CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned.

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS: Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

The Impact of the Great Recession on Long-Term Services and Supports in the United States and England.

The Great Recession substantially affected most developed countries. How countries responded to the Great Recession varied greatly, especially in terms of public spending. We examine the impact of the Great Recession on long-term services and supports (LTSS) in the United States and England. Financing for LTSS in these two countries differs in important ways; by examining the two countries' financing and program structures, we learn how these factors influenced each country's response to this common external stimulus. We find that between 2006 and 2013, LTSS increased in the United States in terms of spending (17%) and number of people served; in contrast, over the same period, LTSS in England decreased in terms of spending (6%) and people served. We find that the use of earmarked LTSS funding in the United States, compared to non-earmarked funding in England, contributed to different trajectories for LTSS in the two countries. Other contributing factors included differences in service entitlements, variations in ability of state and local governments to tax, and larger macroeconomic strategies implemented to combat the recession. We analyze the implications of our findings, especially as related to the potential shift to Medicaid block grant LTSS funding in the United States.

HCBS Spending and Nursing Home Admissions for 1915(c) Waiver Enrollees.

Medicaid waiver programs for home- and community-based services (HCBS) have grown rapidly and serve a population at high risk for nursing home (NH) admission. This study utilized the Medicaid Analytic Extract Personal Summary File and the NH Minimum Data Set and tested whether higher levels of per-beneficiary HCBS spending were associated with (1) lower risk of long-term (90+ days) NH admission and (2) higher functional/cognitive impairment at admission for new enrollees in 1915(c) aged or aged and disabled waiver programs. Waiver enrollees in states and counties with higher HCBS spending were found to have lower risk of long-term NH admission and greater functional impairment at NH admission compared to waiver enrollees in states and counties with lower spending. This indicates that higher per-enrollee HCBS spending may enable waiver enrollees to remain in the community until their functional impairment becomes more severe.

Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative.

OBJECTIVES: The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN: Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS: The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS: We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS: Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS: Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

Evaluating Policies to Decrease the Risk of Introducing SARS-CoV-2 Infections to Nursing Home Facilities.

We used an individual-based microsimulation model of North Carolina to determine what facility-level policies would result in the greatest reduction in the number of individuals with SARS-CoV-2 entering the nursing home environment from 12/15/2021 to 1/3/2022 (e.g., Omicron variant surge). On average, there were 14,287 (Credible Interval [CI]: 13,477-15,147) daily visitors and 17,168 (CI: 16,571-17,768) HCW coming from the community into 426 nursing home facilities. Policies requiring a negative rapid test or vaccinated status for visitors resulted in the greatest reduction in the number of individuals with SARS-CoV-2 infection entering the nursing home environment with a 29.6% (26.9%-32.0%) and 24.0% (CI: 22.2%-25.5%) reduction, respectively. Policies halving visits (21.2% [20.0%-28.2%]), requiring all vaccinated HCW to receive a booster (7.8% [CI: 7.4%-8.7%]), and limiting visitation to a primary visitor (6.5% [CI: 3.5%-9.7%]) reduced infectious contacts to a lesser degree.

Rates of nursing home closures were relatively stable over the past decade, but warrant continuous monitoring.

For years, nursing home closures have been a concern for the industry, policymakers, consumer advocates, and other stakeholders. We analyzed data from 2011 through 2021 and did not find persistent increases in the closure rates. Closures were relatively stable from 2011 to 2017, averaging 118 facilities (0.79%) per year and increasing to 143 (0.96%) in 2018 and 200 (1.34%) in 2019. Closures decreased during the COVID-19 pandemic, averaging 133 facilities in 2020 and 2021 (0.90%). Medicaid-only nursing facilities had higher closure rates than Medicare-only skilled-nursing facilities and dually certified nursing homes. The Census regions (divisions) of the South (West South Central) and Northeast (New England) had the highest closure rates, while the South (South Atlantic and East South Central) had the lowest rates. Facility characteristics associated with increased closure risk included smaller size, lower occupancy rate, urban location, no ownership changes, lower inspection survey ratings, higher staffing ratings, higher percentages of non-White residents and Medicaid residents, lower percentages of Medicare residents and residents with severe acuity, and location in states with more nursing home alternatives. Additional research should examine the impact of closures on resident outcomes and access to care.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population.

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

Nearly One In Five Skilled Nursing Facilities Awarded Positive Incentives Under Value-Based Purchasing.

