apply to six accreditation programs: hospital, critical access hospital, behavioral health care, home care, nursing and rehabilitation center, and ambulatory care. As part of this work, The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another.

Developing ways to assure safe transitions of care requires collaboration among providers all along the care continuum. The Joint Commission recently organized a series of learning visits and focus groups to better understand the progress providers are making and the challenges they still face.

The brief identifies that organizations in all settings must establish seven “foundations” to assure safe transitions from one health care setting to another:
 • Leadership support
• Multidisciplinary collaboration
• Early identification of patients/clients at risk
• Transitional planning
• Medication management
• Patient and family action/engagement
• Transfer of information

INQRI grantees have contributed much to this field of research. Led by Barbara Roberge and Ken Minaker, a team at Massachusetts General Hospital tested the impact of identifying and communicating a pre-hospital preventive patient risk profile on nurse-sensitive outcomes for hospitalized older adults. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. They identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. Cynthia Corbett, Stephen Setter and their team at Washington State University used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. Researchers at the University Pennsylvania, led by Nancy Hanrahan and Phyllis Solomon, are working on a translation of the Transitional Care Model for use with people with serious mental illness as they transition in an out of psychiatric hospitals and emergency services.

Click here for the second issue of "Transitions of Care: The need for collaboration across entire care continuum" from the Joint Commission. 

Click here to access research from INQRI grantees related to transitions of care

Initiatives Designed to Prevent Readmissions

A recent article in the L.A. Times describes an initiative launched at Cedars-Sinai, the 'frailty project,' in which a medical team works to help at-risk elderly avoid lengthy hospital stays or readmission.

Under this initiative, patients receive a holistic approach to care, focusing not just on the disease that brought them to the hospital, but also on all aspects of their health.  The project launched with a pilot in 2011 and it was expanded last year.

Cedars is now working with INQRI director Mary Naylor and her team at the University of Pennsylvania to develop a program for patients once they are discharged from the hospital.

Programs like Naylor's transitional care model and the frailty project are excellent examples of the types of initiatives needed to address the growing problem of hospital readmissions, as discussed at last week's Care About Your Care event.

Care About Your Care

The Robert Wood Johnson Foundation and dozens of organizations will convene February 13 for Care About Your Care, a national initiative that highlights what works to improve care transitions and reduce avoidable hospital readmissions.

Nancy Snyderman, MD, chief medical editor for NBC News, will lead experts and health care leaders from diverse communities in sharing how they bring together patients, care providers, and community services to foster better health care outcomes.

The live event will feature:

• Risa Lavizzo-Mourey, MD - Robert Wood Johnson Foundation president and CEO
• Mary Naylor, PhD, RN, INQRI Program Director - University of Pennsylvania School of Nursing
• Eric Coleman, MD - University of Colorado Anschutz Medical Campus
• Jonathan Blum, MA - Centers for Medicare & Medicaid Services

Representatives from care teams from across the nation who are working on innovative ways to improve care transitions.

When: Wednesday, Feb. 13, 2013 12:30–2:00 p.m. ET

To Register for the Live Webcast: Contact careaboutyourcare@rwjf.org

Join the Twitterverse: With the hashtag #yourcare 

NYT Notes Importance of Evidence-Based Solutions

Yesterday's New York Times featured an excellent piece by David Bornstein that demonstrates the need for widespread use of evidence-based solutions to address society's major issues. The piece highlights impact on improving care and reducing costs via the Transitional Care Model, which provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

Click here to read the piece.

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.

Nurses Save Patients Time and Hospital Money

The local CW affiliate for the Dallas Fort-Worth area, KDAF-TV, detailed how a group of nurses tasked with obtaining detailed history for patients has helped improve care and patient satisfaction. The team of five full-time nurses, better known as DART (discharge, admission, resource, transport), also play a crucial role in the discharge process, ensuring patients understand the medications and instructions given to them by hospital physicians.

To read more about the DART team, click here.

New York Times Op-Ed: The Power of Nursing

Yesterday, the New York Times featured an Op-Ed by David Bornstein discussing a groundbreaking imitative, the Nurse-Family Partnership (NFP). Mr. Bornstein, known for his coverage of social innovations, outlined how the NFP arranges for registered nurses to make regular home visits to first-time low-income or vulnerable mothers. This program has resulted in improved health for mothers and their children, while also contributing to greater society by preventing child abuse and costly hospital admissions from infants.

Click here to read more about Mr. Bornstein's coverage of the NFP program.

A Shift From Nursing Homes to Managed Care at Home

Last week, Joseph Berger, reporting for the New York Times, discussed how providers are moving from the traditional nursing home model of care to managed care at home. This new model of care has not only been proven cost effective, but also allows for able-bodied elderly individuals to live independently. Mr. Berger's article highlights the Program of All-Inclusive Care for the Elderly(PACE), which provides almost all the services a nursing home would but in an 'day care' setting. This program, in addition to similar home health services, receives bundled payments for each patient they treat rather than relying on the traditional fee-for-service reimbursement model. PACE and similar home-care programs are being heralded as the future model of health care for the aging baby boomer generation.

Click here to read the full article.

New Jersey Nurses Train to Coordinate Their Patients' Care

Last week, Beth Fitzgerald, reporting for NJ Spotlight, discussed how new nurses are learning a variety of skills to act as population care coordinators. The program, which is a collaborative effort between Horizon Healthcare Innovations (HHI), Duke University School of Nursing and Rutgers University College of Nursing, emphasizes the importance of new nurses taking on the roles of coach and health advocate in order to improve coordinated follow-up and preventive and wellness care. The program is also based off of the patient-centered medical home model of care and focuses on patient engagement to improve the overall quality of care.

Click here to read more about the new initiative.