© 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine Objectives: The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project led to significant decreases in potentially avoidable hospitalizations of long-stay nursing facility residents in external evaluation. The purpose of this study was to quantify hospitalization risk from the start of the project and describe the heterogeneity of the enrolled facilities in order to better understand the context for successful implementation. Design: Pre-post analysis design of a prospective intervention within a single group. Setting and Participants: A total of 4320 residents in the 19 facilities were included from admission until time to the first hospitalization. Measures: Data were extracted from Minimum Data Set assessments and linked with facility-level covariates from the LTCFocus.org data set. Kaplan-Meier and Cox proportional hazards regression were used to assess risk of hospitalization during the preintervention period (2011-2012), a “ramp-up” period (2013-2014), and an intervention period (2015-2016). Results: The cohort consisted of 4230 long-stay nursing facility residents. Compared with the preintervention period, residents during the intervention period had an increased probability of having no hospitalizations within 1 year, increasing from 0.51 to 0.57, which was statistically significant (P <.001). In adjusted Cox models, the risk of hospitalization was lower in the ramp-up period compared to the pre-period [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.75-0.95] and decreased further during the intervention period (HR 0.74, 95% CI 0.65-0.84). Conclusions and Implications: As part of a large multisite demonstration project, OPTIMISTIC has successfully reduced hospitalizations. However, this study highlights the magnitude and extent to which results differ across facilities. Implementing the OPTIMISTIC program was associated with a 16% risk reduction after the first 18 months and continued to a final risk reduction of 26% after 5½ years. Although this model of care reduces hospitalizations overall, facility variation should be expected.