Grant Details

Under this program, the Centers for Medicare and Medicaid Services (CMS) will select eligible organizations to test a series of evidence-based clinical interventions. The goal of these interventions is to improve the health and health care among nursing facility residents and ultimately reduce avoidable inpatient hospital admissions. Successful applicants will implement such interventions that will have the following objectives:

1. Reduce the frequency of avoidable hospital admissions and re-admissions;
2. Improve resident health outcomes;
3. Improve the process of transitioning between inpatient hospitals and nursing facilities; and,
4. Reduce overall health care spending without restricting access to care of choice providers.

The interventions shall primarily target long-stay Medicare-Medicaid enrollees in Medicare-Medicaid certified nursing facilities, rather than those likely to experience only a brief post-acute stay and then return home. These activities directly support the CMS Center for Medicare and Medicaid Innovation goals to test models of care that deliver better healthcare, better health and reduced costs through improvement.

CMS is not prescribing any specific clinical model; it is allowing applicants to propose interventions to meet the cooperative agreement's objectives. However, all interventions must include the following activities:

1. Hire staff who shall maintain a physical presence at nursing facilities and who shall partner with nursing facility staff to implement preventative services and improve recognition, assessment, and management of conditions such as pneumonia, congestive heart failure, chronic obstructive pulmonary disease and asthma, urinary tract infections, dehydration, skin ulcers, falls, and other common causes of avoidable hospitalizations.
2. Work in cooperation with existing providers, including residents' primary care providers, nursing facility staff, and families to implement best practices and improve the overall quality of nursing facility care, focusing on quality improvement activities that most directly relate to avoidable hospitalizations.
3. Facilitate residents' transitions to and from inpatient hospitals and nursing facilities, including facilitating timely and complete exchange of health information among providers and providing support for residents and nursing facility staff to support successful discharge to the community as appropriate.
4. Provide support for improved communication and coordination among hospital staff (including attending physicians), nursing facility staff, residents' primary care providers and other specialists, and pharmacies.
5. Coordinate and improve management and monitoring of prescription drugs to reduce risk of poly-pharmacy and adverse drug events for residents, including inappropriate prescribing of psychotropic drugs.

All interventions must also:

1. Demonstrate a strong evidence base.
2. Demonstrate strong potential for replication and sustainability in other communities and institutions.
3. Supplement (rather than replace) existing care provided by nursing facility staff.
4. Coordinate closely with State Medicaid and State survey and certification agencies and State public health and health reform efforts, including other CMS demonstrations and waiver.
5. Allow for participation by nursing facility residents without any need for residents or their families to change providers or enroll in a health plan. Residents will be able to opt-out from participating, if they choose.