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Innovative care models across settings: Providing nursing care to older adults
ARTICLE IN PRESS Geriatric Nursing 000 (2020) 1 5
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Innovative care models across settings: Providing nursing care to older adults Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAAN University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
A R T I C L E
I N F O
Article history: Available online xxx Keywords: Evercare/Optum INTERACT NICHE PACE Transitional Care Model
A B S T R A C T
The aging demographic shift occurring world-wide is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided. These models across settings emphasize maximizing the role of nurses and advanced practice nurses. The models reviewed include: On LOK and Programs of All-inclusive Care for the Elderly (PACE); Community Aging in Place, Advancing Better Living for Elders (CAPABLE); Teaching Nursing Homes; Interventions to Reduce Acute Care Transfers (INTERACT); Missouri Quality Initiative (MOQI); Evercare/Optum; Nurses Improving Care for Health System Elders (NICHE); Acute Care for the Elderly Unit (ACE Unit); Hospital Elder Life Program (HELP); Age-Friendly Health Systems; and the Transitional Care Model. Each model emphasizes education on the special needs of older adults, providing easy access to evidence-based tools and interventions, as well as strong interprofessional collaboration. Sustainable evidence-based nursing and interprofessional innovations are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults. © 2020 Published by Elsevier Inc.
Introduction
Community based long-term care models
There has never been such an unprecedented time like the present. We are facing a tremendous challenge of meeting the needs of a growing population of older adults. Population growth of older adults is outpacing younger adults. It is expected that by 2035 there will be 78 million people 65 years and older compared to 76.6 million under the age of 18.1 The demographic shift caused by the dramatically increasing aging population is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing models as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided with lessons learned to provide insights into what it takes to create a sustainable care model. Nursing and interprofessional innovative models of care are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults.
On Lok: Programs of All-Inclusive Care of the Elderly
E-mail address: [email protected] https://doi.org/10.1016/j.gerinurse.2020.01.011 0197-4572/$ see front matter © 2020 Published by Elsevier Inc.
The Program for All-Inclusive Care of the Elderly (PACE), a capitated managed care program, was started by On Lok Senior Health Services in 1971 based on the British day hospital model2 by Dr. William Gee, a dentist, and Marie-Louise Ansak, a social worker. This San Francisco Asian community responded to the pressing long term care support and services (LTSS) needs of their older adults. On Lok Senior Health Services was created to provide an interprofessional community-based system of LTSS.3 On Lok was initially funded through donations and grant funding to provide comprehensive culturally appropriate care to older adults in the Chinatown-North Beach community of San Francisco. In 1983 On Lok received initial Medicare and Medicaid waivers for capitated reimbursement.2 Today, PACE has integrated health, behavioral health, rehabilitation, and social services for frail, older adults to support them safely in the community. Nurses are an integral part of this model of care for persons in need of chronic disease management. In fact, American Academy of Nursing Edge Runner Jennie Chinn Hansen was instrumental in the success of On Lok.4 The University of Pennsylvania's School of Nursing had a nurse-run PACE program for dual-eligible older adults of West Philadelphia known as the Living Independently for Elders
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(LIFE) UPenn. LIFE UPenn received a Medicare waiver which supported advanced practice nurses serving as the primary care providers in collaboration with the Medical Director. Dr. Eileen Sullivan-Marx was recognized as an Edge Runner for her leadership of LIFE UPenn.4 LIFE UPenn was sold to Trinity Health PACE and has expanded the number of their participants to over 500. There are now 123 PACE sponsoring organizations with 250 centers in 31 states. Most of these centers have fewer than 500 older adults in each capitated program.5 As of 2018, 90% of all PACE enrollees were dual eligible. Initially started as not-forprofit organizations, this restriction was removed in 2015 allowing for profit organizations to enter the market.6 Currently 8% of PACE organizations are for-profit.5 Evaluations have shown that PACE successfully integrates acute and long-term care and reduces hospitalizations thereby decreasing costs.5
In addition, this 5-year RWJ demonstration project had significant impact on the nursing homes and the school of nursing faculty.13 The nursing home benefited by improved quality of care, improved clinical decision making and management of complex residents.13 The schools of nursing identified the following enhancements to their school and faculty: increased student interest in clinical rotations in nursing homes and increased faculty administrative and clinical research.13 A survey of these schools and nursing homes 10 years later demonstrated some sustained impact particularly in the areas of sustaining gerontological nursing as part of the undergraduate curriculum and an increase in master’s and doctoral students in the teaching nursing home schools of nursing.13
CAPABLE
The Evercare model was founded in 1987 by two geriatric advanced practice nurses who had a vision for delivering better care to frail older adults in nursing.14 These geriatric advanced practice nurses contracted with Share Minnesota, a Medicare HMO, to become LTC provider teams with geriatricians in order to reduce costs of acute medical care for NH residents; improve coordination of care and improve quality of health care.14 The NP/geriatrician teams were assigned to one nursing home and incentivized to be available to families avoiding duplication of services, eliminating inappropriate services; developing cost effective specialty provider networks and avoiding facilities and providers of questionable quality.14 Now known as Optum CarePlus,15 the target population for this model is Medicare managed care patients in nursing homes, who often spend down their resources and become dually eligible for Medicaid. In this model nurse practitioners are placed in the nursing homes to provide preventive care, monitor changes in health, make early diagnoses and interventions, and engage in and coordinate communication including advanced care planning.15 Evercare became a federal demonstration project, evaluated by the University of Minnesota, with excellent results, including a 50% reduction in emergency room visits and a 40% reduction in hospitalizations without changes in mortality.16 With these findings, federal policy moved this program into permanent status, converting them to Special Needs Plans offered throughout the United States.
