OPTIMISTIC transition visits: A model to improve hospital to nursing facility transfers

Arif Nazir, Kathleen T. Unroe, Bryce Buente, Greg Sachs, Greg Arling

Research output: Contribution to journalArticle

4 Scopus citations


Transitions to and from hospitals and nursing facilities (NFs) expose patients to lapses in care due to miscommunication. Potential consequences of these breakdowns in communication include medication errors, poor follow-up care after transitions, and rehospitalization. In 2012, the Centers for Medicare & Medicaid Services decided to fund an initiative made up of seven projects to reduce potentially avoidable hospital transfers. One of the these projects, the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project, implements registered nurses and nurse practitioners to assist with and close gaps in transitions of care for NF patients. The authors provide an overview of the transition visit model and a preliminary analysis of the outcomes of their interventions.

Original languageEnglish (US)
Pages (from-to)31-36
Number of pages6
JournalAnnals of Long-Term Care
Issue number7
StatePublished - Jul 1 2016


  • Medication reconciliation
  • Nursing home transfers
  • Quality improvement
  • Transitional care

ASJC Scopus subject areas

  • Gerontology
  • Geriatrics and Gerontology

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