'Promising results’ for CMS initiative on reducing hospitalizations among nursing home residents

In 2012, CMS launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents in 143 long-term care (LTC) facilities across seven states. According to a study published in the March 2017 issue of Health Affairs, the approach appears to have been effective.

Written by researchers and scientists at RTI International, the study said the initiative chose locations with high Medicare costs and readmission rates and larger populations of nursing home residents who are dually eligible for Medicare and Medicaid. Seven organizations—including academic institutions, quality improvement organizations, health systems and a hospital foundation—were chosen as Enhanced Care and Coordination Providers (ECCP) to design and implement educational interventions for at least 15 LTC facilities in their states.

The plans had to include certain elements, like hiring on-site staff focused on hospitalization-related issues and hiring supporting nursing staff. Other interventions, such as health IT improvements and education for administrators, were left up to the plan designers.

This resulted in some variation in the estimated effects, but the study determined there were reductions in avoidable hospitalizations and Medicare spending by the end of the program in 2015.

“We estimated net reductions in 2015 of 2.2 to 9.3 percentage points in the probability of an all-cause hospitalization and 1.4 to 7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members,” the study said. "In that year, average per resident Medicare expenditures were reduced by $60 to $2,248 for all-cause hospitalizations and by $98 to $577 for potentially avoidable hospitalizations."

How much a state improved depended on the extent of the intervention. For example, the Alabama ECCP opted for an education-only model for nurses. The effects on all outcomes were insignificant in 2014, while there was some smaller improvement on all-cause and avoidable hospitalizations in 2015.

“The Missouri, Indiana and Pennsylvania models—which included consistent, hands-on clinical care for nursing facility residents on a daily basis, not just training for facility staff or intermittent clinical care—demonstrated greater changes in facility culture, greater support for the need to reduce avoidable hospitalizations, and greater overall buy-in to the initiative from facility staff,” the study said.

Buy-in was crucial to success, the study authors wrote. The ECCPs emphasized that the existing nursing home staff and administrators needed to support not only the goals of the initiative but the specific plans to achieve them. Weaker engagement from facility leadership or turnover in staff led to smaller improvements.

This particular initiative didn’t offer financial incentives for good performance, though the authors noted in their conclusion that this will change in the next phase, offering a comparison to the earlier interventions.

“Medicare will pay participating nursing facilities and their partnering practitioners for treating residents with particular conditions in the facility instead of sending them to the hospital,” the authors wrote. "We will evaluate the effectiveness of this new payment model as it unfolds, relative to that of the model of clinical and educational interventions.”