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Revolutionizing How Nursing Homes Care For The Sick


Indiana researchers hope that providing nursing homes with additional federal funding and in-house clinicians will significantly reduce the number of unnecessary hospitalizations vulnerable residents face.

Researchers with the Regenstrief Institute and Indiana University Center for Aging Research are testing whether providing nursing homes with increased Medicare payments will reduce disruptive and costly trips to hospitals.

Forty Indiana nursing homes and their clinicians are participating in an experiment that reimburses them for on-site treatment of the six most common conditions linked to hospitalizations: pneumonia, urinary tract infection, congestive heart failure, dehydration, skin ulcers and chronic obstructive pulmonary disease.

The goal: provide long-term residents with in-house quality care.

“This is a population with a lot of medical complexity and also a majority of whom have a cognitive impairment, like a diagnosis of dementia” project director Dr. Kathleen Unroe, a Regenstrief Institute and Indian University Center for Aging Research investigator, told Life Matters Media. “It’s a big deal to transfer someone out of a nursing facility to a hospital. Transitions of care are very risky, particularly for this complex population. Things get missed. Things get dropped.”

This effort is part of the second phase of OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care), an innovative model of care management for long-stay nursing home residents.

Phase one of OPTIMISTIC was implemented in 2012 and embedded a collaborative clinical team in nursing facilities to streamline disease management, reduce unnecessary hospitalizations and help residents develop and meet their goals of care.

Phase One saw a 33 percent improvement in reducing hospitalizations even though it did not include financial incentives. Unroe hopes to expand the project to other Indiana nursing homes in the coming years.

“Many of the things that can be done in the ER or hospital can be done in the nursing home setting, such as lab tests, X-rays and ordering medicine,” Unroe said, adding that in-house clinicians are also better at ensuring patient wishes for treatment are honored.

Under the current Centers for Medicare and Medicaid Services payment system, Unroe said nursing facilities are not reimbursed for care provided in-house to residents who become sicker, unless the nursing home sends them to a hospital and then readmits them to a nursing home under the Medicare post-acute care benefit.

“Phase Two of OPTIMISTIC removes financial barriers to keeping people in nursing homes where they can be treated safely in place,” said Laura Holtz, senior research manager of the project, in a statement. “And we can see — by the fact that more than three times as many nursing homes applied to be part of OPTIMISTIC’s second phase than we could accommodate — that nursing homes want to keep nursing home residents on site and not disrupt their care by transferring them to and from hospitals unnecessarily.”

The collaborative clinical care teams implemented in Phase One, will remain in place in the Phase One nursing homes as they participate in the second phase. However, an additional 23 nursing homes joined the program in Phase Two without these health care professionals.

Still, all participating nursing homes are focusing on implementing a CMS payment model which incentivizes them to provide higher levels of care.
Unroe said OPTIMISTIC is set to receive more than $30 million of CMS funding through The Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents by 2020.

It is one of only six nationwide efforts participating in this CMS Center for Innovations-funded clinical demonstration project.
“Medicare pays for hospital care for this population and it’s really shocking the amount that Medicare estimates it spends on avoidable hospitalizations each year,” Unroe said. “It’s billions of dollars.”

Two years remains in Phase Two, and Unroe is cautiously optimistic.

“This is such an exciting project and such an exciting opportunity,” she added. “There hasn’t been a lot of innovation on the payment front.”