Heal Early, Heal Often
Marilyn Rantz keeps elders healthy.
Researcher Marilyn Rantz has set out to counter the too-common idea and experience of aging as an inevitable decline into frailty and dependency. Her mission in life is to replace that defeatist outlook by developing and testing new ways of caring for elderly people so they can remain as independent as possible for as long as possible.
It’s easy to see how much Rantz likes older people, how much she wants to help them live well. The Curators Professor of Nursing and Helen E. Nahm Chair possesses a remarkable healing touch. She lays hands on elderly people as a caring professional who has worked as a floor nurse, a nursing home director and a gerontological researcher. She is an experienced clinician who sometimes observes problems so early on that the patients themselves are unaware. Some cues — perhaps a nuance of errant gait — are so subtle that she registers them as intuitions.
On another level, her healing touch reaches throughout her acclaimed research career. “She’s not about delaying dying at all costs,” says Vicki Conn, MA ’81, MA ’83, PhD ’87, professor of nursing and longtime member of Rantz’s research team. “She works out ways of helping elders live with a high quality of life, which is in great part about maintaining function.”
During fall 2012, Rantz logged two remarkable achievements, either of which would have put her in the nursing history books. On Oct. 15, 2012, she was elected to the Institute of Medicine, an elite cadre of researchers whose authoritative work informs the U.S. government as it makes policy. On Nov. 5, 2012, she received a $14.8 million research grant, the largest ever at MU, to improve nursing home care.
Rantz has won more than $50 million in research funding for a range of projects: She has tamed huge medical databases and put their valuable contents into the hands of front-line caregivers nationwide. She has worked out ways that nurses can monitor elders and coordinate their care to catch problems early, keep them at home and decrease health care costs. And she has collaborated with engineers to create remote-sensing technology that automates and extends her healer’s ability to detect nascent health problems.
“Marilyn Rantz is not just someone who has made a few good findings,” says Angela McBride, former dean of nursing at Indiana University and a national expert in leadership development. She believes Rantz’s ideas are ready for widespread use. People toss around the term “cutting edge” in casual conversation, McBride says. “But Marilyn Rantz’s work really is cutting edge.”
Reinventing Elder Care
Some of Rantz’s most innovative work is based on the grave observation that moving elderly people from place to place often harms them. This holds true even for relocating nursing home residents and their belongings from one room to another that is closer to needed services. In frail elders, the loss of familiar faces and routines can be a large enough shock to their well-being that it causes physical problems. Such moves can precipitate death, she says. So, Rantz envisioned a facility where residents wouldn’t have to move from place to place for services. Instead, services would come to them as needed. This aging-in-place idea sounds common sensical, but it turns a standard nursing home organization on its head.
In 2004, Rantz saw her ingenuity transformed into bricks and mortar at 2910 Bluff Creek Drive in Columbia. TigerPlace, at first glance, comes off as a posh hotel designed for elders. It’s also part nursing home, part assisted living facility, part wellness facility, part research laboratory. Perhaps most important for the future of elder care, it’s a one-of-a-kind proving ground where Rantz and colleagues develop and test the idea of aging in place.
Rantz’s research asks: How can we measure functional decline and develop ways to slow it down? Harking back to her intuitions of subtle clues about residents’ health problems, she wondered, “Are there cues that sensors could pick up, too?” The question led to years of research — still continuing — at TigerPlace. For instance, dozens of residents have volunteered as subjects in studies that placed sensors in their rooms. The monitors feed data to computer software about how and when residents move. Unique patterns emerge for each person. Co-researcher Marjorie Skubic, professor of electrical and computer engineering, has developed software that recognizes patterns and aberrations. Even minor changes in gait or movement patterns can signal early stages of health problems. When that happens, the computer alerts nurses to check out the situation and, if need be, activate other parts of the health care system. Eventually, this technology could be used in private residences to help elders live at home longer.
This is a new way of measuring changes in physical function, Rantz says. “It’s more sensitive than usual observation or usual care, such as measuring blood pressure and heart rate. When we can pick up early indications of problems, we can intervene and avoid decline. That’s the whole idea.”
TigerPlace’s high-tech aspects are just part of what makes it unique. The public spaces — lounges, dining areas, gardens and a movie theater — are on one level where elders live.
Services range from minimal help with bathing to what nursing homes offer their most frail residents. When residents develop health problems, it’s not just services that come to them. A nurse care coordinator helps them navigate the health care system to ensure their treatment is proper and timely.
Aging in place improves health and saves money. “Even with the wellness programs and care coordinator, no resident’s charges have ever exceeded the average cost of living in a nursing home,” Rantz says. Its efficiency derives from more than technology and staff. TigerPlace offers wellness clinics, an exercise room, tasty food and plentiful green space. The basic cost of living at TigerPlace includes all the amenities mentioned above, plus care coordination, access to an on-call nurse and the wellness clinic, four nurse visits a year, and full health assessments twice a year. For care beyond that, charges mount, which motivates residents to keep their costs down by staying healthy.
Rantz’s motives stem from her childhood in East St. Louis, Ill., and a loving relationship with her great-aunt Amelia Oliver. “I had such fun going to her house. I still remember the smells of the old place and the furniture that she and her husband brought from Germany. She was wonderful at sewing and cooking. But if we had a batch of fudge that never firmed up, she would say, ‘It’s OK, we’ll eat it with a spoon!’ ”
In her early teens, Rantz watched as Aunt Amelia declined, spending more and more days resting at the Rantz house. When the news came that Amelia needed to enter a nursing home, Rantz was devastated. “I pleaded with my parents, ‘Can’t you please let Aunt Amelia move in with us. I’ll share my room with her.’ I think that’s what started my focus on elderly people.”
