Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing facilities in Western Pennsylvania (RAVEN).
UPMC will implement an intervention in 19 nursing facilities in the western region of Pennsylvania. UPMC Community Provider Services has created a program called “RAVEN” (Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing facilities in western Pennsylvania). The goals of the program are to: 1) reduce the frequency of avoidable hospital admissions and readmissions among nursing facility residents, 2) Improve nursing facility resident health outcomes; 3) improve the bi-directional process of transitional care between hospitals and nursing facilities; 4) reduce overall health care spending without restricting access to care or choice of providers, and; 5) facilitate knowledge transfer and culture change within partner nursing facilities to sustain these best practices over the long-term. This program will include facility-based nurse practitioners to assist with determining resident care plan goals, and conduct acute change in condition assessments. It will also implement evidence-based clinical communication tools such as INTERACT and others recommended by the American Medical Directors Association to assist in structuring and standardizing clinical assessments and recommendations. The intervention will also provide support from innovative telehealth and information technologies to connect participating nursing facilities into the Western PA Health Information Exchange.