Medicare's Skilled Nursing Facility Value-Based Purchasing Program, which awards value-based incentive payments based on hospital readmissions, distributed its first two rounds of incentives during fiscal years 2019 and 2020. Incentive payments were based on achievement or improvement scores-whichever was better. Incentive payments were as low as -2.0 percent in both program years and as high as +1.6 percent in FY 2019 and +3.1 percent in FY 2020. In FY 2019, 26 percent of facilities earned positive incentives and 72 percent earned negative incentives, compared with 19 percent positive and 65 percent negative incentives in FY 2020. Larger, rural, and not-for-profit facilities were more likely to earn positive incentives, as were those with the highest registered nurse staffing levels. Although these findings indicate the potential to reward high-quality care at skilled nursing facilities, intended and unintended outcomes of this new value-based purchasing program should be monitored closely for possible program refinements, particularly in light of the disproportionate impacts of coronavirus disease 2019 (COVID-19) on nursing facilities.

Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative.

BACKGROUND/OBJECTIVES: Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated. DESIGN: We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status. SETTING: Participating NFs during fiscal years 2017 to 2018. PARTICIPANTS: There were 47,202 long-stay NF residents from 260 facilities in seven states. INTERVENTION: CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform. MEASUREMENTS: Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions. RESULTS: Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital. CONCLUSION: Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Nursing Facilities Can Reduce Avoidable Hospitalizations Without Increasing Mortality Risk For Residents.

Implementation of the Centers for Medicare and Medicaid Services' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents reflected recognition of the adverse impacts of excess hospitalizations on the cost of care and the well-being of long-stay residents. Prior studies of the initiative have found favorable effects on reducing hospitalizations and costs, but were these accompanied by unintended consequences for well-being? We tracked all-cause mortality rates in each year for the period 2014-16 among long-stay residents at nursing facilities in seven states that participated in the initiative, and we found no evidence of excess mortality. The initiative's effects on mortality rates were small-ranging from a reduction of 0.8 percentage points to an increase of 1.5 percentage points, relative to changes in mortality rates at comparison-group facilities-and none of the effects was significant. This suggests that efforts to reduce unnecessary hospitalizations among nursing facility residents can succeed without increasing mortality rates.

Transitioning From Community-Based to Institutional Long-term Care: Comparing 1915(c) Waiver and PACE Enrollees.

Purpose of the Study: To compare the risk of long-term nursing home (NH) admission and the level of functional and cognitive impairment at the time of long-term NH admission in the Program of All-Inclusive Care for the Elderly (PACE) and in 1915(c) aged and aged and disabled waiver programs. Design and Methods: Cohorts of new waiver and PACE enrollees in 12 states were identified (in 2005-2007) and followed (through 2009) using the Medicaid Analytic Extract and the Minimum Data Set. Individual-level outcomes of interest were time from waiver or PACE enrollment to long-term (90+ days) NH admission and functional (29-point activities of daily living [ADL]) and cognitive (7-point Cognitive Performance Scale [CPS]) impairment at NH admission. An overall measure of impairment was also created and categorized as low (ADL < 17 and CPS < 3) versus high (ADL ≥ 17 or CPS ≥ 3). The key independent variable was enrollment in PACE versus waiver program. County-level covariates were included. Analyses employed multivariable models including competing risk proportional hazard and linear and logistic regressions. Results: Compared with waiver enrollees, PACE enrollees had 31% lower risk of long-term NH admission (p < .001). At NH admission, they were overall significantly (p < .0001) more cognitively impaired (0.34 point), with 55% higher odds of severe (CPS ≥ 4) cognitive impairment (p < .001) and 45% higher odds of having overall high impairment (p = .003). Implications: PACE may be more effective than 1915(c) aged and aged and disabled waiver programs in reducing long-term NH use and may be particularly well suited to supporting cognitively impaired individuals, enabling them to remain in the community longer.

Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results.

Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

End-of-Life Care in Nursing Homes: From Care Processes to Quality.

BACKGROUND/OBJECTIVE: Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. DESIGN AND METHODS: We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. RESULTS: Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice. CONCLUSIONS: Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.

Hospitalizations in the Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To measure the rates of hospitalization, readmission, and potentially avoidable hospitalization (PAH) in the Program of All-Inclusive Care for the Elderly (PACE). DESIGN: Retrospective study. SETTING PACE PARTICIPANTS: PACE enrollees. MEASUREMENTS: Hospitalization and PAH rates were measured per 1,000 person-years. Readmission was defined as any return to the hospital within 30 days of prior hospital discharge. PAHs were defined as hospitalizations for conditions that previously established criteria have identified as possibly preventable or manageable without hospitalization. RESULTS: Rate of hospitalization was 539/1,000, vs 962/1,000 for dually eligible aged or disabled waiver (ADW) enrollees. Thirty-day readmission was 19.3%, compared with 22.9% for the national population of dually eligible older enrollees. PAH rate was 100/1,000, compared with 250/1,000 for dually eligible ADW enrollees. Considerable variation was observed between sites. CONCLUSION: PACE enrollees experienced lower rates of hospitalization, readmission, and PAH than similar populations. Variations in hospitalization rates between PACE sites suggest opportunities for quality improvement.