By the early 1980s, Rantz was married, working and continuing her nursing education in and around Milwaukee. She took a job at the county nursing home and, within a few years, rose through the ranks to direct the 328-bed facility.
For nursing home staff, it’s a fact of the job that residents die. But Rantz was stunned when one of her nurses, a woman her age, passed away. “She was 40 years old, had five kids, and one night she just fell over in the kitchen. She had heart disease.” Only months later, Rantz learned that she had heart disease, as well. “My disease was every bit as bad as hers, and it made me stop and think. There had to be a reason I was still OK. There was something I was supposed to do.”
For the time being, her work was to run the nursing home. On days when Rantz’s administrative work was too frustrating, she’d go to the Alzheimer’s unit just to hang out, talk with people and help with care. She loved the times when she could connect with patients, despite their dementia. “Once in a while, you could look in their eyes and see them, who they really were. I lived for those moments.”
But there were disappointments as well, such as when she had to move a large group of her residents to different rooms. Several died soon after. “We did everything using the latest information about transitions, but it wasn’t good enough,” Rantz says. The episode convinced her that she needed more sophisticated tools for protecting her beloved elders. She enrolled in the doctoral nursing program at the University of Wisconsin–Milwaukee and continued directing the nursing home.
The Next Thing
At the time, the federal government also was trying to improve the quality of nursing homes. In 1988, the government sent word that in 1990 it would require facilities to make detailed patient assessments routinely. Homes would transmit that minimum data set (MDS) to Medicare/Medicaid offices, though the end use was unclear. Some called it a black hole.
Through Rantz’s doctoral work, she saw how the MDS could help improve quality at her nursing home. But she would need help. “Our county had computer programmers who did projects for city hall and the hospital. I figured they could work for me, too,” she says. As home staff nationwide prepared to enter data by hand for transmission to Medicare/Medicaid, Rantz set the programmers to work creating one of the first electronic health records using the assessment information.
The app not only saved a lot of time but also put her data into spreadsheets for analysis and graphed reports for staff to follow quality improvement efforts. She could see, for instance, which residents had high care needs or which units’ residents had the highest rates of bedsores. Knowing that, she and the staff could solve patients’ problems one by one or work systematically to improve care.
In 1992, Rantz’s husband, Wally, changed careers, and the couple moved to Missouri. Marilyn joined the Sinclair School of Nursing faculty at MU and continued her database work, which evolved into the Quality Improvement Program of Missouri (QIPMO). By 2000, QIPMO offered all Missouri nursing homes spreadsheets detailing their performance and comparing it to others. QIPMO also offers nursing homes the expertise of geriatric nurse practitioners to help solve problems. Since QIPMO, residents fall less, have fewer behavior-related problems and are less likely to get pressure ulcers.
In the meantime, Rantz also was following up on the dangers of moving elderly people out of familiar surroundings — in this case, their own homes. In 1999, she and other nursing faculty launched a two-year study of 700 seniors. Nurse care coordinators assessed participants and created care plans that coordinated their physicians’ efforts. This arrangement postponed or prevented nursing home admission for more than one-third of participants. They also walked better, were less depressed, had better short-term memory and experienced less pain than their counterparts in nursing homes. Rantz’s research showing the benefits of nurse care coordination helped move Medicare in November 2012 to pay for these services during the critical first month after patients come home from the hospital. “This is a key step for recognizing the complex work that nurses do to help people stay independent,” she says.
Beginning about two years ago, several of Rantz’s friends and family members encountered serious health problems, and she helped care for them. Her older sister had had several surgeries and was struggling physically and emotionally. Rantz’s best friend was hospitalized with a stroke, and her friend’s husband stayed with Rantz in the aftermath of his cancer reoccurrence.
“Should I retire and take care of these loved ones?” Rantz wondered. Although people with her heart condition rarely tolerate the pace and stress of a research career, she hadn’t thought about retirement until then.
Rantz got her answer kneeling at the church rail. “I kept asking, should I retire?” What happened next still surprises her. “I had a vision. There was a bright light and a flash of the work still to be carried on. It was a clear message: You’re on the right path, stay on it.”
So she did. Then a year later her sister-in-law, Dorothy Rantz, became ill at the end stage of multiple diseases and, after a hospital stay, entered a nursing home. Dorothy wrote an advance directive saying that she chose not to return to the hospital when her health deteriorated. That was wise, Rantz says, because for patients in Dorothy’s condition, many times, hospitals can hurt more than they help.
Despite the advance directive, however, matters went awry. “Dorothy blacked out, the nursing home staff panicked and sent her back to the hospital,” Rantz says. After a month there, Dorothy returned to the nursing home but was never again able to get out of bed. That last episode of her life cost about $250,000, and during her last two months alive, her occasional periods of alertness were miserable ones. “That’s not the way you want to spend the end of your life,” Rantz says. “We buried her in February 2012.”
Within weeks, the Centers for Medicare and Medicaid Services sent out a call for research proposals related to nursing homes. The subject: how to prevent needless rehospitalization. Writing the grant application would guarantee a stressful three months of seven-days-a-week writing and meetings for her and her team. “But I thought of Dorothy and said, ‘Yes, we have to do this.’ ”
MU’s Largest Research Grant Ever
That work led to the October 2012 announcement of the $14.8 million grant that is placing highly educated nurses in 16 St. Louis nursing homes. They will assess all residents and help the staff learn and use a set of clinical guidelines for collecting and communicating information about residents. The big idea sounds familiar: recognize problems early and take care of them in the nursing home to avoid hospitalization and its accompanying ills. Rantz expects cost savings to be more than enough to cover the nurses’ salaries.
“If one of these nurses had been there for Dorothy, they would have assessed her, reviewed her wishes with her and the staff, and carried out the plan to keep her comfortable — the plan she wanted.”