Like PACE, the CAPABLE Program (Community Aging in Place, Advancing Better Living for Elders)7 focuses on impoverished older adults and implementing person-centered interprofessional interventions to maintain older adults living safely in the community. The growing awareness that drivers of health fall largely outside the health care system and are found in places where people live, work and play8 has created a need to address social determinants of health in the communities where people live. This program brings together a registered nurse, occupational therapist and handyman team to address the health and functional care needs of older adults.9 It is designed to address the unmet needs and functional challenges not currently addressed by the health care system.7-8 CAPABLE provides a person-directed approach focusing on individual goals and this intervention has increased functional outcomes and decreased disability.7 CAPABLE includes $1300 worth of home repairs and modifications and up to 10 home visits by nurses (4 visits) and occupational therapists (6 visits) to enable self-care and activities most important to them.7,8 This program has been funded by the National Institutes of Health and the Centers for Medicare and Medicaid Services Innovations Center.9 This program is now being tested in 13 cities in eight states.10 In Michigan it is being implemented as a Medicaid waiver program to improve quality of life and delay nursing home admissions.8 Centers for Medicare and Medicaid Services are looking at making CAPABLE a benefit for dually eligible older adults. Sarah L Szanton, PhD, RN has also been recognized by the American Academy of Nursing as an Edge Runner for her work developing and diffusing this innovative interprofessional intervention.10 Long-term Care Models Teaching Nursing Home The Teaching Nursing Home Program was funded by the Robert Wood Johnson for five years from 1982 through 1987 to improve the quality of care provided in nursing homes.11,12 This program was a collaboration between 11 academic nursing programs and nursing homes to improve clinical care, educate nursing students, and foster research in long-term care settings. It was modeled after the ongoing medical school medical center partnerships.11 The approximately $7 million demonstration project’s purpose was to assess the feasibility of improving nursing home care by funding these school of nursing affiliations with nursing homes.7 The quality outcomes from the teaching nursing home program were superior to the comparison homes in hospitalizations, continence of bowel and bladder, functional parameters of dressing and transferring, and limitation of restraint use.11,12 This was due to the pooled resources of the schools and nursing homes, the presence of advanced practice nurses and faculty practice within the nursing homes.13
Evercare/Optum
INTERACT INTERACT (Interventions to Reduce Acute Care Transfers)17 is a comprehensive quality improvement program to decrease hospitalizations of older adults in nursing homes, improve communication among interprofessional team members and improve advanced care planning. There are three key elements to have a successful INTERACT program: executive support and buy into the program; engagement of direct care staff by INTERACT Champions; and a culture dedicated to quality improvement. Outcomes have demonstrated in highly engaged facilities a drop in rehospitalizations by over 20%.17 INTERACT tools can be found at http://interact.fau.edu. One of the widely used tools developed for the implementation of INTERACT, the STOP and WATCH Tool, helps families and certified nursing assistants communicate changes in a person’s condition to the licensed nurse. The licensed nurse can follow up the STOP and Watch with the SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note which is a guided patient investigation for the licensed nurse to complete prior to communicating with the primary care provider.17 The nurse, after completing the SBAR, can then communicate enough information to the provider to determine the need for hospitalization or treating the individual at the NH. Additional resources available through the INTERACT website include: Home to Hospital Transfer form, Hospital to Post-Acute Care Transfer form, Medication Reconciliation Worksheet, Change in
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Condition file cards, Care Paths, Communication Guide and a Comfort Care Interventions tool which includes palliative care order sets.17 From a quality improvement tracking standpoint, INTERACT has proprietary health information technology solutions for QI Dashboards which are commercially available.
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service.26,27 Studies evaluating the effectiveness of ACE units over the last twenty years have consistently shown that ACE units are associated with the provision of higher-value care for hospitalized older adults.25 ACE units are an ideal location to implement and diffuse innovations from the Nurses Improving Care for Healthsystem Elders nursing program.
Missouri Quality Initiative Nurses Improving Care for Healthsystem Elders Building on the success of the Quality Improvement Program for Missouri (QIPMO)18 and leveraging critical tools from the INTERACT model16 the Missouri Quality Initiative (MOQI)19 was spearheaded by Marilyn Rantz, PhD, RN, FAAN and other nursing leaders in Missouri. Federally funded by the Centers for Medicare and Medicaid Innovations Center (CMMI) and the Medicare-Medicaid Coordination Office,20 these two offices sponsored this initiative to reduce avoidable hospitalizations among nursing facility residents.19 This fouryear project provided advanced practice registered nurses (APRNs) for 16 nursing long term care facilities in Missouri.19 An interprofessional team including a project medical director, a social service care transitions coach, health information coordinator and a registered nurse skilled in the Quality Improvement Program for Missouri Nursing Homes (MOQI) supported the APRNs. The intervention included an APRN embedded full-time in each nursing home, a social worker transitions coach, the use of the INTERACT III processes with an INTERACT QI coach, improved health information exchange, an expert MOQI support team, and medical director committed to the goals of this study.20 Each intervention time-period was two years. The goals of the project were to reduce the frequency of avoidable hospitalizations and readmissions, improve resident health outcomes, improve transitions and reduce overall healthcare spending without restricting access to care.20 Within the first three years of the project, MOQI significantly reduced all cause hospitalizations by 40%, potentially avoidable hospitalizations by 58%, ED visits by 54%, and decreased Medicare expenditures for hospitalizations by 34% and ED visits by 50%.21 The MOQI intervention is associated with consistent and significant reductions in outcome measures, as reductions were larger in 2015 than in 2014.22 This interprofessional model of care dramatically improved the care LTC residents received. Dr. Rantz has also been recognized as an American Academy of Nursing Edge Runner for two prior initiatives.4 Acute care
Nurses Improving Care for Healthsystem Elders (NICHE) is a national evidence-based organizational change and practice development program28 inaugurated in 1992 and piloted from 1993 to 1995, that addresses the needs of older adults across the health system.29 The goal of NICHE implementation is to provide organizational tools to modify the nurse practice environment and institutional milieu to make it more geriatric-responsive.29 Once a health system is interested in becoming a NICHE site the system completes a Geriatric Institutional Assessment Profile (GIAP), a 68-item self-report survey on three key domains regarding care of older adults in their health system; perceived quality of geriatric practice, perceived knowledge about geriatric practice and the milieu for geriatric practice.30 Despite the significant increase in older adults receiving care across health systems, hospitalized older adults remains the main focus of NICHE. NICHE has three interrelated elements: (1) nursing care models supporting specialized geriatric care by nurses, nursing assistants and other frontline clinicians; (2) evidence based clinical practice protocols for nursing care and geriatric syndromes experienced by older adults in the hospital; and (3) models of staff development quality improvement and care coordination to promote effective geriatric nursing care across acute care nursing units.30 NICHE programs improve nurses’ clinical knowledge and changes their perceptions of the practice environment to value and support care appropriate for older adults.31 In a recent study to try to have a greater understanding of the uptake of NICHE by health systems, an observational retrospective design was used to link three data sources: the American Hospital Association Annual Survey, NICHE database and the American Nurses Credentialing Center Magnet database.30 System level influences on adoption of NICHE included: being part of a medical home, being in a network, having a pain services program, being in an urban environment and having greater than 100 beds.30 NICHE is considered one of the many evidence-based models of care that could incorporate the Hospital Elder Life Program or HELP.
