Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

Digital Methodology for Mobile Clinical Decision Support Development in Long-Term Care.

The global COVID-19 pandemic has driven innovations in methods to sustain initiatives for the design, development, evaluation, and implementation of clinical support technology in long-term care settings while removing risk of infection for residents, family members, health care workers, researchers and technical professionals. We adapted traditional design and evaluation methodology for a mobile clinical decision support app - designated Mobile Application Information System for Integrated Evidence ("MAISIE") - to a completely digital design methodology that removes in-person contacts between the research team, developer, and nursing home staff and residents. We have successfully maintained project continuity for MAISIE app development with only minor challenges while working remotely. This digital design methodology can be implemented in projects where software can be installed without in-person technical support and remote work is feasible. Team skills, experience, and relationships are key considerations for adapting to digital environments and maintaining project momentum.

Impact of Advanced Practice Registered Nurses on Quality Measures: The Missouri Quality Initiative Experience.

PURPOSE: The purpose of this article is to review the impact of advanced practice registered nurses (APRNs) on the quality measure (QM) scores of the 16 participating nursing homes of the Missouri Quality Initiative (MOQI) intervention. The MOQI was one of 7 program sites in the US, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services Innovations Center. While the goals of the MOQI for long-stay nursing home residents did not specifically include improvement of the QM scores, it was anticipated that improvement most likely would occur. Primary goals of the MOQI were to reduce the frequency of avoidable hospital admissions and readmissions; improve resident health outcomes; improve the process of transitioning between inpatient hospitals and nursing facilities; and reduce overall healthcare spending without restricting access to care or choice of providers. METHODS: A 2-group comparison analysis was conducted using statewide QMs; a matched comparison group was selected from facilities in the same counties as the intervention homes, similar baseline QM scores, similar size and ownership. MOQI nursing homes each had an APRN embedded full-time to improve care and help the facility achieve MOQI goals. Part of their clinical work with residents and staff was to focus on quality improvement strategies with potential to influence healthcare outcomes. Trajectories of QM scores for the MOQI intervention nursing homes and matched comparison group homes were tested with nonparametric tests to examine for change in the desired direction between the 2 groups from baseline to 36 months. A composite QM score for each facility was constructed, and baseline to 36-month average change scores were examined using nonparametric tests. Then, adjusting for baseline, a repeated measures analysis using analysis of covariance as conducted. RESULTS: Composite QM scores of the APRN intervention group were significantly better (P = .025) than the comparison group. The repeated measures analysis identified statistically significant group by time interaction (P = .012). Then group comparisons were made at each of the 6-month intervals and statistically significant differences were found at 24 months (P = .042) and 36 months (P = .002), and nearly significant at 30 months (P = .11). IMPLICATIONS: APRNs working full time in nursing homes can positively influence quality of care, and their impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs. Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes, indicating budgeting for APRN services can be a successful strategy.

Call to action: APRNs in U.S. nursing homes to improve care and reduce costs.

BACKGROUND: Centers for Medicare and Medicaid Innovation Center sponsored the initiative to reduce avoidable hospitalizations among nursing facility residents. PURPOSE: Missouri Quality Initiative (MOQI) designed inter-professional model in nursing homes with advanced practice registered nurses (APRNs). METHOD: MOQI APRN model was implemented for 4 years in 16 nursing homes in a metro area of the Midwest. Hospitalizations were reduced (40% all-cause, 58% potentially avoidable), emergency room visits (54% all-cause, 65% potentially avoidable), Medicare expenditures for hospitalizations (34% all-cause, 45% potentially avoidable), and Medicare expenditures for emergency room visits (50% all-cause, 60% potentially avoidable) for long-stay nursing home residents. DISCUSSION: Success of the MOQI model reinforces decades of research demonstrating that care provided by APRNs is cost-effective, safe, and associated with positive health outcomes and patient satisfaction. CONCLUSION: Nursing homes can implement and benefit by hiring APRNs. However, changes in the Code of Federal Regulation (CFR 483.40) are necessary to improve patient access to care and encourage hiring APRNs in US nursing homes.

Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative.

