Table 1.

Studies selected for review and a summary of design, methods, and results.

Author Last Name	Aim	Sample/Settings	Method	Assessment Tool	Key Findings
Popejoy	Exploring the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of INTERACT (Interventions to Reduce Acute Care Transfers, ACTs (Acute Transfer Tools) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement Initiative (MOQI)	16 nursing homes, ranging from 120 to 321 beds	Cross-sectional descriptive study	INTERACT and ACT	Over one-half of the transfers (54%) were identified as avoidable transfers. Clinical factors related to avoidable transfers included falls, fever, urinary symptoms/incontinence. The transfers had a condition which could have been managed in a nursing home (58%), transfers could have been avoided with better communication (39%), new signs/symptoms detected earlier (31%), and advance directives in place earlier (11%)
Ouslander, Naharci	To determine the types of SNF to hospital transfers that occur within 48 h and 30 days of SNF admission based on root cause analyses (RCAs) and to identify potential areas for improving transitional care between hospitals and SNFs	88 skilled nursing facilities	Trained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period	INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement (QI) tool, retrospective RCA (root cause analyses) on hospital transfers	First, more intensive monitoring of these patients during the first 48 h to 7 days after SNF admission may help identify changes in condition early enough to intervene before hospital transfer is necessary. Teams of physicians and nurse practitioners have been shown to be effective in reducing hospitalizations and potentially avoidable hospitalizations in particular
Bethea	To compare the outcomes in elderly patients whose care was coordinated by trauma nurse practitioner (TNP) versus non trauma NP (NTNP)	1363 patients were analyzed for this study in a Level 1 trauma center between December 2014 and June 2017	Retrospective cohort study	Patient demographics, comorbidities, admission injuries, Injury Severity Score (ISS), hospital length of stay and unplanned ICU admission. Study outcomes also based on discharge location including home, skilled nursing, in-hospital mortality, 30-day readmission and hospital charges	Shorter length of stay for patients under care of TNPs which resulted in decreased hospital charges of $13,000 per admission. Patient under care of TNPs demonstrated higher percentage of home discharges as compared to discharge to skilled nursing facilities
Rantz, Popejoy	To determine if the Missouri Quality Initiative (MOQI) for long-stay nursing home residents reduced the frequency of preventable hospitalizations, improved resident health outcomes, improved the process of transition of care between hospitals and nursing facilities and reduced healthcare costs	16 nursing homes in metro, urban and rural communities	Prospective, single group intervention design	Interventions to Reduce Acute Care Transfers (INTERACT), INTERACT RCA (Root Cause Analysis), Early illness identification (stop and watch), SBAR (Situation, background, assessment, recommendation)	The MOQI (Missouri Quality Initiative) achieved 30% reduction in all-cause hospitalizations with full-time APRNs working in each facility and supported by the MOQI team to assist with quality improvement activities, consistent use of INTERACT, increased end-of-life decision making, and improved use of HIT (health information technology) for secure communication. There was a decline in the nonavoidable transfers from 64% to 47% and an increase in the percentage of avoidable from 47% to 54%
Rantz, Birtley	To study the implementation of an inter-professional model in nursing facilities with advanced practice registered nurses (APRNs) with aim to reduce preventable hospitalizations among nursing home residents	16 nursing homes. SNF, LTC	Retrospective, quasi-experimental	Physician and APRN reimbursement by CPT codes. Allowable APRN visits and orders for SNF versus NF	The model results demonstrated significant reduction in hospitalizations (40% all cause, 58% potentially avoidable), emergency room visits (54% all cause, 65% potentially avoidable), Medicare expenditures for hospitalizations (34% all cause, 45% potentially avoidable), and Medicare expenditures for emergency room visits (50% all cause, 60% potentially avoidable)
Ersek	To reduce the burden of costly hospitalizations of nursing home residents by using the Transforming Institutional Care Project (OPTIMISTIC)	19 skilled nursing facilities. Participants included 23 nursing home staff and leaders, 4 primary care providers, 10 family members, and 26 OPTIMISTIC clinical staff	One time, semi structured qualitative interviews	Advance care planning (ACP), Transforming Institutional Care (OPTIMISTIC), INTERACT	This project provided NPs time to facilitate high quality ACP discussions, conduct comprehensive resident assessment, timely identification and management of acute changes, staff education, thorough discussions with residents and families regarding care plan goals and analysis of root causes for potentially preventable hospitalizations
