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.

Experience, Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform.

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans' experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.

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.

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.

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.

Immigrant and non-immigrant certified nursing assistants in nursing homes: how do they differ?

This study analyzes the 2004 National Nursing Assistant Survey and other survey data to examine the characteristics and experiences of immigrant and non-immigrant certified nursing assistants (CNAs) in nursing facilities. Descriptive results focus on differences in personal characteristics, working conditions, extrinsic rewards, work experiences, job satisfaction, and workplace discrimination. The findings indicate that immigrant CNAs are older, better educated, and somewhat more highly paid than their non-immigrant counterparts but also experience substantial levels of discrimination and language-related communication barriers at work. The paper discusses major policy issues that arise from the increase in immigrant labor in long-term care.

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.

Mode of administration effects on disability measures in a sample of frail beneficiaries.

PURPOSE: To compare disability rates resulting from several modes of survey administration in a single sample of frail elders. DESIGN AND METHODS: Using the same battery of six ADL questions we compared the resulting level of disability across several modes of administration: mail survey with telephone follow-up, in person interview, and evaluation by a registered nurse, further comparing self and proxy responses where both were available. We also created a crosswalk between these measures and clinical evaluations by rehabilitation therapists, allowing another point of comparison. RESULTS: Disability rates varied substantially by mode of survey administration and all survey modes yielded lower rates of disability than those we derived from clinical assessments. IMPLICATIONS: Relying on self-report in evaluating functional status may underestimate disability in clinical evaluations, level of care determinations and service planning. Researchers and policymakers should also take mode of administration effects into account when estimating or comparing disability rates.

Are consumer-directed home care beneficiaries satisfied? Evidence from Washington state.

PURPOSE: This study analyzed the effect of consumer-directed versus agency-directed home care on satisfaction with paid personal assistance services among Medicaid beneficiaries in Washington State. DESIGN AND METHODS: The study analyzed a survey of 513 Medicaid beneficiaries receiving home- and community-based services. As part of a larger study, we developed an 8-item Satisfaction With Paid Personal Assistance Scale as the measure of satisfaction. In predicting satisfaction with personal assistance services, we estimated an ordinary least squares regression model that was right-censored to account for the large percentage of respondents who were highly satisfied with their care. RESULTS: Among the older population, but not younger people with disabilities, beneficiaries receiving consumer-directed services were more satisfied than individuals receiving agency-directed care. There was no evidence that quality of care was less with consumer-directed services. In addition, overall satisfaction levels with paid home care were very high. IMPLICATIONS: This study supports the premise that consumer satisfaction, an important measure of quality, in consumer-directed home care is not inferior to that in agency-directed care. The positive effect of consumer direction for older people underlines the fact that this service option is relevant for this population. In addition, this research provides evidence that home- and community-based services are of high quality, at least on one dimension.

What Are Nursing Facilities Doing to Reduce Potentially Avoidable Hospitalizations?

OBJECTIVES: Hospitalizations among nursing facility residents are frequent and often potentially avoidable. A number of initiatives and interventions have been developed to reduce excessive hospitalizations; however, little is known about the specific approaches nursing facilities use to address this issue. The objective of this study is to better understand which types of interventions nursing facilities have introduced to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. DESIGN: Cross-sectional survey. SETTING: 236 nursing facilities from 7 states. PARTICIPANTS: Nursing facility administrators. MEASUREMENTS: Web-based survey to measure whether facilities introduced any policies or procedures designed specifically to reduce potentially avoidable hospitalizations of long-stay nursing facility residents between 2011 and 2015. We surveyed facilities about seven types of interventions and quality improvement activities related to reducing avoidable hospitalizations, including use of Interventions to Reduce Acute Care Transfers (INTERACT) and American Medical Directors Association tools. RESULTS: Ninety-five percent of responding nursing facilities reported having introduced at least one new policy or procedure to reduce nursing facility resident hospitalizations since January 2011. The most common practice reported was hospitalization rate tracking or review, followed by standardized communication tools, such as Situation, Background, Assessment, Recommendation (SBAR). We found some variation in the extent and types of these reported interventions. CONCLUSIONS: Nearly all facilities surveyed reported having introduced a variety of initiatives to reduce potentially avoidable hospitalizations, likely driven by federal, state, and corporate initiatives to decrease hospital admissions and readmissions.

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.

Personal care satisfaction among aged and physically disabled Medicaid beneficiaries.

We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.

Workforce issues and consumer satisfaction in Medicaid personal assistance services.

This study used a survey of older people and younger persons with disabilities who were receiving Medicaid-financed home and community-based services (HCBS) to assess the effect of workforce issues on consumer satisfaction. We found that recruitment problems had very strong negative and significant effects on consumer satisfaction. An interruption in service was a more important and significant indicator of consumer dissatisfaction than not having the same worker over time. We also found that problems with worker training and respect and treatment of consumers strongly and significantly affected satisfaction with paid care. Efforts to improve workforce issues are needed to improve the quality of care of these services.

Impact of nonresponse on Medicare Current Beneficiary Survey estimates.