PURPOSE: The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center. DESIGN AND METHODS: A prospective, single group intervention design, the MOQI included an advanced practice registered nurse (APRN) embedded full-time within each nursing home (NH) to influence resident care outcomes. Data were collected continuously for more than 3 years from an average of 1750 long-stay Medicare, Medicaid, and private pay residents living each day in 16 participating nursing homes in urban, metro, and rural communities within 80 miles of a major Midwestern city in Missouri. Performance feedback reports were provided to each facility summarizing their all-cause hospitalizations and potentially avoidable hospitalizations as well as a support team of social work, health information technology, and INTERACT/Quality Improvement Coaches. RESULTS: The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents. IMPLICATIONS: As the population of older people explodes in upcoming decades, it is critical to find good solutions to deal with increasing costs of health care. APRNs, working with multidisciplinary support teams, are a good solution to improving care and reducing costs if all nursing home residents have access to APRNs nationwide.

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes.

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

Doppler radar fall activity detection using the wavelet transform.

We propose in this paper the use of Wavelet transform (WT) to detect human falls using a ceiling mounted Doppler range control radar. The radar senses any motions from falls as well as nonfalls due to the Doppler effect. The WT is very effective in distinguishing the falls from other activities, making it a promising technique for radar fall detection in nonobtrusive inhome elder care applications. The proposed radar fall detector consists of two stages. The prescreen stage uses the coefficients of wavelet decomposition at a given scale to identify the time locations in which fall activities may have occurred. The classification stage extracts the time-frequency content from the wavelet coefficients at many scales to form a feature vector for fall versus nonfall classification. The selection of different wavelet functions is examined to achieve better performance. Experimental results using the data from the laboratory and real inhome environments validate the promising and robust performance of the proposed detector.

A New Paradigm of Technology-Enabled 'Vital Signs' for Early Detection of Health Change for Older Adults.

Environmentally embedded (nonwearable) sensor technology is in continuous use in elder housing to monitor a new set of 'vital signs' that continuously measure the functional status of older adults, detect potential changes in health or functional status, and alert healthcare providers for early recognition and treatment of those changes. Older adult participants' respiration, pulse, and restlessness are monitored as they sleep. Gait speed, stride length, and stride time are calculated daily, and automatically assess for increasing fall risk. Activity levels are summarized and graphically displayed for easy interpretation. Falls are detected when they occur and alerts are sent immediately to healthcare providers, so time to rescue may be reduced. Automated health alerts are sent to healthcare staff, based on continuously running algorithms applied to the sensor data, days and weeks before typical signs or symptoms are detected by the person, family members, or healthcare providers. Discovering these new functional status 'vital signs', developing automated methods for interpreting them, and alerting others when changes occur have the potential to transform chronic illness management and facilitate aging in place through the end of life. Key findings of research in progress at the University of Missouri are discussed in this viewpoint article, as well as obstacles to widespread adoption.

Comparing Aging in Place to Home Health Care: Impact of Nurse Care Coordination On Utilization and Costs.

The goal of this study was to compare utilization and cost outcomes of patients who received long-term care coordination in an Aging in Place program to patients who received care coordination as a routine service in home health care. This research offered the unique opportunity to compare two groups of patients who received services from a single home health care agency, using the same electronic health record, to identify the impact of long-term and routine care coordination on utilization and costs to Medicare and Medicaid programs. This study supports that long-term care coordination supplied by nurses outside of a primary medical home can positively influence functional, cognitive, and health care utilization for frail older people. The care coordinators in this study practiced nursing by routinely assessing and educating patients and families, assuring adequate service delivery, and communicating with the multidisciplinary health care team. Care coordination managed by registered nurses can influence utilization and cost outcomes, and impact health and functional abilities.

Nursing home research: the first International Association of Gerontology and Geriatrics (IAGG) research conference.

The International Association of Gerontology and Geriatrics held its first conference on nursing home research in St Louis, MO, in November 2013. This article provides a summary of the presentations.

Automated fall detection with quality improvement "rewind" to reduce falls in hospital rooms.

The purpose of this study was to test the implementation of a fall detection and "rewind" privacy-protecting technique using the Microsoft® Kinect™ to not only detect but prevent falls from occurring in hospitalized patients. Kinect sensors were placed in six hospital rooms in a step-down unit and data were continuously logged. Prior to implementation with patients, three researchers performed a total of 18 falls (walking and then falling down or falling from the bed) and 17 non-fall events (crouching down, stooping down to tie shoe laces, and lying on the floor). All falls and non-falls were correctly identified using automated algorithms to process Kinect sensor data. During the first 8 months of data collection, processing methods were perfected to manage data and provide a "rewind" method to view events that led to falls for post-fall quality improvement process analyses. Preliminary data from this feasibility study show that using the Microsoft Kinect sensors provides detection of falls, fall risks, and facilitates quality improvement after falls in real hospital environments unobtrusively, while taking into account patient privacy.