Yang	To determine which clinical specialties are most significant to care of individuals with dementia in the community and long-term care (LTC) settings	Long term care setting and Community setting. Fee-for-service Medicare beneficiaries with dementia aged 65 years or older	Cross-sectional analysis	Patient characteristics were examined by specialty of the PPC (predominant provider of care) and by community versus LTC settings using t test or chi-squared tests, as appropriate. The maps were used to show geographic variation at the state level for NPs as the PPC of care	More than 90% of beneficiaries had primary care providers as their PPC in LTC compared with 77.3% of beneficiaries in the community. Among the primary care providers, NPs as PPCs had the greatest difference between community (6.9%) and LTC (19.2%). NPs play as PPCs in LTC and how their role differs across states. In LTC, 40 states had NPs serving as PPCs for 12% to 40% of dementia beneficiaries living in LTC facilities
Meunier	The research determines if the use of comprehensive models, such as Program of All-Inclusive Care for the Elderly (PACE), lead to improved functional outcomes for participants and cost savings through decreased utilization	Long term care in community setting. 34 former participants in PACE were monitored every 6 months for 2 years and data was collected	Retrospective, quasi-experimental	Physical Self-Maintenance Scale, Instrumental Activities of Daily Living Scale, 6-point Likert response scale, Saint Louis University Mental Status Exam (SLUMS)	Both number of ED visits and hospitalizations were found to be significantly higher after PACE closure. For every hour of home health per month, the number of ED/hospital visits decreased in a 6-month period by 5.4%. Over the 2-year study period, functional scores ADLs and IADLs significantly declined. The majority of participants (67%) reported a higher level of satisfaction with PACE services as compared to usual care provided post-PACE
Oliver	To examine the relationship between the level of advanced practice registered nurse (APRN) practice (full, reduced, or restricted) allowed and results of analyses of Medicare or Medicare-Medicaid beneficiaries of possibly preventable hospitalizations, readmission rates after inpatient rehabilitation, and nursing home resident hospitalizations	Hospitals, Inpatient rehab, SNF and LTC	Retrospective	Two-sampled t-tests, One-way analysis of variance, Tukey test	States with the highest level of scope of practice for NPs showed reduced hospitalizations and enhanced health outcomes. The study indicates that any type of barriers which restrict NPs to practice within their full scope is inversely related to the positive effect on hospitalizations and state health outcomes
Segal	To examine potentially preventable hospitalizations rates by setting, state, medical condition, and cost	Hospital, Inpatient rehab, SNF, LTC, home health and community	Retrospective	Potentially Avoidable Hospitalization Algorithm, ICD-9 diagnosis	The national rate among MMEs for potentially avoidable hospitalizations was 133 per 1000 person-years, but there was considerable variation across health care settings. For those MMEs receiving care in a skilled nursing facility, the potentially avoidable hospitalizations rate was 690 per 1000 person-years. Five conditions were responsible for nearly 80 percent of potentially avoidable hospitalizations occurring among the study population: congestive heart failure (21%), COPD/asthma (20%), urinary tract infections (15%), pneumonia (13%), and dehydration (11%)
Anderson and Ferguson	Reduce hospital readmissions by an NP completing a systematic medication reconciliation process for all new admissions	90-bed skilled nursing facility	Pre- and postimplementation design	Evidence-based workflow process, chi-square analysis	19.2% hospital readmission rate pre implementation and 13.5% postimplementation, a 29.7% decrease in hospitalizations within a 30-day period
Ingber	Improve the overall health and health care of participating long-stay residents of nursing facilities, reducing potentially avoidable hospitalizations, improving quality of care, and decreasing health care spending	Long-stay residents—total of 143 nursing facilities	Mixed methods, quantitative and qualitative analysis, multivariate regression	Analysis of claims and assessments, site visits, interviews, and surveys	Multipronged NP interventions reduce potentially avoidable hospitalizations and related Medicare expenditures
Kane	Assess the quality of care using Evercare approach which employs NPs to provide additional primary care over and above that provided by physicians	Nursing home residents	Experimental	Data from MDS, Medicare, and United Healthcare, survival analysis, risk adjustment methods applied to the quality indicators	Hazard rates significantly lower for Evercare residents, residents had fewer preventable hospitalizations