Acute Care for the Elderly units
HELP
Acute Care for the Elderly (ACE) units were initially developed in 1990 at the University Hospitals of Cleveland.23 ACE units are designed to primarily prevent functional decline associated with the hospital environment and acute care treatment.24 ACE units use interprofessional team based care, where nurses play a critical role, to integrate the principles of comprehensive geriatric assessment and quality improvement.25 A systematic review of ACE units demonstrated that when implemented comprehensively, the ACE model benefits both patient and system level outcomes.26 ACE units had the following patient level outcomes: decreases in functional decline, iatrogenic events, nursing home discharges, and increased discharges home. The system level outcomes included reduced cost of care and length of stays, without greater readmissions.26 Included in decreasing functional decline, fall reduction is a focus of ACE units. The ACE unit is made up of four main elements: patient-centered care; a specially designed environment, review of medical care, and planning for discharge to help older adults maintain or achieve independence in activities of daily living.27 ACE units have been found to decrease the incidence of falls in hospitalized older adults anywhere from 49% to 73% compared to usual care units or the general medical
The Hospital Elder Life Program (HELP) was initially developed in 1993 as a multicomponent intervention to prevent functional and cognitive decline in older adults by Sharon K. Inouye, MD.32 The HELP model includes an Elder Life Specialist, and Elder Life Nurse Specialist, a geriatrician, patients, caregivers and trained volunteers to coordinate a patient-centered program.32 In 2011 HELP transitioned to a web-based dissemination model to provide accessible resources including implementation materials, training materials for clinicians, information for patients and families, and a searchable database.33 Found at www.hospitalelderlifeprogram.org, this website provides information and guidance for implementation and sustaining a successful Hospital Elder Life Program through online materials, online networking, national conferences, interest groups, newsletters and webinars.33 The value and impact of a proactive, team-based approach designed to optimize care among hospitalized older adults has been demonstrated through multiple studies on HELP.34 HELP has developed core evidence-based intervention protocols which include daily visits, orientation, therapeutic activities, sleep enhancement, early mobilization, vision and hearing adaptation, fluid repletion and feeding assistance.32 To ensure adherence to the National
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Institute for Health Care Excellence guidelines, HELP adapted protocols to include prevention of infection, as well as management of constipation, pain and hypoxia.32 Geriatric nursing interventions are implemented by the Elder Life Nurse Specialist. These evidence-based protocols include delirium, dementia, psychoactive medications, discharge planning, optimizing length of stay, nutrition, function, skin care, incontinence, and social issues. This multicomponent intervention has demonstrated significant decreases in delirium episodes, falls, as well as dramatic cost savings32 to the hospital. With the easily accessible website-based support and training, the HELP model is a strong evidence-based intervention to support Age Friendly Health Systems. Age friendly health systems The John A. Hartford Foundation has joined forces with Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States.35 In 2017, 5 major United States health systems signed on as pioneers to help create a social movement: Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health and Trinity Health.36 Creating Age-Friendly Health Systems (AFHS) Initiative, has a goal to reach 20% of the US hospitals and health systems by 2020.37 An Age-Friendly Health System aims to provide older adults with the best possible care, reduce iatrogenic events to older adults, and optimize value for all: patients, families, caregivers, health care providers and health systems.35 By identifying both the latest evidence in age-friendly care as well as the barriers to providing age friendly care, this initiative identified four high level interventions to guide age friendly health systems, the 4 M Model. The 4 M Model includes four essential, interrelated elements that guide health care interactions with older adults: What Matters, Medications, Mobility and Mentation.36 In AFHS, patients’ goals and preferences are valued, family caregivers are supported and engaged in the treatment plan, and improved and safe patient transitions are ensured.38 Over 75 health systems nationwide have joined the movement to deliver care that addresses the 4 Ms while increasing satisfaction and cost effectiveness.36 In 2018, the first virtual learning community, Age-Friendly Health Systems Action Community, was formed; welcoming 125 teams from more than 75 health systems and the second Action Community launched in April 2019.38 The resources to support embarking on becoming an AFHS are housed on IHI’s website (www.ihi.org/Engage/Initia tives/Age-Friendly-Health-Systems/Pages/default.aspx). New resources are being added all the time as health systems develop and refine evidence-based interventions to support the 4 Ms. There is even a report on The Business Case for Becoming an Age-Friendly Health System (www. ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/documents/IHI_ Business_Case_for_Becoming_an_Age_Friendly_Health_System.pdf) which can be used to garner administrative support for this initiative. The 4 Ms Framework is considered a shift in how we care for older adults. The 4Ms are implemented together as a set of evidence-based interrelated high-quality care practices interprofessional teams can implement to improve care for older adults.35 This interprofessional and system effort aims to change the way we care for and engage older adults and their families across the care continuum. Across Health Settings Transitional Care Model Mary Naylor, PhD, RN, FAAN and a team of interprofessional researchers at the University of Pennsylvania have been refining the Transitional Care Model (TCM) since 1994 through NIH funded research and foundation funding (https://www.nursing.upenn.edu/ ncth/transitional-care-model/).39-44 A master’s prepared advanced practice nurse, following an average of 100 h of orientation on the TCM and evidence-based protocols, uses the Transitional Care Model