Nighttime restfulness during daytime dance therapy: an exploratory study using bed sensors.

Dance-based therapy has the potential to slow the progression of functional limitations in older adults. The purpose of this study was to explore the feasibility of measuring the impact of dance-based therapy on the nighttime restfulness patterns of older adults in an aging-in-place facility using passive bed sensors. A secondary data analysis of the continuous 2-month nighttime bed sensor data was reviewed for measurable change during a dance study. A measurable variation in nighttime restfulness level was detected between the dancers and nondancers, and no high or very high restlessness was detected during this period for the dance-based therapy group. Although these exploratory variations are modest, the findings suggest that bed sensors can be used to measure nighttime restfulness following a therapeutic dance intervention. More research is needed in this emerging area.

Evaluation of health alerts from an early illness warning system in independent living.

Passive sensor networks were deployed in independent living apartments to monitor older adults in their home environments to detect signs of impending illness and alert clinicians so they can intervene and prevent or delay significant changes in health or functional status. A retrospective qualitative deductive content analysis was undertaken to refine health alerts to improve clinical relevance to clinicians as they use alerts in their normal workflow of routine care delivery to older adults. Clinicians completed written free-text boxes to describe actions taken (or not) as a result of each alert; they also rated the clinical significance (relevance) of each health alert on a scale of 1 to 5. Two samples of the clinician's written responses to the health alerts were analyzed after alert algorithms had been adjusted based on results of a pilot study using health alerts to enhance clinical decision-making. In the first sample, a total of 663 comments were generated by seven clinicians in response to 385 unique alerts; there are more comments than alerts because more than one clinician rated the same alert. The second sample had a total of 142 comments produced by three clinicians in response to 88 distinct alerts. The overall clinical relevance of the alerts, as judged by the content of the qualitative comments by clinicians for each alert, improved from 33.3% of the alerts in the first sample classified as clinically relevant to 43.2% in the second. The goal is to produce clinically relevant alerts that clinicians find useful in daily practice. The evaluation methods used are described to assist others as they consider building and iteratively refining health alerts to enhance clinical decision making.

In-home fall risk assessment and detection sensor system.

Falls are a major problem in older adults. A continuous, unobtrusive, environmentally mounted (i.e., embedded into the environment and not worn by the individual), in-home monitoring system that automatically detects when falls have occurred or when the risk of falling is increasing could alert health care providers and family members to intervene to improve physical function or manage illnesses that may precipitate falls. Researchers at the University of Missouri Center for Eldercare and Rehabilitation Technology are testing such sensor systems for fall risk assessment (FRA) and detection in older adults' apartments in a senior living community. Initial results comparing ground truth (validated measures) of FRA data and GAITRite System parameters with data captured from Microsoft(®) Kinect and pulse-Doppler radar are reported.

Sensor technology to support Aging in Place.

Older adults want to age in place at home. Sensor technology has the potential to help by monitoring individuals' health status, detecting emergency situations, and notifying health care providers. Researchers at the University of Missouri are investigating the impact of registered nurse care coordination and technology on the ability of older adults to age in place. Technology coupled with care coordination has improved clinical outcomes. This article presents an overview of the Aging in Place research, TigerPlace as a Missouri-sponsored Aging in Place facility, and the sensor technology developed to support Aging in Place.

The influence of teams to sustain quality improvement in nursing homes that "need improvement".

OBJECTIVES: Qualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement." DESIGN/SETTING/PARTICIPANTS: A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. RESULTS: The qualitative analysis revealed a subgroup of homes ("Full Adopters") likely to continue quality improvement activities that were able to effectively use teams. "Full Adopters" had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. "Full Adopters" also selected care topics for the focus of their quality improvement team, instead of "communication" topics of the "Partial Adopters" or "Non-Adopters" in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. "Full Adopters" had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems. CONCLUSIONS: Results of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.