Skip to main content

New grant supports care model targeting unnecessary hospitalizations of older adults


INDIANAPOLIS — Approximately 1.4 million older adults in America live in nursing homes. A new grant from the John A. Hartford Foundation will enable clinician-researchers from the Indiana University Center for Aging Research and the Regenstrief Institute and their partners, to prepare for the expansion of OPTIMISTIC, their long-term nursing home resident care model.

The Hartford Foundation grant of $621,697 over the next 18 months will support enhanced evaluation of OPTIMISTIC, an acronym for “Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care.” The new funding will allow for the development of training materials, as well as planning efforts related to the marketing and business sustainability of the approach to ensure its effective dissemination.

OPTIMISTIC, a long-term nursing home resident care model, is designed to improve the quality of care, reduce hospitalizations and increase access to palliative care for this medically complex and frail population.

“This significant investment from the Hartford Foundation is critical as we work to reach more nursing homes and nursing home residents in Indiana and beyond,” said OPTIMISTIC co-director Kathleen Unroe, M.D., an Indiana University Center for Aging Research and Regenstrief Institute scientist and an IU School of Medicine assistant professor of medicine. “Our nursing home and community partners are committed to improving care of nursing home residents – this grant is an exciting opportunity to expand the scope of our current work.”

OPTIMISTIC is supported by a four-year, 2012 award of $13.4 million from the Centers for Medicare and Medicaid Services (CMS). The demonstration project goal is to improve care and communication within nursing homes and between these facilities and acute-care institutions so problems can be caught and solved before transporting a resident to the hospital becomes necessary.

Long-stay nursing home residents suffer from high rates of multiple chronic illnesses and dementia. Despite their needs and frailty, their care is often fragmented by hospitalizations, re-hospitalizations, and gaps in primary and palliative care, which increase suffering and costs of care.

Currently, specially trained OPTIMISTIC nurses are stationed on site at 19 central Indiana nursing facilities, supported by nurse practitioners, to provide direct support to long-stay residents as well as education and training to the staff. OPTIMISTIC nurses also lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications and clarify care goals.

“This new grant not only provides essential support to begin planning to take OPTIMISTIC to a national scale, it represents an amazing vote of confidence from the Hartford Foundation,” said Greg A. Sachs, M.D., OPTIMISTIC co-director, an Indiana University Center for Aging Research and Regenstrief Institute scientist and an IU School of Medicine professor of medicine.  “They believe in our vision for improving care in nursing homes, as well as our ability to play a leadership role in helping to disseminate the effective interventions being developed at six other CMS-funded sites around the country.”

The interdisciplinary OPTIMISTIC project team includes Arif Nazir, M.D., IU School of Medicine (medical director); Susan E. Hickman, Ph.D., IU School of Nursing (palliative care component lead); Ellen Miller, PT, Ph.D., Center for Aging & Community, University of Indianapolis (education/training component lead); Monica Tegeler, M.D., (transitions of care component lead) and Greg Arling, Ph.D., Purdue University, (data core lead). Laura Holtz is project manger and Shannon Effler is project coordinator. Both are with the IU Center for Aging Research and the Regenstrief Institute.

The John A. Hartford Foundation, founded in 1929, is a private philanthropy working to improve the health of older Americans.