Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

Objectives As the U.S. population ages, the prevalence of disability and functional limitations, and demand for long-term services and supports (LTSS), will increase. This study identified the distribution of older adults across different residential settings, and how their health characteristics have changed over time. Methods A cross-sectional analysis of older adults residing in traditional housing, community-based residential facilities (CBRF), and nursing facilities using three data sources: The Medicare Current Beneficiary, 2008 and 2013; the Health and Retirement Study, 2008 and 2014; and the National Health and Aging Trends Study, 2011 and 2015. We calculated age-standardized prevalence of older adults by setting, functional limitations, and comorbidities, and tested for health characteristics changes relative to the baseline year (2002). Results The proportion of older adults in traditional housing increased over time, relative to baseline (p < 0.05), while the proportion of older adults in CBRF was unchanged. The proportion of nursing facility residents declined from 2002 to 2013 in the MCBS (p < 0.05). The prevalence of dementia and functional limitations among traditional housing residents increased, relative to the baseline year in the HRS and MCBS (p < 0.05). Discussion The proportion of older adults residing in traditional housing is increasing, while the nursing facility population is decreasing. This change may not be due to better health; rather, older adults may be relying on non-institutional LTSS.

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BACKGROUND/OBJECTIVES Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on‐site acute care to long‐stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative‐related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated. DESIGN We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on‐site treatment under the initiative as well as in‐hospital treatment both before and during the initiative, and measure health status. SETTING Participating NFs during fiscal years 2017 to 2018. PARTICIPANTS There were 47,202 long‐stay NF residents from 260 facilities in seven states. INTERVENTION CMS initiative to reduce avoidable hospitalizations among NF residents—payment reform. MEASUREMENTS Percentage per year who received on‐site treatment (2017–2018), and who received in‐hospital treatment (2014–2018), for the six conditions. RESULTS Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital. CONCLUSION Although the initiative sought to reduce hospitalizations, in‐hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on‐site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long‐stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. Context In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education‐based interventions (Clinical‐Only) aimed to reduce hospitalizations among long‐stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment‐Only). Methods Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in‐person interviews to investigate aspects of implementation and a difference‐in‐differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. Findings Three key components were necessary for successful implementation of the Initiative—staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical‐Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment‐Only interventions were successful in reducing hospitalizations. Conclusions Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct‐care staff in the nursing home, as well as hands‐on care. Use of Medicare payment incentives alone to encourage on‐site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.