By November 2025, an interdisciplinary, palliative care–led intervention was developed to address the complex needs of polychronic, high-cost, high-need patients, reducing acute utilization by 25%. Led by trained palliative care subject matter...
The objective of this quality improvement (QI) project was to reduce fall-related complications, particularly fragility fractures, among residents and patients in skilled nursing facilities. This population is at high risk for falls and subsequent...
Increase the discussion of choices in addressing chronic disease and end of life, measured by an increase in the number of Life Sustaining Treatment Initiative and Goals of Care Conversation notes written. This is relevant as individuals live longer...
This project aims to enhance continuity of care for patients at a 180-bed skilled nursing facility in Colorado by streamlining communication processes with external medical providers with the goal to increase the documentation and therefore...
The objective of this quality improvement (QI) project was to evaluate whether a structured, evidence-based educational intervention impacted post-acute and long-term care (PALTC) clinical staff knowledge, confidence, and perceived clinical...
To reduce 30-day HF readmissions in short-stay SNF patients (65+) by implementing the AHA Heart Failure Program. HF is a major cause of preventable readmissions and impacts quality of life and care costs. SMART Aim: Decrease 30-day HF readmissions...
Adapt and implement the Safewards interventions in an assisted living (AL) community serving formerly homeless individuals to reduce aggressive incidents and calls to 911.
The objective of the project was to implement a shared PALTC–dialysis care coordination tool across six nursing homes in CMS ESRD Network 6, and within 6 months, achieve 90% documented tool completion while reducing missed or shortened dialysis...
Within 90 days, reduce non-concordant acid-suppression therapy by ≥15% from baseline among SNF residents receiving PPIs/H2RBs by aligning prescribing with guideline-supported indications and durations. Sought to reduce resident pill burden and...
The Institute for Healthcare Improvement (IHI) Leadership Alliance established an End-of-Life Care/Ending-Life Care Accelerator to define a continuum of care for patients as they progress from curative care, to palliative care, to hospice care, to...
