A six-year initiative in Missouri has demonstrated that unnecessary hospitalizations of nursing home residents can be reduced by having full-time, advanced practice registered nurses (APRNs) on staff, backed by an operations support team. Called the Missouri Quality Initiative (MOQI), the project was one of several interventions designed by the Medicare-Medicaid Coordination Office in collaboration with the Center for Medicare and Medicaid Innovation.
The project ran from 2014 to 2019 in 16 nursing homes in St. Louis and surrounding areas. The nursing homes ranged in size from 121 to 321 beds, and all were corporate owned, with 88% categorized as for profit. The average age of eligible residents was 81. The total number of residents included in the project averaged from 1,819 in 2014 to 1,068 in 2019.
There were two phases to the project: phase 1 focused on improving clinical care, while phase 2 tested a new payment model to support higher-intensity treatment services for residents who may otherwise have been hospitalized.
The full-time APRN at each facility focused on basics of care delivery, early illness detection, acute illness and medication management, and implementation of systems changes through quality improvement (QI) efforts. A five-member multidisciplinary operations team consisting of a nurse project supervisor, QI coach, health information coordinator, care transitions coach, and medical director provided ongoing support. In addition, four researchers provided the overall initiative with expertise in QI, care coordination, advance care planning, informatics, and transitional care.
A study presenting the project's findings appeared in the January Journal of Nutrition, Health and Aging. Between 2014 and 2019 the total number of hospitalizations was 6,913, with the average transfer rate per 1,000 resident-days declining from 2.48 in 2014 to 1.89 in 2018; the rate increased slightly to 1.99 in 2019. Eleven of the 16 nursing homes saw a sustained decline in their hospital transfer rate; five did not. Essential to the reduction of hospitalizations, the researchers concluded, were the on-site APRNs, who assessed ill residents, provided ongoing education and role modeling to the nursing staff, and ensured effective communication with providers about residents' needs. Also key were the operations support teams, which provided best practice resources, guidance in root cause analyses, and data-based feedback.
"The results of this study and others," the researchers wrote, "provide evidence supporting the widespread hiring of APRNs in this setting. There are state regulations that limit APRNs from practicing to the full extent of their license and it is now time to abolish these regulations that limit practice state by state." Medicare regulations, they added, which currently restrict APRNs employed by nursing homes from billing Medicare for direct care services, also need to be modified.
While the debate over the scope of practice of APRNs isn't likely to be resolved anytime soon (with such organizations as the American Medical Association continuing to argue against a lifting of limitations), during the COVID-19 pandemic 21 states and U.S. territories temporarily suspended or waived practice agreement requirements as an emergency measure, joining 24 other states and territories where APRNs already have full practice authority. Now, organizations such as the Tennessee Nurses Association are leveraging the experience of the pandemic to put forth bills to permanently remove physician oversight of APRNs. Their contention: if APRNs can practice fully during an emergency, then why not during normal times?-Dalia Sofer