When the nursing team at the Chesterfield, Missouri-based Delmar Gardens West needed to leverage proactive insights to optimize system-wide health outcomes, they streamlined the process and chose the one, right tool: a human.

“Everyone here who has Optum can’t wait to see Sarah every day,” says one Delmar Gardens patient. “She’s just wonderful.”

This is Sarah Kozak, a nurse practitioner with Optum, the advanced care model that brings a layer of nursing support into care facilities, focusing on care coordination, chronic conditions support and the proactive prevention of patient decline.

It’s no small need. Long-term care organizations are under increasing pressure to manage residents with complex medical needs while reducing avoidable hospitalizations and supporting families and staff.

For Delmar Gardens, what began as added clinical support evolved into a deeply integrated, in-place care model that strengthens care coordination, improves clinical decision-making, delivers wins in their daily operations and enhances confidence across the organization.

Now they’re creating benefits for residents and wins for their business. What kind of wins? Facilities working with Optum have seen:

• 51% reduction in emergency visits¹ 

• 38% reduction in avoidable hospitalizations¹ 

Here is a look at how Optum delivers.

The Community Care approach

Like many long-term care communities, Delmar Gardens was navigating a growing gap between routine nursing care and acute medical intervention. Residents experiencing subtle, difficult-to-detect health declines meant an increase in the likelihood of emergency department transfers and hospitalizations.

Without an advanced clinician consistently on site, families often defaulted to hospital care when concerns arose. All of this created disruption for residents, anxiety for families and operational strain for staff managing complex conditions with limited clinical escalation options.

Delmar Gardens’s solution was Optum. By partnering up, Delmar Gardens embeds caring, dedicated nurse practitioners like Kozak into their facilities, ensuring immediate, direct contact with the community on a daily basis. Optum delivers:

• An on-site clinician who visits multiple days each week, with additional nursing support nearly daily, allowing care to be delivered where residents live rather than defaulting to external settings 

• A nurse practitioner focused on early assessment, proactive care planning and coordination with facility staff, physicians and families 

• A daily presence, enabling close familiarity with residents’ routines, making it easier to identify subtle changes that may indicate emerging health issues and intervene before they escalate 

“What I love about Sarah is the amount of time that she spends with our residents,” says Delmar Gardens administrator Richard Taylor. “Having Sarah in the building, we can catch those subtle declines and start treatment plans to prevent those hospitalizations.”

“I know the people that sleep late,” Kozak says. “I know the people that go outside. I know the people that are always at bingo. And if they’re not at bingo, something’s wrong.”

Those daily interactions are the key to the Optum model. By having an advanced clinician on site, Delmar Gardens can assess and manage many acute issues within the community. Early detection and contingency planning help prevent unnecessary emergency department visits and reduce hospital transfer disruption.

Facility leadership notes that the ability to catch subtle declines sooner supports more timely treatment and better clinical outcomes. Residents benefit from remaining in a familiar environment, maintaining routines and avoiding care transition risks.

“She saved my life a couple times,” one patient says. “I get pneumonia quite a bit and she’s caught it every time.”

Introducing a scalable model for long-term care organizations

For residents and families of Delmar Gardens West, the embedded care model from Optum provides a greater sense of reassurance. Consistent access to a nurse practitioner who knows the residents, communicates regularly and coordinates care helps create confidence that concerns will be addressed promptly and appropriately.

“Sarah’s been wonderful to us,” says the parent of one resident. “She’s been there and not only for (my son) but also for me, and that’s very reassuring as a parent.”

With Optum, families report feeling more secure knowing an advanced clinician can evaluate changes on site and communicate next steps clearly. This trust allows families to feel comfortable stepping away when needed, confident that their loved ones are being closely monitored and supported.

“We were able to take a trip for the first time in probably 15 years or more, and I felt like if we were gone for a two-week period, he would be okay,” the parent says.

Furthermore, the presence of an on-site nurse practitioner also strengthens Delmar Gardens’s internal clinical ecosystem. Nursing staff benefit from real-time collaboration, clinical guidance and shared decision making when complex situations arise. Regular interaction with an advanced clinician can help:

• Support skill development 

• Improve communication during acute episodes 

• Increase staff confidence in managing residents in place  

This collaborative model helps align care teams and supports more consistent, coordinated care delivery. It’s a scalable model that long-term care organizations can use to go to the next level. The Optum-Delmar Gardens partnership demonstrates how embedding advanced clinical care into long-term care communities can help bridge gaps in care delivery. By shifting from reactive, episodic interventions to proactive, relationship-based care, organizations can better support residents, families and staff while strengthening operational resilience.

For Delmar Gardens West, the result is a more integrated care model that delivers stability for residents, confidence for families and partnership for staff — creating a stronger foundation for long-term care delivery.

“Sarah has brought an advanced level of skill to our nurses,” says Delmar Gardens Director of Nursing Brenda Schmidt. “It’s comforting for them to know that there’s a nurse practitioner that they can bounce questions off of.”

Adds the aforementioned parent: “She’s our guardian angel.”

This Views article is sponsored by Optum. To learn more, visit Optum here: “Embedding Advanced Clinical Support in Long-Term Care Settings”

¹Stats from: McGarry and Grabowski, 2019