Primary care practices use a software-facilitated process to proactively schedule and efficiently complete required components of Medicare's Annual Wellness Visit and to identify and address care gaps, leading to improvements in the provision of preventive services and high physician and patient satisfaction.
Hospital-based interdisciplinary teams conduct daily reviews of real-time information on all inpatients ages 65 and older to identify and address risk factors that can lead to negative outcomes; the program reduced use of urinary catheters and increased use of physical therapy and social work evaluations.
Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
Nurses and nursing assistants conduct hourly rounds to assess and address patient needs, contributing to reductions in falls, pressure ulcers, and call light use, and to improvements in patient satisfaction with nursing care.
Hospital volunteers support individuals with dementia and/or delirium by engaging with them and assisting with various activities, resulting in fewer patient falls and improvements in patients' nutrition, hydration, safety, and emotional well-being.
Working in collaboration with geriatricians, a nurse practitioner comanaged the care of frail, elderly patients with any of five chronic conditions, leading to better adherence to recommended care processes.
A fall prevention toolkit uses a computerized algorithm to assess the risk of falling, identify patient-specific risk factors, and design individualized interventions to reduce those risks, leading to fewer falls in the inpatient setting.
Emergency medical technicians screen rural-dwelling older adults for depression, medication-related problems, and falls. A case manager follows up with at-risk individuals to conduct an in-home assessment and provide needed referrals, leading to enhanced access to medical and social services and high levels of satisfaction.
Liberty Country Living, a long-term care facility for people with dementia, offered nurse-managed care in a home-like setting, with a focus on supporting residents' capabilities. The facility had a high ratio of staff to residents and promoted social interaction, ambulation, and continence. The program helped residents stay ambulatory, maintain continence, avoid weight loss, avoid falls and disruptive behaviors, and reduce psychotropic medication use. After 5 years of operation, Liberty closed abruptly due to changes in State regulations.
Seton Northwest Hospital continuously designs and tests nurse-led quality improvement projects at the patient's bedside, allowing nurses to be more efficient and spend more time with patients, reducing falls and nurse turnover, accelerating patient discharge, and yielding positive feedback from staff and patients.