CMS Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Model
Overview
For the past three years, the Centers for Medicare & Medicaid Services (CMS) has been partnering with seven organizations to implement strategies to reduce avoidable hospitalizations for Medicare-Medicaid enrollees who are long-stay residents of nursing facilities. This work, the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, is a result of collaboration between the Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation. The Initiative directly supports CMS’ ongoing work to reduce avoidable hospitalizations for Medicare-Medicaid enrollees and improve quality of care in post-acute and long-term care settings. To launch the second phase of this initiative, CMS is announcing a new funding opportunity that will allow currently participating organizations to apply to test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by long-stay nursing facility residents.
Background
Improving the care experience for individuals who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligibles” – is a critical priority for CMS. Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, and providers (Medicare Parts A, B, and D and Medicaid). Total annual spending for their care is approximately $300 billion across both programs. Medicare-Medicaid enrollees are among the most chronically ill and complex enrollees in both programs.
Hospitalizations can be disruptive and costly for Medicare-Medicaid enrollees residing in nursing facilities. Research shows that nearly 45 percent of hospitalizations among this population are avoidable, meaning they could have been prevented or treated in a lower intensity care setting.
Initiative Design
The goal of this Initiative is to:
- Reduce the number of and frequency of avoidable hospital admissions and readmissions;
- Improve beneficiary health outcomes;
- Provide better transitions of care for beneficiaries between inpatient hospitals and nursing facilities; and
- Promote better care at lower costs while preserving access to beneficiary care and providers.
Seven organizations selected to participate in the initiative are partnering with CMS to implement evidence-based interventions to accomplish these goals among Medicare-Medicaid enrollees who are residents of long-term care facilities (see Appendix A). Each Enhanced Care and Coordination Provider (ECCP) provides on-site services in its partner nursing facilities, including direct care and staff training. Nursing facility participation is voluntary.
The awarded interventions in the first phase of the initiative have reached about 16,000 beneficiaries each month. Successful ECCP applicants would be able to continue these interventions in conjunction with the new payment model.
Interim Evaluation
In July 2015, CMS released a report entitled, "Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Summary of Evaluation as of December 2014." This summary report presents results of the quantitative and qualitative analysis of data from the first Initiative year, 2013.
The report includes promising initial results through 2013, though it is too early to draw any firm conclusions because the ECCPs were phasing in their interventions during this period. The report found that, in the first year alone, six of the seven ECCPs showed reduction in the likelihood of a potentially-avoidable hospitalization for participating beneficiaries. For two of the ECCPs, the effect was statistically significant. For all-cause hospitalizations, five of the seven ECCPs showed some degree of improvement, of which three were statistically significant. This report can be found at http://innovation.cms.gov/Files/reports/irahnfr-secondevalrpt.pdf.
Payment Model
The intent of the new payment model is to reduce potentially-avoidable hospitalizations by funding higher-intensity interventions in nursing facilities for residents who may otherwise be hospitalized upon an acute change in condition. Improving the capacity of nursing facilities to treat medical conditions as effectively as possible on-site has the potential to improve the residents’ care experience at lower cost than a hospital admission. The model also includes payments to practitioners (i.e., physicians, nurse practitioners and physician assistants) that are similar to the payments they would receive for treating beneficiaries in a hospital. Practitioners would also receive new payments for engagement in multidisciplinary care planning activities. Successful ECCP applicants would implement the payment model with both their existing partner facilities, where they provide training and clinical interventions, and in a comparable number of newly recruited facilities. The payment model is slated to run from October 2016 to October 2020.
Additional Resources
For more information on this initiative, please go to https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ReducingPreventableHospitalizationsAmongNursingFacilityResidents.html.
Appendix A - Participants
- HealthInsight of Nevada is implementing an intervention, named the “Nevada Admissions and Transitions Optimization Program” or “ATOP”. The initiative includes the creation of pods that consist of a physician extender (nurse practitioner or physician’s assistant) and two registered nurses (RNs) who are physically on-site at nursing facilities. Each one of the five pods provide enhanced care and coordination to residents in five facilities. HealthInsight of Nevada has also implemented a medication management program to reduce polypharmacy and the inappropriate use of antipsychotics.
- Indiana University is implementing an intervention called “OPTIMISTIC” (“Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care”). This initiative includes the deployment of RNs and advanced practice nurses (APNs) to be on-site at the nursing facilities to coordinate with nursing facility staff and residents’ primary care providers, allowing for enhanced recognition and management of acute change in medical conditions.
- The Curators of the University of Missouri is implementing the Missouri Quality Initiative whereby advanced practice RNs (APRNs) are assigned to facilities to provide direct services to residents while mentoring, role-modeling, and educating the nursing staff about early symptom/illness recognition, assessment, and management of health conditions commonly affecting nursing home residents. Additionally, the intervention includes the use of social workers who work closely with each facility’s social worker, the residents’ primary care providers, nursing facility staff, and APRNs, to assure consistent communication about resident’s needs and preferences.
- Alabama Quality Assurance Foundation initiative includes the implementation of “EMPOWER” (Enhancing My Profession and Organization with Empathy and Respect), which is a training program to help nursing facility staff enhance their skills for managing workplace demands and professional relationships. Additionally, the intervention staff works with each facility to adopt and measure consistent assignment as defined by the Advancing Excellence in America’s Nursing Homes campaign.
- UPMC Community Provider Services has created a program called “RAVEN” (Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing facilities in western Pennsylvania). This program includes facility-based nurse practitioners to assist with determining resident care plan goals, and conduct acute change in condition assessments. The intervention provides support from innovative telehealth and information technologies to connect participating nursing facilities into the Western PA Health Information Exchange.
- Alegent Health deploys nurse practitioners in the partnering nursing facilities in Nebraska to enhance care by improving medication management based on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. An innovative aspect of this program is the use of a dentist and dental hygienist to improve oral care for beneficiaries. This type of care is typically not provided in the nursing facility environment and contributes to better overall health, while also working to prevent other conditions that lead to avoidable hospitalizations.
- The Greater New York Hospital Foundation, Inc. deploys RNs in the partnering nursing facilities to train the nursing facility staff on the American Medical Director Association Clinical Practice Guidelines on Acute Change in Condition. The project is also implementing an electronic system to eliminate the need for the paper-based format and to provide real-time access to beneficiary information to all providers across the continuum of care.
All seven organizations also work with their partner facilities to implement INTERACT (Interventions to Reduce Acute Care Transfers) tools.
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