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The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff (2022)

Chapter:Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

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Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Appendix B

Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

This appendix provides examples of successful demonstration projects in the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. (Details of the initiative and the related phases are in Chapter 3.) These examples all had a strong clinical focus. Table B-1 provides an overview of each program, including program details and specific components of the intervention. Table B-2 shows the impact of the interventions on clinical outcomes and cost savings in phase one. The assessment focused on the following measures: all-cause hospitalizations, potentially avoidable hospitalizations, all-cause emergency department (ED) visits, and potentially avoidable ED visits. Table B-3 shows the impacts demonstrated in phase two of the initiative on the two different groups. In phase two, the Centers for Medicare & Medicaid Services offered payment incentives that were added to the facilities that participated in phase one (leaving registered nurse and advanced practice registered nurse support in place) and added an additional “payment only” intervention group (without the phase one supports).

Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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TABLE B-1 Program Details and Components for Demonstration Projects

PROGRAM PROGRAM DETAILS COMPONENTS
Missouri Quality Initiative (MOQI)

SOURCES: Nursing Home Help, 2021a,b.

  • Targeted nursing homes with high hospital transfer rates
  • Phase one: 16 nursing homes
  • Phase two: 40 nursing homes
  • Currently continuing through New Path Health Solutions, LLC

GOALS:

  • Reduce hospitalizations
  • Reduce Medicare expenditures
  • Increase use of advance directives and end-of-life planning
  • Improve early illness recognition
  • Improve management of health conditions
  • Increase the use of health information technology (HIT)
  • Reduce medication use (including antipsychotic medications among people with dementia)
Multilevel intervention included:
  • Hiring a full-time advanced practice registered nurse (APRN) and MOQI team member to implement the program and share best practices for each nursing home
  • Employing processes and tools from the Interventions to Reduce Acute Transfers (INTERACT) program
  • Using feedback forms of the clinical outcome measures to facilities monthly
  • Encouraging physician engagement
  • Using advance directives
  • Supporting homes to implement and sustain HIT
  • Engaging a multidisciplinary support team
New York – Reducing Avoidable Hospitalizations (NY-RAH)

SOURCE: NY-RAH, 2013.

  • Phase one: 29 nursing homes
  • Phase two: 40 nursing homes

This was the only program in the initiative where the registered nurse (RN) was employed to act more in an advisory role focused on knowledge sharing rather than in a clinical role. This resulted in a much slower buy-in, implementation, and knowledge dissemination.

NY-RAH disseminated a toolkit from programs such as INTERACT and Medical Orders for Life Sustaining Treatment to onsite providers with tools and interventions to improve care, reduce hospitalizations, and improve hospital transition processes.

These evidence-based interventions were complemented with initiatives to use electronic methods to share information and resources, collect data, and create and analyze metrics.

Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC)

SOURCES: OPTIMISTIC, 2021, 2022.

The OPTIMISTIC program ran through Indiana University and other collaborative partners in the state from September 2012 through October 2020.

19 facilities were a part of the OPTIMISTIC program in phase one and 25 additional facilities in phase two (OPTIMISTIC, 2021).

OVERALL GOALS:

  • Reduce unnecessary hospitalization
  • Improve medical care
  • Enhance transitional care
  • Support palliative care

Leaders of OPTIMISTIC subsequently helped establish the startup company Probari to implement a program modeled after OPTIMISTIC.

Train-the-trainer model to
  • Build nursing staff capacity
  • Implement evidence-based practices for care and communication
  • Invest in advanced care planning

Two pillars of the program:

  • An electronic data tracking system for patient records and employing RNs
  • Using APRNs to facilitate standardized education on quality improvement
Reduce Avoidable Hospitalizations Using Evidence-Based Interventions for Nursing Facilities (RAVEN)

SOURCE: RAVEN, 2021.

In 2012, the University of Pittsburgh Medical Center began RAVEN by implementing five interventions across 18 diverse long-term care facilities to reduce hospitalizations, improve resident health outcomes, decrease spending, and foster culture change. The five interventions were
  • Facility-based enhanced care staff
  • Evidenced-based assessment and clinical documentation tools
  • Innovative education
  • Enhanced medication management
  • Telemedicine.

The primary pillar of the program involved having full-time APRNs deliver clinical care and education.

Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×

TABLE B-2 Phase One: Improvements in Outcomes and Cost Savings for Demonstration Projects

All Medicare Services Reductions in All-Cause Hospitalization Reductions in Potentially Avoidable Hospitalizations Reductions in All-Cause Emergency Department (ED) Visits Reductions in Potentially Avoidable ED Visits
Phase one cost savings Phase one outcomes Phase one cost savings Phase one outcomes Phase one cost savings Phase one outcomes Phase one cost savings Phase one outcomes Phase one cost savings
MOQI 6.3% 32.0% 28.6% 49.9% 40.2% 41.7% 36.3% 56.0% 42.8%
NY-RAH 1.9% 11.4% 7.3% 19.4% 13.3% 12.4% 8.7% 14.4% 9.8%
OPTIMISTIC 6.9% 24.9% 21.6% 38.1% 24.9% 7.1% 8.7% 17.6% 24.1%
RAVEN 12.3% 17.3% 27.6% 29.6% 35.3% 2.5% 20.5% 25.5% 39.9%

SOURCE: RTI International, 2017.

TABLE B-3 Phase Two: Outcomes for Different Intervention Groups

Phase Two: Payment plus Clinical Supports Group Phase Two: Payment Only Group
MOQI Potentially avoidable emergency department visits and potentially avoidable all-cause transfers significantly increased for the six qualifying diagnoses Mixed results, no significant changes across all measures
NY-RAH Mixed direction results for use and expenditure measures, none statistically significant No significant changes in use and expenditure measures
OPTIMISTIC Increases in most measures for hospitalization use and expenditures, a few were statistically significant Mixed direction for significant changes in expenditures but no significant changes in use measures
RAVEN Significant increases in hospital use and expenditure measures No significant changes across all

SOURCE: RTI International, 2021.

Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×

REFERENCES

Nursing Home Help. 2021a. MOQI initiative. https://nursinghomehelp.org/moqi-initiative (accessed March 3, 2021).

Nursing Home Help. 2021b. The Missouri Quality Initiative for nursing homes (MOQI) (2012-2020). https://nursinghomehelp.org/wp-content/uploads/2021/05/Missouri-Quality-Initiative-Brief-Phases-12-10-page-052521.pdf (accessed June 11, 2021).

NY-RAH. 2013. About NY. https://www.nyrah.org/About.aspx (accessed March 3, 2021).

OPTIMISTIC. 2021. OPTIMISTIC. https://www.optimistic-care.org/ (accessed March 3, 2021).

OPTIMISTIC. 2022. Introducing Probari! https://www.optimistic-care.org/probari (accessed February 8, 2022).

RAVEN. 2021. About RAVEN. https://raven.upmc.com/aboutus.htm (accessed March 3, 2021).

RTI International. 2017. Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Final report. Waltham, MA: RTI International.

RTI International. 2021. Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment reform: Fourth annual report. Waltham, MA: RTI International.

Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×

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Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Page557
Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Page558
Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Page559
Suggested Citation:"Appendix B: Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Nursing homes play a unique dual role in the long-term care continuum, serving as a place where people receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care.

With support from a coalition of sponsors, the National Academies of Sciences, Engineering, and Medicine formed the Committee on the Quality of Care in Nursing Homes to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff identifies seven broad goals and supporting recommendations which provide the overarching framework for a comprehensive approach to improving the quality of care in nursing homes.

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