CMS Penalties Fund Program Designed to Reduce Readmissions, Improve Skilled Nursing Outcomes

Thirty nursing homes in the state of Washington will benefit from a federal program that injects penalty recoveries back into initiatives that boost nursing home quality — and the ramifications of the funding could go well beyond the facilities in that one state.

The grant, totaling more than $644,000, comes from the Centers for Medicare & Medicaid Services’ (CMS) Civil Money Penalty Reinvestment Program, which applies a portion of fines collected from nursing home operators toward care improvement initiatives.

The funds were awarded by the Washington Department of Social and Health Services to a program at New York University Rory Meyers College of Nursing that focuses on education and leadership training to implement evidence-based care for older adults.


“Nursing homes do a great job at finding out who that resident they’re caring for is,” Jennifer Pettis, associate director of the Nurses Improving Care for Healthsystem Elders (NICHE) at NYU Meyers, told Skilled Nursing News. “They learn about them, they understand their needs, they understand their goals of care, they understand what is important to that individual to inform their caregiving. Unfortunately, the piece of the puzzle that’s missing in that evidence-based practice for nursing homes is the availability of the best evidence to them.”

From acute care to long-term care

NICHE got its start about 27 years ago in the acute care setting, Mattia Gilmartin, executive director of NICHE at NYU Meyers, explained; it now boasts approximately 580 member hospitals.

The model involves members paying an annual fee in exchange for accessing a portfolio of online education for nurses, licensed practical nurses, and certified nursing assistants, as well as access to a set of evidence-based care protocols. The program also offers survey and benchmarking services for evaluating member practices.


But it wasn’t until three years ago that it was able to adapt its hospital-based model for nurses and residents in the long-term care and post-acute settings, Gilmartin told SNN, via a grant from the John A. Hartford Foundation. About 80 nursing homes are now part of the NICHE program, and the funds from CMS could help that number grow.

“We are interested in expanding the program into the nursing home sector,” Gilmartin told SNN. “And so the CMP grant is one way to help support this work.”

In the acute care setting, the NICHE program has helped to drive declines in hospital stays and readmissions, as well as with falls, incontinence, delirium and pain, Pettis told SNN. While outcomes are still being evaluated in the SNF setting, given how new NICHE is to the space, nurses are reporting that they practice differently based on the training, she added.

Readmissions in particular are a major issue for SNFs; under the Value-Based Purchasing program, they automatically lose 2% of their Medicare reimbursements, which can be won back by hitting certain readmission-rate benchmarks. In the first round of results, announced in November of last year, 73% of providers had reduced payments under the program.

Though she stressed that she could not speak to rates of readmission, Pettis emphasized the importance of equipping nurses to act on “subtle changes” in patient condition in the nursing home setting, to prevent unnecessary transfers to acute care.

“Empowering the front line to identify changes and then, importantly, to act on the changes — it is vital in nursing homes,” she told SNN.

Depression, delirium, dementia

Under the grant, the 30 SNFs — which will be part of NICHE’s Long-Term Care program for three years — will work with the program’s mentors to develop a quality improvement project focused on one of three clinical areas: delirium, depression, and dementia.

In Washington state, depression is a particular area of focus, since according to CMS’ Nursing Home Compare data, its prevalence of depression is above the national average, Pettis noted.

It’s also a major area of focus under the new Patient-Driven Payment Model (PDPM), which took effect at the start of October. In fact, training frontline caregivers to recognize the signs of depression in SNF residents will be crucial for success under the system, Zimmet Healthcare Services Group chief innovation officer Steven Littlehale argued at the company’s annual conference this summer.

Even so, many operators appear to be missing this as a diagnosis, according to recent data from Zimmet.

“If you take anything from this report, please review your October billing and count how many of your Nursing scores end in 2,” the company noted in its report, referring to depression-related scores. “If you don’t find any, your facility is either incredibly pleasant and soothing, or you’re leaving upwards of $35 Medicare/day on the table; our advice is to pick them up.”

That said, the nursing homes in Washington can choose which of those three they need to focus on, based on their residents and their local needs. After all, many residents in the SNF setting have multiple diseases and issues that front-line staff have to be able to identify, and putting more evidence-based practices in the hands of nurses is one way to help them provide better care, Pettis and Gilmartin stressed.

It’s a need that’s especially pressing in the post-acute sector.

“It’s well documented that long-term care is slow on the uptake of new information about how to care for different geriatric issues,” Pettis noted. “What NICHE provides those nursing homes is care protocols for older adults that are all evidence-based, so they have the very best information about how to care for those older adults at their fingertips.”

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