The Medicare Current Beneficiary Survey (MCBS) has been used by policymakers and research analysts to provide information on a wide array of topics about the Medicare Program. Nonresponse bias is potentially one of the most important threats to the validity of the estimates from the MCBS. In this article we present results of our methodological study that analyzes the impact of nonresponse on MCBS estimates, including initial round unit nonresponse, panel attrition, and item nonresponse. Our findings indicate that for most of the measures studied, the bias caused by differences between nonrespondents and respondents in the MCBS was substantially reduced or eliminated by the nonresponse procedures currently employed.

Comparison of utilization of dental care services among Chinese- and Russian-speaking immigrant elders.

OBJECTIVE: The purpose of the study was to identify factors predictive of use of dental services among Chinese- and Russian-speaking immigrant elders. METHODS: The data for this analysis were collected from the 1997 survey "Assessing public health and health care needs of Russian-speaking elderly immigrants." A similar survey was replicated among Chinese-speaking elderly immigrants in 2000. Community-based samples of 300 Russian elders and 177 Chinese elders were recruited for the study. RESULTS: Chinese elders used dental care services at lower rates than Russian elders. Education, length of stay in the U.S., social support, and smoking behavior were significant predictors for the use of dental services among Chinese. However, among Russian elders, age, income, and denture use predicted utilization of dental services. CONCLUSIONS: Although Chinese- and Russian-speaking elders have similar immigrant experiences and share the same geographic location and urban setting, the two groups have different patterns of dental service use. These differences may be due to differences in socio-demographic characteristics, values, attitudes and knowledge of oral health and dental care, and unique cultural backgrounds.

Children in the Oregon Health Plan: how have they fared?

This study examines the impact of the Oregon Health Plan (OHP) on children's access to care. A telephone survey was conducted in 1998 of two groups of children: OHP enrollees and food stamp recipients not enrolled in OHP. Much of OHP's impact has been realized by the simple extension of health insurance coverage to Oregon's low-income children. The availability of insurance significantly increased the use of physician visits and dental care. The priority list had little effect on children, affecting only 2 percent of OHP children surveyed, most of whom succeeded in getting the service anyway. Thus, despite the negative publicity prior to its implementation, there is no evidence that "rationing" under OHP has substantially restricted access to needed services for children.

Impact of the Oregon Health Plan on access and satisfaction of adults with low income.

OBJECTIVE: To evaluate the effects of the Oregon Health Plan (OHP) on beneficiary access and satisfaction. DATA SOURCES: Telephone survey of nondisabled adults in 1998. STUDY DESIGN: Two groups of adults were surveyed: OHP enrollees and Food Stamp recipients not enrolled in OHP. The Food Stamp sample included both privately insured and uninsured recipients. This allowed us to disentangle the insurance effects of OHP from other effects such as its reliance on managed care and the priority list. OHP and Food Stamp adults were compared along the following measures: usual source of care, utilization of health care services, unmet need, and satisfaction with care. DATA COLLECTION: The survey was conducted by telephone, using computer-assisted telephone interviewing techniques. PRINCIPAL FINDINGS: Much of OHP's impact has been realized by its extension of health insurance coverage to Oregon's low-income residents. The availability of health insurance significantly increased the utilization of many health care services and reduced unmet need for care. OHP was associated within a higher percentage of enrollees having a usual source of care and higher rates of Pap test screening among women compared with Food Stamp recipients. OHP enrollees also reported significantly higher use of dental care and prescription drugs; use we attribute to the expanded benefit package under the priority list. At the same time, OHP enrollees reported a greater unmet need for prescription drugs. Drug treatment for below-the-line conditions was one reason for this unmet need, but often the specific drug simply was not in the plan's formulary. OHP enrollees were as satisfied with their health care as those Food Stamp recipients with private health insurance. CONCLUSIONS: Despite the negative publicity prior to its implementation, there is no evidence that "rationing" under OHP's priority list has substantially restricted access to needed services. OHP adults appear to enjoy access equal to or better than that of low-income persons with private health insurance and have far greater access than the uninsured.

Covering Uninsured Adults Through Medicaid: Lessons from the Oregon Health Plan.

The Oregon Health Plan (OHP), Oregon's section 1115 Medicaid waiver program, expanded eligibility to all residents living below poverty. We use survey data, as well as OHP administrative data, to profile the expansion population and to provide lessons for other States considering such programs. OHP's eligibility expansion has proved a successful vehicle for covering large numbers of uninsured adults, although most beneficiaries enroll for only a brief period of time. The expansion population, particularly childless adults, is relatively sick and has high service use rates. Beneficiaries are also likely to enroll when they are in need of care.

Estimation of non-response bias in the Medicare FFS HOS.

We examined non-response bias in physical component summary scores (PCS) and mental component summary scores (MCS) in the Medicare fee-for-service (FFS) Health Outcomes Survey (HOS) using two alternative methods, response propensity weighting and imputation for non-respondents. The two approaches gave nearly identical estimates of non-response bias. PCS scores were 0.74 points lower and MCS scores 0.51 points lower after adjustment for non-response through imputation and 0.63 and 0.46 lower after adjustment for propensity weighting. These levels are small for component scores suggesting that survey non-response to the FFS HOS does not adversely affect estimates of average health status for this population.