Krichbum	Test effectiveness of nursing intervention model to improve health function, and return-home outcomes using a gerontological advanced practice nurse (GAPN) to provide interventions 6 months post-acute care, making biweekly visits and/or phone calls	33 elders 65 years and older with a hip fracture	Randomized clinical trial	Mini Mental Status Exam (MMSE), Global (GH) self-ratings, Geriatric Depression Scale (GDS), Functional Status Index (FSI) and listing of living situation	Improved function in mobility, home chores, and personal care activities
Miller	Evaluate how receipt and timing of nursing home palliative care consultations by nurse practitioners with palliative care expertise are associated with end-of-life care transitions and acute care use	Nursing home residents who died from 2006 to 2010 living in 46 nursing homes in two states	Propensity score-matched retrospective cohort study	Multivariate logistic regression analysis	Lower rates of hospitalizations, improved end-of-life nursing home care
Ploeg	Report the perceptions of residents and family members about the role of the nurse practitioner in long term care settings	35 residents and family members from four long-term care settings that employed a nurse practitioner	Qualitative descriptive approach, individual and focus groups interviews	Conventional content analysis was used to identify themes and subthemes	Perceptions of residents and family members of the nurse practitioner role in long-term care setting consistent with person-centered and relationship-centered care, enhanced quality of care, positive care experience
Poghosyan	Determine the impact of state and organizations on nurse practitioner practice environment	291 nurse practitioners in MA and 278 nurse practitioners in NY	Cross-sectional survey design; online surveys	Nurse Practitioner Primary Care Organizational Climate Questionnaire	NPs have positive perceptions of their relationship with physicians, NP’s perceptions of the relationships they have with administration is deficient, state and organizational policies should be taken into consideration to ensure least restrictive practice
Rantz	Review impact of advance practice registered nurses (APRNs) on the quality measure scores of 16 nursing homes participating the Missouri Quality Initiative (MOQI) intervention	16 nursing homes	Two-group comparisons	Data was collected for 36 months and analysis of results conducted to create a composite quality measure score for each facility, Interventions to Reduce Acute Care Transfers (INTERACT) using the Stop and Watch and Situation, Background, Assessment, Recommendation (SBAR)	APRNs working full-time in nursing homes positively influenced quality of care, reduced unnecessary hospitalizations and emergency room transfers, improved the process of transitioning between inpatient hospitals and nursing facilities, and reduced overall healthcare spending without restricting access to care
Rosenfeld	Determine the national practice patterns of nurse practitioners providing care in long-term care facilities	All physicians who are members of the American Medical Directors Association (AMDA)	Mailed survey	The survey mailed out included six domains: (1) the number of LTC facilities that have NPs involved in providing care; (2) the number of NPs engaged in care at these facilities; (3) the types of employment/financial arrangements between NPs and LTC facilities; (4) the types of services provided by the NPs; (5) the effectiveness of the NPs as perceived by the medical director; and (6) the perceived future demand for NPs in LTC	NPs involved in LTC are more likely to be involved in facilities with 100+ beds, performed a wide range of services, are effective at maintaining physician, resident, and family satisfaction, were highly effective with regard to emergency room transfers, increasing the quality of care, survey preparedness, and hospital admissions. Respondents to the survey were overwhelmingly positive about working with NPs
Ryskina	Describe current practice behaviors to identify areas where interventions could improve post-acute care outcomes	Fee-for-service Medicare beneficiaries, 65+ years old, discharged from an acute care hospital to a SNF in the period of January 2012–October 2014	Retrospective	Aggregate data from Medicare claims January 2012–October 2014, supplemental information from MDS and Provider of Services	Timely access to physicians or NPs after hospital discharges to a SNF depends on local practice patterns, not clinical needs
Kaasalainen	To evaluate the level of involvement of nurse practitioners (NPs) in activities related to preventing and managing fractures in long-term care (LTC)	Long term care (LTC)	A cross-sectional survey, qualitative interviews	The first section focused on demographic information, the second section gathered information on practice patterns of NPs related to fracture-risk assessment, post-fracture management and use of evidence-based guidelines, the third section surveyed on the processes NPs would follow to respond to related care decisions, and last section focused on identification of the barriers and facilitators faced by NPs to prevent and manage fractures	The finding suggest that the NP were involved in caring for residents’ post fractures and in risk factors assessments. The role of NP in managing fractures can be optimized by addressing barriers such as inadequate staffing at the facility and lack of timely access to diagnostic services
