Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

As the population of the United States continues to age, we face numerous challenges in health care delivery systems that go beyond health services and impact supportive and appropriate housing issues as well. Most Americans want to age in place, that is, stay in their own homes as their abilities wane and health needs increase. But ideal housing is not easy to find and retaining independence is difficult. Our systems need to think differently about the organization of health and independent housing services than what is available for most elders today.

With the federal government tackling the cost and quality of health available to citizens, nursing as a profession needs to pay attention to the discussion. Independent housing, aging in place (AIP) and the optimum packaging of supportive services need creative solutions with sound evaluations to perpetuate what works and model outstanding programs. Following legislation to test the AIP model In Missouri, the Sinclair School of Nursing at the University of Missouri, partnership with Americare Systems, Inc., built “TigerPlace,” a senior housing facility with care coordination as the centerpiece.

The March April 2014 issue of NURSING OUTLOOK describes the statewide evaluation of the continued success of TigerPlace and the registered nurse (RN) care coordination model for long term care. Dr. Marilyn Rantz discusses here how this model has evolved over time and its successes can be replicated in other states.

Marilyn Rantz, is Curators’ Professor and  Helen E. Nahm Chair at the University Hospitals; and Clinics Professor of Nursing and Executive Director for Aging In Place and TigerPlace. She is also Associate Director for the Interdisciplinary Center on Aging, Sinclair School of Nursing, University of Missouri.

For links to the Aging in Place in Missouri, click here: www.agingmo.com.

We invite commentary that is thoughtful and provocative! Join the online dialogue!


Click here for the TigerPlace website”:

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN

Marilyn J. Rantz, PhD, RN, FAAN

Sinclair School of Nursing at the University of Missouri

Question 1. What will it really take to make senior housing options, like TigerPlace, to “spring up” across the country so the benefits of cost and quality outcomes demonstrated in this state evaluation are realized nationwide?

To listen, click here.

The key, from my point of view, is to have a funding mechanism for RN care coordination. What we found in our state evaluation at TigerPlace, is that the corner stone is care coordination. It needs to be done by a well-qualified nurse, and we built TigerPlace around those ongoing costs of health promotion: we bundled the cost of health promotion; we combined a 24 hour nurse on call, wellness center hours that are open several times per week, and four private visits from a nurse per year in your home; and organized exercises class. Those are really health promotion. We do a class called healthy steps and another class on Tai Chi and Yoga – lots of strength building, those kinds of focuses for health promotion classes that are movement oriented – because we know that if people keep moving it really helps them promote their health. We combined those costs, bundled those costs so that there’s a small charge that is combined into the monthly rent of everyone’s apartment. In TigerPlace, the monthly rent also includes meals, housekeeping, and transportation – those amenities of living in a typical assisted living setting, and also in a lot of independent housing settings. But we put the health promotion package in there too and that small investment really helps promote the health of all the people who live there, and it results in a lot of major improvements surrounding the physical function, the mental function. And the declines that typically we see through the end of life are shortened, to a shorter period of time at the end of life and people can be really functionally active through the end of life. It is really wonderful to see the outcomes of lower costs overall – we save about $20 thousand per year on the cost of typical long term care, nursing home care when our residents would qualify for nursing home care. That cost savings is really helpful for them and their families. But, more importantly, they have a better quality of life and better function through the end of life.

Another thing that it’s going to take is: we really need to learn how to used Advanced Practice Nurses and other qualified care providers under the new CMS guidelines and payment mechanisms for complex chronic care coordination and also for transitional care management services. We now have CPT codes. Those codes we will put in the document that goes along with this narrative. Those codes are relatively new on the scene for us to use, and we have not at TigerPlace, tried to use them yet for billing purposes for an Advanced Practice Nurse. So we would really welcome other people who have been successful at billing through those codes. I suspect that we can use that mechanism and help promote TigerPlace concepts across the country using that payment mechanism.

The other thing that would be very helpful to happen across the country is the policy work that needs to take place, state by state, to enable the construction of elder hosing that allows people to stay there through the end of life with this health promotion focus. (Because) you really can’t continue to do business as usual, forcing people to move from setting to setting to setting because of the licensure and regulation across those settings. Typically, one is forced to move from senior housing, to assisted living to nursing home, because of the state and regulation. But, what we did in Missouri is work through those with our Division of Aging and also passed legislation that enabled us to license the care and NOT the setting. Although, in the end, we ended up licensing the building as intermediate care, so that people could use their long term care insurance – that was a piece of the puzzle that people had found really helpful. But we still have the care provided under the licensure of home care and that seems to be a really sound approach than focusing on making people move from place to place to place.

