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).
TABLE B-1 Program Details and Components for Demonstration Projects
| PROGRAM | PROGRAM DETAILS | COMPONENTS |
|---|---|---|
|
Missouri Quality Initiative (MOQI)
SOURCES: Nursing Home Help, 2021a,b. |
GOALS:
|
Multilevel intervention included:
|
|
New York – Reducing Avoidable Hospitalizations (NY-RAH)
SOURCE: NY-RAH, 2013. |
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. |
|
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:
Leaders of OPTIMISTIC subsequently helped establish the startup company Probari to implement a program modeled after OPTIMISTIC. |
Train-the-trainer model to
Two pillars of the program:
|
|
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
The primary pillar of the program involved having full-time APRNs deliver clinical care and education. |
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.
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.
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