to identify patient’s health goals, design and implement a plan of care and provide support for continuity of care across settings and between providers.43,45 The advanced practice nurses lead teambased care to provide continuity of care for fragile, high-risk patients with multiple co-morbidities, who are transitioning across health care settings and providers.44 A well-developed TCM intervention using all 10 components of the evidence-based protocol in order to help facilitate safe transitions has demonstrated reduced readmissions, improved health outcomes, increased patient satisfaction, decreased resource use and decreased cost.42,44 The components include: (1) delivering services from hospital to home; (2) screening at risk older adults; (3) relying on advanced practice nurses; (4) promoting continuity of care; (5) coordinating care; (6) collaborating with patients, their caregivers, and the healthcare team; (7) maintaining relationships with patients and caregivers; (8) engaging patients and caregivers; (9) managing symptoms and other risks; and (10) educating and promoting self-management.44 Initially developed to improve the home to hospital transitions, the TCM is now being implemented across health care settings and has been tested as an added benefit to Patient Center Medical Homes.43 Dr. Naylor has also been recognized as an Edge Runner by the American Academy of Nursing.4 Discussion Nursing and interprofessional innovations have been a mainstay in caring for older adults. Older adults require a team approach across settings to address their health care needs. Many, but not all older adults, are challenged in day to day self-care of an accumulation of multiple chronic conditions. Each of these models of care translates evidence into practice by providing education and training to nurses and advanced practice nurses to better care for older adults. Nurses and advanced practice registered nurses are successful leaders of interprofessional teams and have consistently demonstrated their evidence-based solutions to improve care and reduce costs.13 Nurses and APRNs developing and translating evidence into practice is also a distinct feature of these models of care. This is seen most prominently in the Teaching Nursing Home Project, Evercare/Optum, NICHE, Transitional Care Model, MOQI and CAPABLE all nurse led interventions. However, the interprofessional models: INTERACT, ACE, HELP and AFHS fully embrace the nurses’ role in improving care of older adults as well as provide evidence based interventions for use by nurses. Nurses engaged and practicing to the top of their license and full scope of practice is necessary for these models to continue to improve the lives of older adults. Many of these models’ developers and leaders have been recognized as Edge Runners by the American Academy of Nursing. The Edge Runner Initiative was designed to recognize nurse designed models of care and interventions that decrease cost, improve quality and improve consumer satisfaction (https://www.aannet.org/initiatives/ edge-runners).45 In addition, to the Edge Runners highlighted above, there are an additional four Edge Runners Nurses recognized for improving the care of older adults: Kathryn Bowles, PhD, RN, FAAN, FAMCI4 for RightCare Solutions, a Discharge Decision Support Tool (D2S2) that focuses on factors that influence patients’ selfcare ability upon discharge; Diane McGee, MSN, RN4 for Senior ASSIST (Assisting Seniors to Stay Independent through Services and Teaching) a program where geriatric trained registered nurses provide in home comprehensive assessments and follow-up care with their providers and connecting older adults with community resources; Claudia Beverly, PhD, RN, FAAN4 for spearheading the Arkansas Aging Initiative (AAI), a network of eight regional centers across the state that provide interprofessional care to older adults, innovative education programs, and influences health policy to reduce health disparities in an underserved population. And, finally, Graham McDougall, PhD, RN, FAAN4 for SeniorWISE
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(Wisdom Is Simply Exploration) that engages nurses with participants to facilitate learning to cope with anxiety linked to memory lapses using evidence-based interventions. SeniorWISE has been implemented in at least three states. To meet the needs of the growing older adult population, nurses and advanced practice nurses will need to leverage these innovative nursing and interprofessional models to provide the best evidencebased care available to the nation’s older adults. Nursing innovation and interprofessional collaboration is evident within all the practice trends reviewed. Nurses using a systems-thinking approach and solving nursing and health care challenges through rigorous evaluation have consistently addressed person centered goals, health system goals and helped nurses thrive in practice. These innovative nursing and interprofessional interventions have demonstrated improved patient outcomes, decreased costs and improved quality and safety. Thus, sustained effort to further expand the reach of these models of care to older adults and their families across the country is imperative. References 1. United States Census Bureau. Older people projected to outnumber children for the first time in U.S. History. 2018. www.census.gov/newsroom/press-release/2018/ cb18-41-popuulation-projections.html. Accessed on June 30, 2019. 2. Li GK, Phillips C, Weber K. On Lok: a successful approach to aging at home. Healthc Pap. 2009;10(1):44–48. 3. National PACE Association. Understanding PACE. 2019a. https://www.npaonline. org/sites/default/files/Profile%20of%20PACE_December%202016.pdf. Accessed on June 20, 2019. 4. American academy of nursing. Edge Runners Profiles 2015. https://www.aannet. org/initiatives/edge-runners/profiles. Accessed on August 4, 2019. 5. National PACE Association. PACE by the numbers. 2019b. https://www.npaonline. org/sites/default/files/PACE%20Infographic%20Feb%202018.pdf. Accessed on June 20, 2019. 6. U.S. Department of Health and Human Services. Report to congress: the centers for medicare & medicaid services evaluation of for-profit pace programs under section 4804(b) of the balanced budget act of 1997. 2015. https://innovation.cms.gov/Files/ reports/RTC_For-Profit_PACE_Report_to_Congress_051915_Clean.pdf. Accessed on August 4, 2019. 7. Szanton SL, Roth J, Nkimbeng M, Savage JDR, Klimmek R. Improving unsafe environments to support aging independence with limited resources. Nurs Clin North Am. 2014;49(2):133–145. 8. Szanton SL, Leff B, Wolff JL, Roberts L, Gitlin LN. Home-based care program reduces disability and promotes aging in place. Health Aff. 2016;35(9):1558–1563. 9. Szanton SL, Wolff JL, Leff B, et al. Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J Am Geriatr Soc. 2015;63:371–374. 10. American academy of nursing edge runners community aging in place: advancing better living for elders (CAPABLE) accessed on august 4, 2019. https://www.aan net.org/initiatives/edge-runners/profiles/edge-runners—community-aging-place. 11. Mezey M, Lynaugh J. Teaching nursing home program: a lesson in quality. Geriatr Nurs (Minneap). 1991;12:76–77. March-April. 12. Shaughnessey PW, Kramer AM, Hittle DF, & Steiner JF. Quality of care in teaching nursing homes: findings and implications. Health care fin rev summer. 1995; 55+ U. S. department of health and human services. http://www.cms.hhs.gov/HealthCare FinancingReview. Accessed on June 30, 2019. 13. Mezey MD, Mitty EL, Bottrell M. The teaching nursing home program: enduring educational outcomes. Nurs Outlook. 1997;45:133–140. 14. Polich CL, Bayard J, Jacobson R, Parker M. A nurse-run business to improve health care for nursing home residents. Nurs Econ. 1990;8(2):96–101. 15. Lipton C.UnitedHealthcare nursing home plan evercare clinical model telemedicine initiatives. 2012. https://www.slideshare.net/gatelehealth/cathy-lipton31512. Accessed on June 30, 2019. 16. Kane RL, Flood S, Bershadsky B, Keckhafer G. The effect of an innovative medicare managed care program on the quality of care for nursing home residents. Gerontologist. 2004;44(1):95–103. 17. Ouslander JG, Bonner A, Herndon L, Shutes J. The interact quality improvement program: an overview for medical directors and primary care clinicians in longterm care. J Am Med Dir Assoc. 2014;15(3):162–170.
