Advanced practice registered nurses improve quality of care for nursing home residents

Marilyn Rantz still remembers the day she got the call that her mother, whose health had been declining, had fallen and fractured her shoulder. After rushing to the hospital, her mother told her she didn't understand how she ended up on a helicopter pad after the traumatic incident.

A nearby nurse told Rantz the noise from the MRI scanning tube had caused her frightened mother to mistakenly believe she had been airlifted to the hospital on a helicopter.

Determined to prevent avoidable hospitalizations, as well as the stress and panic that often comes along with the ambulance ride, Rantz, now a Curators' professor emerita at the University of Missouri's Sinclair School of Nursing, dedicated her career to improving the quality of care in nursing homes.

In a recent study, Rantz and her team evaluated the effectiveness of the Missouri Quality Improvement Initiative, a $35 million program funded by the Centers for Medicare and Medicaid that implemented advanced practice registered nurses (APRNs) full time into 16 Missouri nursing homes.

They recently evaluated the program over a six-year period and found the APRNs improved the quality of care for nursing home residents which resulted in reduced avoidable hospitalizations and emergency room visits, leading to better overall health and more than $31 million in savings.

"These highly qualified nurses have either a doctoral or master's degree in nursing, and their impact on both reducing costs and improving quality of care is significant," Rantz said. "Most of the care nursing home residents need can be provided right there in the nursing home. With the APRNs' advanced training, they have been able to help the nursing home staff recognize issues early and identify declines in health status quickly so that evidence-based interventions could be implemented to help avert problems such as hospital transfers or emergency room visits."

Rantz added that dehydration tends to be an underlying cause in many avoidable hospitalizations, and the quality improvement program puts protocols in place to ensure residents are hydrated as well as active and moving to improve mobility.

"We put care systems in place to allow residents to receive additional fluids several times a day," Rantz said. "Having the APRNs teach the nursing home staff about what types of things to be alert for helped identify small issues and early signs of illness before they became bigger issues that required an avoidable hospitalization."

Given the high rates of staff turnover nursing homes often face, the implementation of APRNs working full time in the nursing homes while being guided by a support team successfully sustained the improved quality of care in the majority of nursing homes over a six-year period.

"When residents did become ill, whether it was a urinary tract infection or pneumonia, we have previously seen these types of illnesses often lead to hospital transfers or emergency room visits," said Amy Vogelsmeier, an associate professor in the Sinclair School of Nursing and corresponding author on the study. "Now, with the APRNs coaching and mentoring the nursing home staff, they can provide the right IV fluids or give antibiotics so the residents are being appropriately cared for while still being able to remain in the long-term care living facility."

Since older adults tend to lose functional mobility with age, Rantz is committed to helping avoid traumatic and stressful hospital transfers like the one her mother experienced.

If we can intervene and manage these residents in nursing homes where they are already familiar with the staff and the routine, that is the best place for them to be. This is truly why I believe I was put on this Earth. This is my life's work, to help improve the care for older adults."

Rantz, Curators' Professor Emerita, Sinclair School of Nursing, University of Missouri