OPTIMISTIC Research study: POLST most effective and helpful tool in nursing home care

Introduction: Study authors Mary Ersek, PhD, RN, Susan E. Hickman, PhD, Anne C. Thomas, PhD, ANP-BC, GNP, FAANP, Brittany Bernard, BS, and Kathleen T. Unroe, MD, MHA, published a paper, “Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project” in The Geronotologist.

OPTIMISTIC is aimed at improving care for nursing home patients via the implementation of a multicomponent collaborative care model, which includes advance care planning (ACP) and specifically the use of POLST (in this study called POST, or Physician Orders for Scope of Treatment, since the study took place in Indiana). OPTIMISTIC is a clinical demonstration project funded by the Center for Medicare and Medicaid Innovation (CMMI) as part of its national Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents (Centers for Medicare and Medicaid Services, 2017).

OPTIMISTIC embeds registered nurses (RNs) and nurse practitioners (NPs) at no cost to the facility; the RNs facilitate ACP, mentor nursing home staff, and implement evidence-based tools; NPs address gaps in coverage and coordination of care. In this paper, specifically, goals were to (1) collect stakeholder opinions on the most and least effective components in meeting the overall program goal of reducing hospitalizations,  (2) describe barriers to program implementation, and (3) explore program features that facilitated its adoption. Results in this study focused on long-term-care patients in 19 Indiana facilities between February 2013 and October 2016.

Methods: Data were collected by means of interviews with 23 nursing home staff and leaders (for example, administrators and director of nursing home services) from three facilities, all 26 OPTIMISTIC clinical staff, which included 19 RNs and 7 NPs, 4 primary care providers, and 10 family members.

Results: To quote the study authors,

The most frequently cited successful component was the ACP component including POST completion. This view was widely shared by OPTIMISTIC RNs, providers, families, and facility staff. As one facility physician commented, “You need to continue and enhance the end-of-life discussions. POST implementation has been very helpful and it has helped everyone understand about palliative care and hospice and how they are different.”

Respondents identified the comprehensiveness of the ACP discussions as critical to the program’s success, as pointed out by an OPTIMISTIC RN: “I think that the advance care planning, that’s been a huge success… I see it as something that was really not implemented prior to OPTIMISTIC other than just getting a signature on a DNR form.” Family members concurred that the OPTIMISTIC program’s approach to ACP was effective and helpful. In the words of one family surrogate decision maker:

“I thought that [the ACP discussion] went very well. She [OPTIMISTIC RN] covered every aspect of it. She talked about the different levels of care that would be given. All of our questions were answered and yeah, I just felt really good when we came away from there with the care plan. We knew what my mother wanted and we kind of knew what we felt was best for her, but it felt really good having it actually put down in paper that there is a plan that other hospitals and nursing facilities can follow.”

While other effective components were identified, the ACP component was the one tool that OPTIMISTIC staff, facility staff and families all cited. Other components, mostly cited by OPTIMISTIC and sometimes facility staff, included features of palliative care (more broad than ACP) , collaborative care reviews, and other facility-based services.

References and further reading

Ersek M, SE Hickman, AC Thomas, B Bernard, and KT Unroe (2017). “Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project” The Gerontologist. (E-pub ahead of print.) (limited access). doi:10.1093/geront/gnx155

OPTIMISTIC website: http://www.optimistic-care.org

Centers for Medicare and Medicaid Services – Innovation website: https://innovation.cms.gov

Centers for Medicare and Medicaid Services – Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents website: https://innovation.cms.gov/initiatives/rahnfr/

OPTIMISTIC lowers long-stay nursing home residents’ avoidable hospitalizations by a third:
The John A Hartford Foundation press release (11/29/17)| Regenstrief Institute press release (11/28/17)