1. Missouri Quality Initiative (MOQI) for Nursing Homes
Marcia K. Flesner, PhD, RN
MOQI Project Coordinator Emeriti
Cathy Murray, EdD, MBA, RN, NHA
MOQI Project Coordinator
VOYCE Conference June 8, 2017
St. Louis, Missouri

2. objectives
Share clinical and processes of care information gained from a 4 year (2012 to 2016) federally funded grant in 16 Missouri nursing homes in STL area.
Advanced Practice Registered Nurses (APRN) were placed in 16 nursing homes in the St. Louis region to work on 3 primary goals:
Reduce unnecessary hospital transfers from NH
Increase use of INTERACT tools so that early condition changes would be recognized by nursing staff
Increase the use of Advanced Directives for end of life care.

3. Why is MOQI important? Video Speakers: Marilyn Rantz, PhD, RN, FAAN
Project Director
Marcia K. Flesner, PhD, RN
Project Coordinator Emeriti

4. Foundation of the Intervention
Complexity Science
40 years of research about APRNs
40 years of research about how to change nursing practice in NH
40 years of research about service/care of older adults (across all settings)

5. Intervention Foundation, Continued Complexity Science
and Hospitals for the Future of Health Information Exchange
Preparing Nursing Homes and Hospitals for the Future of Health Information Exchange
Preparing Nursing Homes and Hospitals for the Future of Health Information Exchange
“Traditional bureaucratic approaches to management [in LTC], impose barriers to the freedom of interaction needed for effective self-organization.”

6. 3 components of complexity science
Relationships among staff
Trusting relationship among leaders and NH staff: common goals, clear expectations
Communication
Two way communication
Cognitive diversity
People who do the work participate in decision making about work

7. Intervention foundation, continued APRNs Research
40 years of research on APRNs demonstrated that APRNs have been delivering safe and effective health care to all populations across settings and in many specialties (Horricks, Anderson & Salisbury, 2002)
Review of 38 studies of the care of nursing home residents by APRNs reports that there is evidence APRNs provide extensive education to residents, families and staff which results in improved outcomes (Bakerjian, 2008)
Our research team studies
1990s to current

8. Intervention Foundation, Continued Change nursing practice
APRNs are effective in nursing homes
It’s all about Quality efforts that lead to changes in the practice setting, no matter the name
Quality assurance, CQI, Quality Improvement, QAPI
Engaged Leadership by NHA and DON
Leaders set the expectations and culture in the nursing home

9. MOQI Model and Key Components
Number of facilities/Avg Dly Census
Key components of model
Describe any innovative or unique features
What most excited about in model
We will be presenting the HIT components in later presentation so will not discuss them here.

10. Outcomes of moqi 2013-2015 40% all-cause hospitalizations (ACH)
58% potentially avoidable hospitalizations(PAH)
54% all-cause ED visits
34% Medicare expenditures for ACH
45% Medicare expenditures for PAH
50% Medicare expenditures for ED visits

11. What Makes MOQI Intervention Work?
Incorporating Advanced Practice Registered Nurses (APRN) into SNFs to model effective communication strategies about residents’ change in condition
Use of INTERACT tools (S&W, SBAR, Transfer Log, RCA) and quality improvement techniques to reduce unnecessary hospital transfers

12. What Makes MOQI Intervention Work?
Establish approaches for increasing end of life care planning and communication within nursing homes
Periodic and planned medication reviews that address issues of polypharmacy, antipsychotic use, or inappropriate medications that lead to resident safety

13. APRN Role in Long-Term Care
Geriatric Clinical Focus
Care Delivery System Focus
Education
Role-Modeling for Staff
Clinical Leader
Role Modeling for Leadership

14. Use of aprns in ltc Video Speakers: Annette Lueckenotte, RN
Project Supervisor
Carrie Bowling, MOQI APRN

15. APRN and MOQI Team is Working to Change Practice in NH
We are increasing facility nursing staff skills and capabilities
We are changing facility culture toward treating residents in house
We are role-modeling best nursing and medical practices
MOQI Medical Director

16. APRN Has Full-Time Presence in the Nursing Home
Integrated into the NF Staff
Demonstrate Advance Practice Skills (advanced assessment, actions, directing care in the right way)
Communication with residents, families, and staff
Crucial conversations about end of life care planning (training of APRNs and key NH staff)

17. First Step Feedback Reports of Key Outcomes to be Achieved!
Facilities are identified, they agreed to
share reports with each other

18. USE OF FEEDBAKC REPORTS
Video
Speakers:
Annette Lueckenotte, RN
Project Supervisor
Marilyn Rantz, PhD, RN, FAAN
Project Director
Jennifer Burgess, MSW
NHA, Delmar Gardens at Meramec Valley

19. Monthly Hospitalizations with Goal

20. Reduction in Hospital Transfers

21. Hospital transfers 1/2016 to 4/2017

22. Monthly Hospital Transfer Rates

23. 3-month Trend of Total Hospital Transfer Rates

24. 3-month Trend of Total Hospitalization Numbers

25. Potentially Avoidable Total Transfers

27. Conditions that Put the Resident at Risk

28. 25% of hospital transfers related to infections
Video
Speakers:
Tiffany Nelson, RN
MOQI APRN
Carrie Bowling, RN

29. Physician transfer feedback

30. physician engagement Video Speaker:
Charles Crecelius, MD, PhD, FACP, CMD
MOQI Medical Director

31. physician engagement Monthly COMMUNIQUE to attending physicians
Educational topics:
Choosing Wisely program, Use of INTERACT tools, Inappropriate CPR in LTC, advanced care planning, litigation and communication, polypharmacy
Webinars about MOQI goals

32. Root Cause Analysis (RCA)
INTERACT TOOL
Collected data for Monthly Reports and Analysis - database
Project Coordinator and Supervisor reviewed RCA with APRN where occurred about systems and processes

33. Action Steps Based on RCA
APRN reported at nursing home QAPI meeting summary of hospital transfers
Discussion held on precursors in the clinical setting that led to transfer
Recommendations were offered about processes and systems of care needing adjustment

34. Systems of Care that Support Efforts
Hydration
Nutrition
Mobility
Continence
Engagement With Life
Goals Of Care
End-of-Life Decision-making

35. It’s Really ALL About…
Basics Of Care And Getting Systems In Place-ACTION STEPS
APRN Clinical Skills Guiding Improved Practice-TAKING ACTION
Leadership Buying In And Really Working With APRN-TAKING ACTION

36. Hydration, hydration, hydration
Video
Speaker:
Marcia K. Flesner, PhD, RN

37. It’s Really ALL About…
Monthly Feedback Reports Of Key Data To Guide Improvement-ACTION STEPS
Continuous Quality Improvement Methods-TAKING DELIBERATIVE ACTION
Complexity Science-communication, Diversity, Relationships-DELIBERATE, INTENTIONAL PLANNING, TAKING ACTION

38. Moqi at the Start of a Successful Journey

39. Phase 2 of moqi (2016-2020) Started October 2016
MOQI homes can bill for rx of 6 dx:
CHF, COPD, dehydration, pneumonia, skin infections/pressure ulcers, UTI
20 comparison homes can bill but do not have APRN in NH
Reimbursement for EOL consultation with physician

40. Questions???

41. RESOURCES
INTERACT AgingMO Click on Research, then Click on Nursing Home Quality 34 Articles on nursing home studies