Question 2. What can organized nursing do to enable the “springing up” of TigerPlace concepts around the country?

To listen, click here.

A major initiative that needs help across this country that would facilitate this is APRN unrestricted practice. We really need unrestricted practice in every state in this country. That needs to happen. I know that organized nursing nationally has been focusing on this, and helping states one by one change their regulations and their nurse practice acts to enable unrestrictive practice for advance practice nurses.

We have restrictive practice in this state, where collaborative practice arrangements are required and some onerous review processes as well as onerous limitations on the distance once can be from your collaborating physician. We have also done an analysis of the health outcomes in our state and health outcomes in all states comparing restrictive practice guidelines regulations with the health outcomes and then hospitalizations of Medicare and Medicaid patients and all of those are highly correlated in each state with restrictions on advance practice nurses. It is time that we get unrestrictive practice nation-wide. That needs to happen! And that will facilitate the development of these types of operations because we can have a funding mechanism with the Medicare availability under the CPT codes that I talked about earlier, which are the transitional care management and the complex chronic care coordination services. It would be possible then to have a funding mechanism available for APRN independent practices in these housing developments and facilitate this nation-wide.

That will be critical in something that organized nursing state by state needs to embrace. I know we have in this state. I know we have legislation pending, but once again, we are at that time of year and we have now been thwarted again by organized medicine and we are going to have another initiative next year. Hopefully we will be successful next year and try some slightly different strategies and hopefully that will have a positive outcome in this state. And I hope other states are doing that too.

The other thing that organized nursing can do is to continue policy forums where nurse entrepreneurial efforts are promoted and you demonstrate the cost and quality outcomes. We do that in the American Academy of Nursing through the recognition of Edge Runner programs. TigerPlace and the Aging In Place research that has been done at the University of Missouri is an Edge Runner program. That helps to promote new modes of care that hold the answers for many of the complex care problems and cost and quality programs that we have in health care across the nation. Nursing can take the lead, nursing has many of the answers and we can bring other disciplines to the table.

Question 3. Do you have any advice for others wanting to replicate or build on what you have learned in the Aging In Place evaluation at TigerPlace?

To listen, click here.

You know, that is my goal! We have done consistent evaluations, and what we had wanted to do in our state demonstration project is lay a good foundation of data as well as a good foundation of materials for people to use to be able to build on what we have done. We have been very careful to document all of the evaluations and publish those. We have been very careful also to document process descriptions of how we went about doing different things and the major components of The Aging in Place project and particularly building TigerPlace. We have a compendium and lots of information about Aging in Place on our website. You can use those materials and we will work with you, too, as you use those materials, but we have lots of that on our website.

The other thing that we did that I think works really well: in fact at lunch today, I am going to Jeff city our state capital and meeting with state regulators. You have to have a relationship with your state regulators. Develop a positive relationship, maintain that positive relationship and work with them because they want to see that projects like this succeed. They will collaborate with us. They will work with us. They have the same goals in mind of helping older people, of any population that you want to work with, but these are particularly people who are focused on older adults. They want to see that people get the right care and services, so they’re open to new ideas. Develop those relationships and figure out how you can gain their cooperation to do projects like this within your state. I think some states will need very little change, if any, to be able to just go ahead and duplicate TigerPlace within your state, and, other states will require some adjustments in state statute or regulation. We had to adjust statute and regulation in this state to enable its construction, and it’s flourishing. So, I really want to work with people and we are working with some people, but it’s important to have the regulators and have a positive relationship with them as you are developing this.
The third thing is that we have prepared the operational materials too, to help others implement this idea, particularly the concepts of care coordination in senior housing settings. Right now we are in discussion with the College of Nursing at the University of Arkansas for Medical Sciences in Little Rock and they really want to replicate the Aging in Place model. So we have got really good potential working with that college of nursing to be able to replicate what we have been able to accomplish here at TigerPlace. Particularly care coordination and doing another key in our model of care is doing variable billing on the costs of care, so that as people need more services, we put services around them, and withdraw those services as they become independent again. That controls the costs. They are very interested in helping to replicate this model and particularly to be able to work on the changes in funding and the variable billing for funding.

It has been a delight to be able to be a part of the Aging in Place Project here at the University of Missouri. I have spent almost 20 years working on this project now. We started in 1996, and I can tell you it has been some of the most exciting work that I have been able to do. Sometimes, I very much feel that this is the work that I was intended to do and that is why I was put here.