OPTIMISTIC: A Program to Improve Nursing Home Care and Reduce Avoidable Hospitalizations

“Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care” (OPTIMISTIC) is a multi-component model of care which provides enhanced services and opportunities for quality improvement for long-stay nursing home residents, with a primary goal of reducing avoidable hospitalizations. Registered Nurses (RNs) placed full-time in nursing facilities, supported by Nurse Practitioners (NPs), deliver interventions including championing INTERACT quality improvement tools, comprehensive advance care planning, facilitating collaborative chronic care, and improving transitions of care for residents who do transfer out of the facility.