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Hospital elder life program: systemic review and meta-analysis of effectiveness. Am J Geriatr Psychiatry. 2018;26 (10):1015–1033. 33. Chen P, Dowal S, Schmitt E, et al. Hospital elder life program in the real world: the many uses of the hospital elder life program website. J Am Geriatr Soc. 2015;63:797–803. 34. Scheunemann LP, Girard TD, Skidmore ER, Resnick NM. The hospital elder life program: past and future. Am J Geriatr Psychiatry. 2018;26(10):1034–1035. 35. Institute of Healthcare Improvement. Age-Friendly health systems: guide to using the 4Ms in the care of older adults. 2019; www.ihi.org/Engage/Initiatives/Age-FriendlyHealth-systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf. Accessed on June 30, 2019. 36. Fulmer T. Age-Friendly health systems transform care for older adults. Mod Healthc. 2019. www.johnahartford.org/images/uploads/resources/MonderHealthcareExecutiveInsight_TF_2.11.19.pdf. Accessed on July 2. 37. Mate KS, Berman A, Laderman M, Kabcenell A, Fulmer T. Creating age-friendly health systems A vision for better care of older adults. Healthcare. 2018;6:4–6. 38. Fulmer T, Li N. Age-friendly health systems for older adults with dementia. JNP. 2018;14(3):160–165. 39. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann of Intl Med. 1994;120:999–1006. 40. Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–620. 41. Naylor M, Brooten D, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized controlled trial. J Am Geriatri Soc. 2004;52:675–684. 42. Naylor MD, Hirschman KB, Hanlon AL, et al. Comparison of evidence-based interventions on outcomes of hospitalized cognitively impaired older adults. J Comp Eff Res. 2014;3:245–257. 43. Hirshman KB, Shaid E, Bixby MB, et al. Transition care in the patient-centered medical home: lessons in adaptation. J Healthcare Qual. 2017;39(2):67–77. 44. Naylor MD, Hirschman KB, Toles MP, Jarrín OF, Shaid E, Pauly MV. Adaptions of evidence-based transitional care model in the U.S.. Soc Sci Med. 2018;213:28–36. 45. McCauley K, Bradway C, Hirschman KB, Naylor MD. Studying nursing interventions in acutely ill, cognitively impaired older adults. AJN. 2014;114(10):44–52.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Innovative care models across settings: Providing nursing care to older adults Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAAN University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
A R T I C L E
I N F O
Article history: Available online xxx Keywords: Evercare/Optum INTERACT NICHE PACE Transitional Care Model
A B S T R A C T
The aging demographic shift occurring world-wide is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided. These models across settings emphasize maximizing the role of nurses and advanced practice nurses. The models reviewed include: On LOK and Programs of All-inclusive Care for the Elderly (PACE); Community Aging in Place, Advancing Better Living for Elders (CAPABLE); Teaching Nursing Homes; Interventions to Reduce Acute Care Transfers (INTERACT); Missouri Quality Initiative (MOQI); Evercare/Optum; Nurses Improving Care for Health System Elders (NICHE); Acute Care for the Elderly Unit (ACE Unit); Hospital Elder Life Program (HELP); Age-Friendly Health Systems; and the Transitional Care Model. Each model emphasizes education on the special needs of older adults, providing easy access to evidence-based tools and interventions, as well as strong interprofessional collaboration. Sustainable evidence-based nursing and interprofessional innovations are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults. © 2020 Published by Elsevier Inc.
Introduction
Community based long-term care models
There has never been such an unprecedented time like the present. We are facing a tremendous challenge of meeting the needs of a growing population of older adults. Population growth of older adults is outpacing younger adults. It is expected that by 2035 there will be 78 million people 65 years and older compared to 76.6 million under the age of 18.1 The demographic shift caused by the dramatically increasing aging population is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing models as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided with lessons learned to provide insights into what it takes to create a sustainable care model. Nursing and interprofessional innovative models of care are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults.
On Lok: Programs of All-Inclusive Care of the Elderly
E-mail address: [email protected] https://doi.org/10.1016/j.gerinurse.2020.01.011 0197-4572/$ see front matter © 2020 Published by Elsevier Inc.
The Program for All-Inclusive Care of the Elderly (PACE), a capitated managed care program, was started by On Lok Senior Health Services in 1971 based on the British day hospital model2 by Dr. William Gee, a dentist, and Marie-Louise Ansak, a social worker. This San Francisco Asian community responded to the pressing long term care support and services (LTSS) needs of their older adults. On Lok Senior Health Services was created to provide an interprofessional community-based system of LTSS.3 On Lok was initially funded through donations and grant funding to provide comprehensive culturally appropriate care to older adults in the Chinatown-North Beach community of San Francisco. In 1983 On Lok received initial Medicare and Medicaid waivers for capitated reimbursement.2 Today, PACE has integrated health, behavioral health, rehabilitation, and social services for frail, older adults to support them safely in the community. Nurses are an integral part of this model of care for persons in need of chronic disease management. In fact, American Academy of Nursing Edge Runner Jennie Chinn Hansen was instrumental in the success of On Lok.4 The University of Pennsylvania's School of Nursing had a nurse-run PACE program for dual-eligible older adults of West Philadelphia known as the Living Independently for Elders
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(LIFE) UPenn. LIFE UPenn received a Medicare waiver which supported advanced practice nurses serving as the primary care providers in collaboration with the Medical Director. Dr. Eileen Sullivan-Marx was recognized as an Edge Runner for her leadership of LIFE UPenn.4 LIFE UPenn was sold to Trinity Health PACE and has expanded the number of their participants to over 500. There are now 123 PACE sponsoring organizations with 250 centers in 31 states. Most of these centers have fewer than 500 older adults in each capitated program.5 As of 2018, 90% of all PACE enrollees were dual eligible. Initially started as not-forprofit organizations, this restriction was removed in 2015 allowing for profit organizations to enter the market.6 Currently 8% of PACE organizations are for-profit.5 Evaluations have shown that PACE successfully integrates acute and long-term care and reduces hospitalizations thereby decreasing costs.5
In addition, this 5-year RWJ demonstration project had significant impact on the nursing homes and the school of nursing faculty.13 The nursing home benefited by improved quality of care, improved clinical decision making and management of complex residents.13 The schools of nursing identified the following enhancements to their school and faculty: increased student interest in clinical rotations in nursing homes and increased faculty administrative and clinical research.13 A survey of these schools and nursing homes 10 years later demonstrated some sustained impact particularly in the areas of sustaining gerontological nursing as part of the undergraduate curriculum and an increase in master’s and doctoral students in the teaching nursing home schools of nursing.13
CAPABLE
The Evercare model was founded in 1987 by two geriatric advanced practice nurses who had a vision for delivering better care to frail older adults in nursing.14 These geriatric advanced practice nurses contracted with Share Minnesota, a Medicare HMO, to become LTC provider teams with geriatricians in order to reduce costs of acute medical care for NH residents; improve coordination of care and improve quality of health care.14 The NP/geriatrician teams were assigned to one nursing home and incentivized to be available to families avoiding duplication of services, eliminating inappropriate services; developing cost effective specialty provider networks and avoiding facilities and providers of questionable quality.14 Now known as Optum CarePlus,15 the target population for this model is Medicare managed care patients in nursing homes, who often spend down their resources and become dually eligible for Medicaid. In this model nurse practitioners are placed in the nursing homes to provide preventive care, monitor changes in health, make early diagnoses and interventions, and engage in and coordinate communication including advanced care planning.15 Evercare became a federal demonstration project, evaluated by the University of Minnesota, with excellent results, including a 50% reduction in emergency room visits and a 40% reduction in hospitalizations without changes in mortality.16 With these findings, federal policy moved this program into permanent status, converting them to Special Needs Plans offered throughout the United States.
