Table. Some Resources Used by MOQI APRNs and Support Team.

Interventions to Reduce Avoidable Hospitalizations (INTERACT) https://pathway-interact.com/	A omprehensive set of tools and resources that promotes early illness recognition, communication regarding condition change and transfer, hospital transfer log review, advanced care planning, and quality improvement.
Hand-In-Hand training https://qsep.cms.gov/pubs/HandinHand.aspx	Training modules developed to assist staff to provide person-centered care for residents with dementia. The course can be used as a full course or in segments. APRNs were central in working with staff to identify and deliver content that was most appropriate to their setting.
Improved quality care	Examples include the following: (a) antipsychotic medication reduction included using evidence-based practice. The APRNs engaged with providers, pharmacy, and NH staff to identify residents appropriate for dosage reduction and nonpharmacological interventions; (b) identification and treatment of urinary tract infections following national guidelines.
Goals of care and end-of-life planning https://theconversationproject.org/wp-content/uploads/2015/09/TCP_StarterKit_Final.pdf https://www.ariadnelabs.org/serious-illness-care/ https://training.vitalsmarts.com/courses/crucial-conversations-online-2018	Worked with facilities to develop a process for having goals of care discussions and ensuring that advance directives were available or if not available resident with capacity were offered the opportunity to complete a directive. Developed a system for completing advance directives during National Healthcare Decisions Day (Apr 16 annually). Crucial Conversations Training (APRN, leaders, RN, SWs)

Abbreviations: APRN, advanced practice registered nurse; NH, nursing home; RN, registered nurse; SW, social worker.