CMS experiment saves millions, decreases hospital visits

The CMS has seen a drop in avoidable hospitalizations of seniors and generated nearly $50 million in savings from an experiment that aimed to keep nursing home residents out of inpatient care.

The agency recently touted the results of its three-year Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, which saw a 17% relative reduction in potentially avoidable hospitalizations in participating facilities.

"These findings provide persuasive evidence of the initiative's effectiveness in reducing hospital inpatient admissions, ED visits and hospitalization-related Medicare expenditures," the report said.

Under the model, third-party organizations known as enhanced care and coordination providers, or ECCPs, hired nurses to provide education and clinical support to nursing home staff and help keep residents out of the hospital. All in all, 143 nursing homes in seven states as well as health systems, universities and consultants participated in the program, which ran from 2012 to 2016.

One in four Medicare beneficiaries residing in a nursing home was hospitalized in 2011, costing the CMS $14.3 billion, according to a new report from the HHS' Office of Inspector General. A Health Affairs study found that 47% of hospitalizations of nursing home residents were potentially avoidable.

Given the frail state of many nursing home residents, moving them to the hospital can do more harm than good since the stress of the transfer can worsen a patient's condition and make them even more expensive to treat over time.

"It's pure misery having a person with dementia sitting in an emergency room for hours waiting to be admitted," said Dr. Kathleen Unroe, a geriatrician and assistant professor of medicine at the IU School of Medicine, an ECCP program participant.

About 65% of nursing home residents are on Medicaid, which doesn't reimburse at a high rate. As things are now, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage. After a 3-day inpatient stay, the resident may qualify for Medicare payment for post-acute care in the nursing home. Medicare pays at a rate that is three to four times the daily rate paid by Medicaid, according to a New England Journal of Medicine analysis.

Health systems that participated in the experiment as ECCPs praised the initiative, even though it aimed to reduce inpatient traffic, which could affect their bottom line. The providers acknowledged that it can be better to keep patients in surroundings they know.

"Very often, if a person has some confusion or some cognitive challenges, a hospitalization can be very difficult and they often lose ground," said Brenda Bergman-Evans, vice president of the advanced practice at CHI Health, a Nebraska-based health system made up of 15 acute-care hospitals.

Hospitals can also gain from reducing potentially avoidable Medicare admissions, as it reduces the chance that they will get hit with a Medicare penalty. A 2015 study in the Journal of the American Geriatrics Society showed that patients discharged to a nursing home had a higher 30-day readmission rate than the general community, at 34.4% versus 22.6%.

Hospitals face $564 million in readmission penalties next year. That's up $27 million from fiscal 2017, which ended Sept 30.

"Hospitals are looking for ways to reduce readmissions of high-risk patients, who are often times nursing home residents who have chronic illnesses," said Amy Vogelsmeier, associate professor of nursing at the University of Missouri which served as an ECCP in Missouri.

The experiment could lead to a sea change in how nursing homes care for patients, where the facilities catch ailments early and address them in-house rather than sending residents to the hospital, according to Tim Johnson, executive director of the Greater New York Hospital Association Foundation, which served as the ECCP for New York.

"Most clinicians have been trained to believe that the hospital is the best place for anyone with an acute change of condition," Johnson said. "This belief can result in what turn out to be avoidable hospitalizations."

Initiative participants have moved on to the second phase of the model, which pays nursing homes at Medicare rates to treat patients with one of six specific ailments in their facilities and out of hospitals.

The six conditions—pneumonia, dehydration, congestive heart failure, urinary tract infections, skin ulcers and asthma—are linked to approximately 80% of potentially avoidable hospitalizations among long term care facility residents, according to the CMS.

ECCPs believe this second phase will generate even better results than the first phase of the initiative and puts nursing homes on equal footing with rates to hospitals.

"If the nursing facility is providing the same level of care as a hospital why shouldn't they get the same level of reimbursement," said Deborah Huber, executive director for HealthInsight Nevada, the ECCP of that state. "This levels the playing field."

An​ edited​ version​ of​ this​ story​ can​ also​ be​ found​ in​ Modern​ Healthcare's​ Oct.​ 30​ print​ edition.