Like PACE, the CAPABLE Program (Community Aging in Place, Advancing Better Living for Elders)7 focuses on impoverished older adults and implementing person-centered interprofessional interventions to maintain older adults living safely in the community. The growing awareness that drivers of health fall largely outside the health care system and are found in places where people live, work and play8 has created a need to address social determinants of health in the communities where people live. This program brings together a registered nurse, occupational therapist and handyman team to address the health and functional care needs of older adults.9 It is designed to address the unmet needs and functional challenges not currently addressed by the health care system.7-8 CAPABLE provides a person-directed approach focusing on individual goals and this intervention has increased functional outcomes and decreased disability.7 CAPABLE includes $1300 worth of home repairs and modifications and up to 10 home visits by nurses (4 visits) and occupational therapists (6 visits) to enable self-care and activities most important to them.7,8 This program has been funded by the National Institutes of Health and the Centers for Medicare and Medicaid Services Innovations Center.9 This program is now being tested in 13 cities in eight states.10 In Michigan it is being implemented as a Medicaid waiver program to improve quality of life and delay nursing home admissions.8 Centers for Medicare and Medicaid Services are looking at making CAPABLE a benefit for dually eligible older adults. Sarah L Szanton, PhD, RN has also been recognized by the American Academy of Nursing as an Edge Runner for her work developing and diffusing this innovative interprofessional intervention.10 Long-term Care Models Teaching Nursing Home The Teaching Nursing Home Program was funded by the Robert Wood Johnson for five years from 1982 through 1987 to improve the quality of care provided in nursing homes.11,12 This program was a collaboration between 11 academic nursing programs and nursing homes to improve clinical care, educate nursing students, and foster research in long-term care settings. It was modeled after the ongoing medical school medical center partnerships.11 The approximately $7 million demonstration project’s purpose was to assess the feasibility of improving nursing home care by funding these school of nursing affiliations with nursing homes.7 The quality outcomes from the teaching nursing home program were superior to the comparison homes in hospitalizations, continence of bowel and bladder, functional parameters of dressing and transferring, and limitation of restraint use.11,12 This was due to the pooled resources of the schools and nursing homes, the presence of advanced practice nurses and faculty practice within the nursing homes.13
Evercare/Optum
INTERACT INTERACT (Interventions to Reduce Acute Care Transfers)17 is a comprehensive quality improvement program to decrease hospitalizations of older adults in nursing homes, improve communication among interprofessional team members and improve advanced care planning. There are three key elements to have a successful INTERACT program: executive support and buy into the program; engagement of direct care staff by INTERACT Champions; and a culture dedicated to quality improvement. Outcomes have demonstrated in highly engaged facilities a drop in rehospitalizations by over 20%.17 INTERACT tools can be found at http://interact.fau.edu. One of the widely used tools developed for the implementation of INTERACT, the STOP and WATCH Tool, helps families and certified nursing assistants communicate changes in a person’s condition to the licensed nurse. The licensed nurse can follow up the STOP and Watch with the SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note which is a guided patient investigation for the licensed nurse to complete prior to communicating with the primary care provider.17 The nurse, after completing the SBAR, can then communicate enough information to the provider to determine the need for hospitalization or treating the individual at the NH. Additional resources available through the INTERACT website include: Home to Hospital Transfer form, Hospital to Post-Acute Care Transfer form, Medication Reconciliation Worksheet, Change in
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Condition file cards, Care Paths, Communication Guide and a Comfort Care Interventions tool which includes palliative care order sets.17 From a quality improvement tracking standpoint, INTERACT has proprietary health information technology solutions for QI Dashboards which are commercially available.
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service.26,27 Studies evaluating the effectiveness of ACE units over the last twenty years have consistently shown that ACE units are associated with the provision of higher-value care for hospitalized older adults.25 ACE units are an ideal location to implement and diffuse innovations from the Nurses Improving Care for Healthsystem Elders nursing program.
Missouri Quality Initiative Nurses Improving Care for Healthsystem Elders Building on the success of the Quality Improvement Program for Missouri (QIPMO)18 and leveraging critical tools from the INTERACT model16 the Missouri Quality Initiative (MOQI)19 was spearheaded by Marilyn Rantz, PhD, RN, FAAN and other nursing leaders in Missouri. Federally funded by the Centers for Medicare and Medicaid Innovations Center (CMMI) and the Medicare-Medicaid Coordination Office,20 these two offices sponsored this initiative to reduce avoidable hospitalizations among nursing facility residents.19 This fouryear project provided advanced practice registered nurses (APRNs) for 16 nursing long term care facilities in Missouri.19 An interprofessional team including a project medical director, a social service care transitions coach, health information coordinator and a registered nurse skilled in the Quality Improvement Program for Missouri Nursing Homes (MOQI) supported the APRNs. The intervention included an APRN embedded full-time in each nursing home, a social worker transitions coach, the use of the INTERACT III processes with an INTERACT QI coach, improved health information exchange, an expert MOQI support team, and medical director committed to the goals of this study.20 Each intervention time-period was two years. The goals of the project were to reduce the frequency of avoidable hospitalizations and readmissions, improve resident health outcomes, improve transitions and reduce overall healthcare spending without restricting access to care.20 Within the first three years of the project, MOQI significantly reduced all cause hospitalizations by 40%, potentially avoidable hospitalizations by 58%, ED visits by 54%, and decreased Medicare expenditures for hospitalizations by 34% and ED visits by 50%.21 The MOQI intervention is associated with consistent and significant reductions in outcome measures, as reductions were larger in 2015 than in 2014.22 This interprofessional model of care dramatically improved the care LTC residents received. Dr. Rantz has also been recognized as an American Academy of Nursing Edge Runner for two prior initiatives.4 Acute care
Nurses Improving Care for Healthsystem Elders (NICHE) is a national evidence-based organizational change and practice development program28 inaugurated in 1992 and piloted from 1993 to 1995, that addresses the needs of older adults across the health system.29 The goal of NICHE implementation is to provide organizational tools to modify the nurse practice environment and institutional milieu to make it more geriatric-responsive.29 Once a health system is interested in becoming a NICHE site the system completes a Geriatric Institutional Assessment Profile (GIAP), a 68-item self-report survey on three key domains regarding care of older adults in their health system; perceived quality of geriatric practice, perceived knowledge about geriatric practice and the milieu for geriatric practice.30 Despite the significant increase in older adults receiving care across health systems, hospitalized older adults remains the main focus of NICHE. NICHE has three interrelated elements: (1) nursing care models supporting specialized geriatric care by nurses, nursing assistants and other frontline clinicians; (2) evidence based clinical practice protocols for nursing care and geriatric syndromes experienced by older adults in the hospital; and (3) models of staff development quality improvement and care coordination to promote effective geriatric nursing care across acute care nursing units.30 NICHE programs improve nurses’ clinical knowledge and changes their perceptions of the practice environment to value and support care appropriate for older adults.31 In a recent study to try to have a greater understanding of the uptake of NICHE by health systems, an observational retrospective design was used to link three data sources: the American Hospital Association Annual Survey, NICHE database and the American Nurses Credentialing Center Magnet database.30 System level influences on adoption of NICHE included: being part of a medical home, being in a network, having a pain services program, being in an urban environment and having greater than 100 beds.30 NICHE is considered one of the many evidence-based models of care that could incorporate the Hospital Elder Life Program or HELP.
