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.

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.

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.

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.

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.

Automated technology to speed recognition of signs of illness in older adults.

Our team has developed a technological innovation that detects changes in health status that indicate impending acute illness or exacerbation of chronic illness before usual assessment methods or self-reports of illness. We successfully used this information in a 1-year prospective study to alert health care providers so they could readily assess the situation and initiate early treatment to improve functional independence. Intervention participants showed significant improvements (as compared with the control group) for the Short Physical Performance Battery gait speed score at Quarter 3 (p = 0.03), hand grip-left at Quarter 2 (p = 0.02), hand grip-right at Quarter 4 (p = 0.05), and the GAITRite functional ambulation profile score at Quarter 2 (p = 0.05). Technological methods such as these could be widely adopted in older adult housing, long-term care settings, and in private homes where older adults wish to remain independent for as long as possible.

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.

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis.

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for the first 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Evaluation of aging in place model with home care services and registered nurse care coordination in senior housing.

A state-sponsored evaluation of aging in place (AIP) as an alternative to assisted living and nursing home has been underway in Missouri. Cost, physical, and mental health assessment data reveal the cost-effectiveness and positive health measures of AIP. Findings of the first four years of the AIP evaluation of two long-term care settings in Missouri with registered nurse care coordination are compared with national data for traditional long-term care. The combined care and housing cost for any resident who received care services beyond base services of AIP and who qualified for nursing home care has never approached or exceeded the cost of nursing home care at either location. Both mental health and physical health measures indicate the health restoration and independence effectiveness of the AIP model for long-term care.

Improving nurse care coordination with technology.

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Pain management in nursing homes: what do quality measure scores tell us?

Pain management for older adults residing in nursing homes continues to present multifaceted challenges to health care practitioners and researchers. This study, which focuses on improvement in pain assessment and management, is a secondary analysis of data from a larger study, which used an intervention simultaneously directed at all levels of staff with change in quality measure (QM)/quality indicator (QI) scores to determine improvement in resident outcomes. We anticipated that focused improvement efforts in resident care regarding pain management would be reflected by correspondingly lower QM/QI scores over time. Findings of increased QM/QI scores may be positive in that they may point to increased attention by staff regarding pain management for residents.

Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research.

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

Dance-based therapy in a program of all-inclusive care for the elderly: an integrative approach to decrease fall risk.

BACKGROUND: Loss of balance and diminished gait are major fall risk factors in older persons. Literature suggests that physical activity based on dance may improve balance and gait. The aim of this pilot study was to determine whether dance-based therapy affects the balance/gait of community-based frail seniors. CONCEPTUAL FRAMEWORK: The Roy Adaptation Model and Environmental Press Theory were used as joint frameworks. PARTICIPANTS: Eleven participants were recruited from a Program of All-inclusive Care for the Elderly (PACE). Inclusion criteria were (1) Mini-Mental State Examination score of 23 or more, (2) attending PACE on Monday, Wednesday, and Friday, and (3) able to stand with or without assistance. METHODS: A Lebed Method dance intervention was conducted using a longitudinal design 3 times a week for 6 weeks. Functional Reach and Timed Get Up and Go were measured at baseline, 6 weeks after the start of the intervention, and 6 weeks postintervention and repeated to estimate the persistence of the effect. CONCLUSIONS: Graphs were compared looking for functional trends; postintervention interviews were conducted with each subject. IMPLICATIONS: Dance therapy results in positive functional trends, suggesting that further study using dance-based therapy will be useful to decrease fall risks in older persons.

Helping nursing homes "at risk" for quality problems: a statewide evaluation.

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.