Ouslander, Naharci	To determine if conducting root cause analyses (RCA) on transition of residents from skilled nursing facility to hospitals can help prevent preventable emergency department (ED) visits and hospitalizations	Sixty-four of 88 SNFs	Retrospective, quasi-experimental	INTERACT (Interventions to Reduce Acute Care Transfers), Quality Improvement (QI) tool	The studies indicate that using RCAs provides important insights to factors contributing to the transfers, propose several areas of attention for process improvements and related education which may help reduce preventable hospitalizations
Kuo	The use of nurse practitioners (NPs) is one way to address the shortage of physician primary care providers	Medicare beneficiaries aged 65 or older with Parts A and B coverage and not in a health maintenance organization (HMO) for the entire twelve months of each year during 1998–2010	We identified individual providers by their Unique Provider Identification Number for 1998–2007 and National Provider Identifier for 2007–10	Hierarchical generalized linear mixed models	The overall number of NPs reimbursed for evaluation and management services in the 5 percent Medicare claims data rose from 3114 in 1998 to 37,638 in 2010
Mullaney	To understand the impact of mortality risk assessments (MRAs) and advance care planning (ACP) discussions completed by nurse practitioners (NP) on clinical outcomes for newly registered Medicare Advantage nursing home residents	The final sample of 87 patients was 72% female with a mean age of 81 years, LTC	Prospective, nonexperimental approach	Mortality Risk Assessment (MRA) & Advance Care Planning (ACP)	The study demonstrated positive clinical outcomes post ACP discussions. The outcomes include increase in number of patients with a comfort goal of care, decline in full-code status patients, reduced hospitalizations and improved quality in end-of-life care
Cole	NPs collaborative practice with physician and nursing colleagues to reduce hospitalization	190-bed residential care facility in New Brunswick, LTC	Retrospective	Daily clinical monitoring	As shown in this case, the presence of an NP clearly impacted a reduction in emergency room visits and hospitalizations, events that often accelerate further physical, mental, and functional decline particularly among the frail elderly
Hullick	To examines the impact of the aged care emergency services (ACE) on residential aged care facilities (RACF) residents’ transfers to hospitals	Four RACFs, LTC	Prospective, retrospective	Generalized estimating equations	This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities
Ordonez	To examine the outcome of a gerontological nurse practitioner (GNP) care coordination model on healthy transition and 30-day rehospitalizations among older adults. In this study, the patients are discharged from a hospital to a SNF for rehabilitation post coronary artery bypass graft (CABG) surgery	10 older adults with age > 65 years status post CABG. Skilled nursing facility	Retrospective, quasi-experimental	Scale 1-4 including control of signs and symptoms, functional status, depression, sense of integrity	Findings indicate five to eight percent more effectiveness in outcomes with GNP care coordination model than the standard of care. The project demonstrates the effectiveness of the GNP care coordination model in decreasing the risk of 30-day rehospitalization and facilitating the development of realistic and achievable goals
Dwyer	Reducing avoidable hospitalizations of aged care facility (ACF) residents can improve the resident experience and their health outcomes	Aged care facility (ACF), LTC	Retrospective	Donabedian model	The studies indicate that the NPs with their advanced clinical skills and prescribing rights, were able to deliver a range of timely health services within the ACF in the absence of a PCP. This resulted in reduced hospitalization and managing of care of residents at the facility
Reidt	To study an interprofessional collaborative practice model aimed to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The model includes a geriatrician, nurse practitioner and a pharmacist	SNF, LTC	Prospective, Retrospective	Comparison of intervention and control groups	This study suggests that collaboration among a geriatrician, nurse practitioner, and pharmacist may be an effective means of decreasing hospitalizations and ED visits within 30 days after SNF discharge
Arendts	To enhance quality of life and reducing hospitalizations for people living in residential aged care facilities (RACF)	Six facilities (352 beds each) were included, RACF, LTC	Prospective, Retrospective, quasi-experimental. A cluster controlled clinical trial of nurse practitioner care in RACF. Six facilities were included: three randomly allocated to intervention where nurse practitioners working with general practitioners and using a best practice guide were responsible for care, and three control	Modified Barthel Index (MBI), Psychogeriatric Assessment Scale (PAS) assessments	Nurse practitioner care coordination resulted in no statistically significant change in rates of ED transfer or health care utilization, but better maintained resident quality of life