Acute Care for the Elderly units
HELP
Acute Care for the Elderly (ACE) units were initially developed in 1990 at the University Hospitals of Cleveland.23 ACE units are designed to primarily prevent functional decline associated with the hospital environment and acute care treatment.24 ACE units use interprofessional team based care, where nurses play a critical role, to integrate the principles of comprehensive geriatric assessment and quality improvement.25 A systematic review of ACE units demonstrated that when implemented comprehensively, the ACE model benefits both patient and system level outcomes.26 ACE units had the following patient level outcomes: decreases in functional decline, iatrogenic events, nursing home discharges, and increased discharges home. The system level outcomes included reduced cost of care and length of stays, without greater readmissions.26 Included in decreasing functional decline, fall reduction is a focus of ACE units. The ACE unit is made up of four main elements: patient-centered care; a specially designed environment, review of medical care, and planning for discharge to help older adults maintain or achieve independence in activities of daily living.27 ACE units have been found to decrease the incidence of falls in hospitalized older adults anywhere from 49% to 73% compared to usual care units or the general medical
The Hospital Elder Life Program (HELP) was initially developed in 1993 as a multicomponent intervention to prevent functional and cognitive decline in older adults by Sharon K. Inouye, MD.32 The HELP model includes an Elder Life Specialist, and Elder Life Nurse Specialist, a geriatrician, patients, caregivers and trained volunteers to coordinate a patient-centered program.32 In 2011 HELP transitioned to a web-based dissemination model to provide accessible resources including implementation materials, training materials for clinicians, information for patients and families, and a searchable database.33 Found at www.hospitalelderlifeprogram.org, this website provides information and guidance for implementation and sustaining a successful Hospital Elder Life Program through online materials, online networking, national conferences, interest groups, newsletters and webinars.33 The value and impact of a proactive, team-based approach designed to optimize care among hospitalized older adults has been demonstrated through multiple studies on HELP.34 HELP has developed core evidence-based intervention protocols which include daily visits, orientation, therapeutic activities, sleep enhancement, early mobilization, vision and hearing adaptation, fluid repletion and feeding assistance.32 To ensure adherence to the National
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Institute for Health Care Excellence guidelines, HELP adapted protocols to include prevention of infection, as well as management of constipation, pain and hypoxia.32 Geriatric nursing interventions are implemented by the Elder Life Nurse Specialist. These evidence-based protocols include delirium, dementia, psychoactive medications, discharge planning, optimizing length of stay, nutrition, function, skin care, incontinence, and social issues. This multicomponent intervention has demonstrated significant decreases in delirium episodes, falls, as well as dramatic cost savings32 to the hospital. With the easily accessible website-based support and training, the HELP model is a strong evidence-based intervention to support Age Friendly Health Systems. Age friendly health systems The John A. Hartford Foundation has joined forces with Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States.35 In 2017, 5 major United States health systems signed on as pioneers to help create a social movement: Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health and Trinity Health.36 Creating Age-Friendly Health Systems (AFHS) Initiative, has a goal to reach 20% of the US hospitals and health systems by 2020.37 An Age-Friendly Health System aims to provide older adults with the best possible care, reduce iatrogenic events to older adults, and optimize value for all: patients, families, caregivers, health care providers and health systems.35 By identifying both the latest evidence in age-friendly care as well as the barriers to providing age friendly care, this initiative identified four high level interventions to guide age friendly health systems, the 4 M Model. The 4 M Model includes four essential, interrelated elements that guide health care interactions with older adults: What Matters, Medications, Mobility and Mentation.36 In AFHS, patients’ goals and preferences are valued, family caregivers are supported and engaged in the treatment plan, and improved and safe patient transitions are ensured.38 Over 75 health systems nationwide have joined the movement to deliver care that addresses the 4 Ms while increasing satisfaction and cost effectiveness.36 In 2018, the first virtual learning community, Age-Friendly Health Systems Action Community, was formed; welcoming 125 teams from more than 75 health systems and the second Action Community launched in April 2019.38 The resources to support embarking on becoming an AFHS are housed on IHI’s website (www.ihi.org/Engage/Initia tives/Age-Friendly-Health-Systems/Pages/default.aspx). New resources are being added all the time as health systems develop and refine evidence-based interventions to support the 4 Ms. There is even a report on The Business Case for Becoming an Age-Friendly Health System (www. ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/documents/IHI_ Business_Case_for_Becoming_an_Age_Friendly_Health_System.pdf) which can be used to garner administrative support for this initiative. The 4 Ms Framework is considered a shift in how we care for older adults. The 4Ms are implemented together as a set of evidence-based interrelated high-quality care practices interprofessional teams can implement to improve care for older adults.35 This interprofessional and system effort aims to change the way we care for and engage older adults and their families across the care continuum. Across Health Settings Transitional Care Model Mary Naylor, PhD, RN, FAAN and a team of interprofessional researchers at the University of Pennsylvania have been refining the Transitional Care Model (TCM) since 1994 through NIH funded research and foundation funding (https://www.nursing.upenn.edu/ ncth/transitional-care-model/).39-44 A master’s prepared advanced practice nurse, following an average of 100 h of orientation on the TCM and evidence-based protocols, uses the Transitional Care Model
