OPTIMISTIC About Better Post-Acute Care

By Kindred Healthcare

As the nation’s leading provider of post-acute care services, Kindred is well-positioned to make important contributions to cutting-edge initiatives aimed at improving delivery of post-acute care across the continuum, from the long-term acute care hospital through the skilled nursing facility, rehabilitation hospital, home health and hospice.

In two Indiana skilled nursing facilities, Kindred is participating in a Centers for Medicare and Medicaid Services-sponsored initiative called OPTIMISTIC – Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care. The project aims to improve health care, reduce avoidable hospitalizations and increase access to palliative care.

“OPTIMISTIC benefits our long-term residents,” said Pamela Zanes, RN, BSN, Ed.M., senior director of care transitions for Kindred Healthcare.

An experienced and highly trained RN-level nurse from OPTIMISTIC conducts assessments and evaluations of patients in the facilities, according to Zanes.

“This work supplements, complements and informs the care that our nursing center staff provide,” she said. “The OPTIMISTIC nurse's findings are reviewed and discussed with the physician and nurse practitioner caring for the patient as well as the other members of the interdisciplinary care team. OPTIMISTIC also provides educational sessions for our staff which enhance their ability to care for our residents."

OPTIMISTIC is based on the premise that reducing avoidable hospitalizations could save the healthcare system billions of dollars per year. According to an article in McKnight’s Long Term Care News, “…ambulance rides can be harrowing, avoidable and expensive. In fact, nearly half (45%) of hospitalizations among Medicare-Medicaid enrollees in SNFs [skilled nursing facilities] could be prevented...”

Enter OPTIMISTIC, which places trained nurses at participating facilities to educate and train the staff and offer another layer of support for long-term stay residents, conducting care management reviews with the goal of improving chronic disease management, reducing unnecessary medications and providing clarity for care goals.

OPTIMISTIC is currently being used in two Kindred Indianapolis-area skilled nursing facilities – Kindred Transitional Care and Rehabilitation – Greenwood and Kindred Transitional Care and Rehabilitation – Wildwood.

According to Zanes, Kindred was a natural fit for the OPTIMISTIC program, which is currently underway in just a handful of other states – Alabama, Missouri, Nebraska, New York, Nevada and Pennsylvania. Use of the INTERACT program is one reason why. INTERACT, a program that helps caregivers at all levels document the changes they see in patients, is used by OPTIMISTIC nurses and Kindred staff alike, making for a seamless onboarding process. INTERACT, which stands for Interventions to Reduce Acute Care Transfers, aims to achieve early identification of warning signs so that treatment can begin before a problem escalates to hospitalization-level.

“OPTIMISTIC really allows us to harness all of the most innovative systems to care for our patients,” Zanes said. “The nurses are responsible for fewer patients at a time than a typical nurse, which allows them to delve deeper and they are well-versed in programs like POST, or Physician Orders for Scope of Treatment, which helps ensure that patient preferences for extent of treatment are honored across care settings.”

Kindred has been participating with OPTIMISTIC for about a year and the OPTIMISTIC nurses have four-year tenures at the facilities.

“We’re thrilled to be involved with a program like this that is really advancing the field of post-acute care,” Zanes said. “It is forward-thinking projects like this that really help us take hope, healing and recovery to the next level as we work toward the best outcomes for each and every one of our patients, no matter what their goals may be.”

Kindred Transitional Care and Rehabilitation – GreenwoodKindred Transitional Care and Rehabilitation – Wildwood