The Project
With backing from the Patient-Centered Outcomes Research Institute (PCORI), a team from Florida Atlantic University set out to develop a decision guide to help residents and their families understand the reasons to stay in the nursing home or go to the hospital when an acute change in condition occurs. They conducted 270+ interviews with residents, families and providers in 19 Florida nursing homes to incorporate their perspective and concerns in this Guide.
With support from the states of CMS Region IV (AL, GA, FL, KY, MS,
NC, SC, TN) a pilot project was then rolled out to 16 nursing homes
in Region IV. Data on readmissions was collected for three months
before and after implementation of the Guide. Training videos,
case studies and other materials were developed to support use
of the Guide. The pilot nursing homes achieved 31% reduction.
in hospital readmissions.
In the second phase of the project, the team offered 20 training workshops across Region IV and a series of webinars to over 1300 participants representing facilities, state agencies, ombudsmen, long-term care organizations, corporations and several interested hospitals. Workshop participants surveyed reported an average 28% reduction in hospital readmissions achieved after implementing the Guide. Ninety-seven percent of them said it was helpful, only 3% said it was not.