to identify patient’s health goals, design and implement a plan of care and provide support for continuity of care across settings and between providers.43,45 The advanced practice nurses lead teambased care to provide continuity of care for fragile, high-risk patients with multiple co-morbidities, who are transitioning across health care settings and providers.44 A well-developed TCM intervention using all 10 components of the evidence-based protocol in order to help facilitate safe transitions has demonstrated reduced readmissions, improved health outcomes, increased patient satisfaction, decreased resource use and decreased cost.42,44 The components include: (1) delivering services from hospital to home; (2) screening at risk older adults; (3) relying on advanced practice nurses; (4) promoting continuity of care; (5) coordinating care; (6) collaborating with patients, their caregivers, and the healthcare team; (7) maintaining relationships with patients and caregivers; (8) engaging patients and caregivers; (9) managing symptoms and other risks; and (10) educating and promoting self-management.44 Initially developed to improve the home to hospital transitions, the TCM is now being implemented across health care settings and has been tested as an added benefit to Patient Center Medical Homes.43 Dr. Naylor has also been recognized as an Edge Runner by the American Academy of Nursing.4 Discussion Nursing and interprofessional innovations have been a mainstay in caring for older adults. Older adults require a team approach across settings to address their health care needs. Many, but not all older adults, are challenged in day to day self-care of an accumulation of multiple chronic conditions. Each of these models of care translates evidence into practice by providing education and training to nurses and advanced practice nurses to better care for older adults. Nurses and advanced practice registered nurses are successful leaders of interprofessional teams and have consistently demonstrated their evidence-based solutions to improve care and reduce costs.13 Nurses and APRNs developing and translating evidence into practice is also a distinct feature of these models of care. This is seen most prominently in the Teaching Nursing Home Project, Evercare/Optum, NICHE, Transitional Care Model, MOQI and CAPABLE all nurse led interventions. However, the interprofessional models: INTERACT, ACE, HELP and AFHS fully embrace the nurses’ role in improving care of older adults as well as provide evidence based interventions for use by nurses. Nurses engaged and practicing to the top of their license and full scope of practice is necessary for these models to continue to improve the lives of older adults. Many of these models’ developers and leaders have been recognized as Edge Runners by the American Academy of Nursing. The Edge Runner Initiative was designed to recognize nurse designed models of care and interventions that decrease cost, improve quality and improve consumer satisfaction (https://www.aannet.org/initiatives/ edge-runners).45 In addition, to the Edge Runners highlighted above, there are an additional four Edge Runners Nurses recognized for improving the care of older adults: Kathryn Bowles, PhD, RN, FAAN, FAMCI4 for RightCare Solutions, a Discharge Decision Support Tool (D2S2) that focuses on factors that influence patients’ selfcare ability upon discharge; Diane McGee, MSN, RN4 for Senior ASSIST (Assisting Seniors to Stay Independent through Services and Teaching) a program where geriatric trained registered nurses provide in home comprehensive assessments and follow-up care with their providers and connecting older adults with community resources; Claudia Beverly, PhD, RN, FAAN4 for spearheading the Arkansas Aging Initiative (AAI), a network of eight regional centers across the state that provide interprofessional care to older adults, innovative education programs, and influences health policy to reduce health disparities in an underserved population. And, finally, Graham McDougall, PhD, RN, FAAN4 for SeniorWISE
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(Wisdom Is Simply Exploration) that engages nurses with participants to facilitate learning to cope with anxiety linked to memory lapses using evidence-based interventions. SeniorWISE has been implemented in at least three states. To meet the needs of the growing older adult population, nurses and advanced practice nurses will need to leverage these innovative nursing and interprofessional models to provide the best evidencebased care available to the nation’s older adults. Nursing innovation and interprofessional collaboration is evident within all the practice trends reviewed. Nurses using a systems-thinking approach and solving nursing and health care challenges through rigorous evaluation have consistently addressed person centered goals, health system goals and helped nurses thrive in practice. These innovative nursing and interprofessional interventions have demonstrated improved patient outcomes, decreased costs and improved quality and safety. Thus, sustained effort to further expand the reach of these models of care to older adults and their families across the country is imperative. References 1. United States Census Bureau. Older people projected to outnumber children for the first time in U.S. History. 2018. www.census.gov/newsroom/press-release/2018/ cb18-41-popuulation-projections.html. Accessed on June 30, 2019. 2. Li GK, Phillips C, Weber K. On Lok: a successful approach to aging at home. Healthc Pap. 2009;10(1):44–48. 3. National PACE Association. Understanding PACE. 2019a. https://www.npaonline. org/sites/default/files/Profile%20of%20PACE_December%202016.pdf. Accessed on June 20, 2019. 4. American academy of nursing. Edge Runners Profiles 2015. https://www.aannet. org/initiatives/edge-runners/profiles. Accessed on August 4, 2019. 5. National PACE Association. PACE by the numbers. 2019b. https://www.npaonline. org/sites/default/files/PACE%20Infographic%20Feb%202018.pdf. Accessed on June 20, 2019. 6. U.S. Department of Health and Human Services. Report to congress: the centers for medicare & medicaid services evaluation of for-profit pace programs under section 4804(b) of the balanced budget act of 1997. 2015. https://innovation.cms.gov/Files/ reports/RTC_For-Profit_PACE_Report_to_Congress_051915_Clean.pdf. Accessed on August 4, 2019. 7. Szanton SL, Roth J, Nkimbeng M, Savage JDR, Klimmek R. Improving unsafe environments to support aging independence with limited resources. Nurs Clin North Am. 2014;49(2):133–145. 8. Szanton SL, Leff B, Wolff JL, Roberts L, Gitlin LN. Home-based care program reduces disability and promotes aging in place. Health Aff. 2016;35(9):1558–1563. 9. Szanton SL, Wolff JL, Leff B, et al. Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J Am Geriatr Soc. 2015;63:371–374. 10. American academy of nursing edge runners community aging in place: advancing better living for elders (CAPABLE) accessed on august 4, 2019. https://www.aan net.org/initiatives/edge-runners/profiles/edge-runners—community-aging-place. 11. Mezey M, Lynaugh J. Teaching nursing home program: a lesson in quality. Geriatr Nurs (Minneap). 1991;12:76–77. March-April. 12. Shaughnessey PW, Kramer AM, Hittle DF, & Steiner JF. Quality of care in teaching nursing homes: findings and implications. Health care fin rev summer. 1995; 55+ U. S. department of health and human services. http://www.cms.hhs.gov/HealthCare FinancingReview. Accessed on June 30, 2019. 13. Mezey MD, Mitty EL, Bottrell M. The teaching nursing home program: enduring educational outcomes. Nurs Outlook. 1997;45:133–140. 14. Polich CL, Bayard J, Jacobson R, Parker M. A nurse-run business to improve health care for nursing home residents. Nurs Econ. 1990;8(2):96–101. 15. Lipton C.UnitedHealthcare nursing home plan evercare clinical model telemedicine initiatives. 2012. https://www.slideshare.net/gatelehealth/cathy-lipton31512. Accessed on June 30, 2019. 16. Kane RL, Flood S, Bershadsky B, Keckhafer G. The effect of an innovative medicare managed care program on the quality of care for nursing home residents. Gerontologist. 2004;44(1):95–103. 17. Ouslander JG, Bonner A, Herndon L, Shutes J. The interact quality improvement program: an overview for medical directors and primary care clinicians in longterm care. J Am Med Dir Assoc. 2014;15(3):162–170.
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