CMS-Backed Clinical Program Drastically Lowers Avoidable Hospitalizations at SNFs

Potentially avoidable hospitalizations for long-stay nursing facility residents can be significantly reduced by embedding nurses and nurse practitioners, according to a new analysis. In turn, the strategy could substantially slash Medicare spending.

That’s according to an independent evaluation of the OPTIMISTIC program prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI). OPTIMISTIC was developed and implemented by clinician-researchers from Indiana University and their partners, and has received more than $30 million in total funding from the Centers for Medicare & Medicaid Services (CMS).

“It’s shocking how many transfers of nursing home residents to the hospital are considered preventable,” Kathleen Unroe, of the Indiana University Center for Aging Research and Regenstrief Institute, told Skilled Nursing News.


The initial phase of OPTIMISTIC, which stands for Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care, lasted for four years and focused on enhanced clinical care. Through the program, nurse practitioners and nurses were embedded in 19 nursing homes in central Indiana. They provided direct support for long-term residents and their families, in addition to educating and training facility staff.

This led to an estimated annual reduction of 19.3% for all-cause hospitalizations and an estimated annual decrease of 32.6% for potentially avoidable hospitalization, according to the evaluation.

As a result, Medicare expenditures per nursing home resident were lowered by $1,589 per year, for a total Medicare spending decrease of almost $13.5 million and a net savings of over $3.4 million from 2014 to 2016.


But there’s more to the results than the simple addition of a nurse or nurse practitioner.

“The success is completely dependent on the willingness of the nursing facility to take advantage of this additional resource to integrate our nurses into the way they provide care,” Unroe said.

The nurses that served as part of the OPTIMISTIC program were paid for by funds from CMS, so there was no cost to the facilities in terms of personnel, Unroe noted. Many facilities, however, did opt to make their own adjustments, such as additions to electronic medical records or having staff participate in in-service training.

“Nursing facilities do need to make a real investment into integrating these nurses… in order to get the benefit of participating in the project and the results,” Unroe explained.

New Upsides

The OPTIMISTIC nurses provide some unique upsides for a SNF.

“This is a novel role,” Unroe said. “It was never intended nor was it allowed to just be an additional nurse in the nursing facility.”

The OPTIMISTIC nurses worked in a variety of areas, notably in advanced care planning (ACP), which was where residents and family often recognized OPTIMISTIC staff, according to the evaluation.

“When you look at advanced care planning, the nurse’s responsibility is facilitation of these conversations and working with the director of the facility to ensure policies are in place surrounding advanced care planning,” Unroe explained.

This could include checking the patient’s chart to ensure ACP preferences are recorded and that night and weekend staff understand those choices.

OPTIMISTIC also took aim at the fragmentation of care that occurs with multiple hospitalizations, trying to ensure the best information follows patients when they must go to the hospital — and that nursing facilities get the best information in turn.

“On the nursing home side, we can’t control the information we get from the hospital and we are often left frustrated trying to understand what happened in that setting,” Unroe said.

To address this, nurses with the OPTIMISTIC program conducted transition visits, aimed at deeply diving into a resident’s hospitalization. They are not intended to be a substitute for a primary care physician visit, Unroe noted, but as a supplement.

Next steps

The program’s Phase II is a payment demonstration project, which saw the recruitment of an additional 25 facilities for the payment-only group. The new phase is aimed at addressing nursing facilities’ existing economic incentives, which don’t allow for much in the way of additional resources and intensive care in place, Unroe explained.

“Phase I demonstrated that those work, that those enhanced resources did help care for residents in place and drive down unnecessary hospital transfers,” she said.

Written by Maggie Flynn

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