Enhanced Care and Coordination Providers Information



The Centers for Medicare & Medicaid Services (CMS) is working with the following Enhanced Care and Coordination Providers:

Alabama Quality Assurance Foundation (AQAF) is working with 40 nursing facilities (NFs) across the state in an effort to reduce avoidable transfers and hospitalizations. AQAF has implemented an intervention in 19 of these facilities where Registered Nurses (RNs) are deployed to enhance the level of assessment of long-term residents and facilitate the implementation of tools such as the Interventions to Reduce Acute Care Transfers (INTERACT). Additionally, the RNs promote various tools and methods, such as medication management, advance care planning, consistent staffing, quality assurance and performance improvement (QAPI), etc., in an effort to increase the early recognition of any changes in condition and promote best practices for treating residents in place when appropriate. Likewise, in these same 19 facilities, along with 21 other facilities in the state, AQAF serves as the liaison for promoting and educating facilities and practitioners on the payment reform model. 

Comagine Health (formerly known as HealthInsight of Nevada) has developed the Admissions and Transitions Optimization Program (ATOP), now named ATOP2. ATOP2 aims to improve the quality of life for NF residents in their homes by training NF staff to identify subtle changes in residents' conditions, and to communicate these changes to providers so residents can be treated at home. Currently, a total of 13 Nevada NFs receive clinical support in addition to technical assistance and education related to payment reform implementation. Payment reform was also implemented in Colorado, where 21 NFs benefit from the new payment model but are not provided additional clinical interventions. ATOP2 provides clinical support (Nevada only), education, and technical assistance to our participating NFs.   

Indiana University has created a program named "OPTIMISTIC" ("Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care") which includes the deployment of RNs and Advanced Practice Nurses (APNs) to be on-site at the NFs, allowing for enhanced recognition and management of acute change in medical conditions. RNs and APNs provide direct clinical support, advance care planning, education, and training to NF staff. In addition to employing INTERACT tools, this enhanced staffing model will adapt and apply other evidence-based models which have proven to reduce hospitalizations in other settings.

The Curators of the University of Missouri have implemented the Missouri Quality Initiative. In this intervention, APRNs are assigned to facilities to provide direct services to residents while mentoring, role-modeling, and educating the nursing staff about early symptom/illness recognition, assessment, and management of health conditions commonly affecting NF residents. Additionally, the intervention includes the use of a mater's prepared social worker who works closely with each facility's social worker/social services staff, the residents' primary care providers, NF staff, and APRNs to assure consistent communication about resident's needs and preferences. Health information exchange, another component of the initiative, facilitates communication among providers and staff. APRNs also focus on root cause analysis and meet monthly with the Project Coordinator to review each facility transfer. Customized NF feedback reports on transfers are used by the APRNs to target education and work with facility quality improvement committees. 

The Greater New York Hospital Foundation, Inc. implemented a program, New York-Reducing Avoidable Hospitalizations (NY-RAH). Originally, NY-RAH deployed RNs in the partnering NFs to act as educators and consultants, but not provide direct clinical care, to the NF staff on early recognition and communication of acute changes of condition using INTERACT tools. Additionally, RNs identified the root causes for potentially avoidable hospitalizations and modified policies and procedures to prevent such hospitalizations. In 2018, the RNs were replaced by Quality Improvement Specialists that have a demonstrated quality improvement background in using data to drive change. NY-RAH analyzes Medicare claims data for eligible residents to further evaluate the root cause of potentially avoidable hospitalizations related to the six conditions that are the focus of Phase Two. NY-RAH also emphasizes palliative care and advance directive education and the implementation of electronic solutions for NFs. 

UPMC Community Provider Services has created a program named “RAVEN” (Reduce AVoidable hospitalizations using Evidence-based interventions for NFs) in Pennsylvania. This program includes facility-based Nurse Practitioners (NPs) to assist with determining resident care plan goals and conduct acute change in condition assessments. RAVEN has also implemented evidence-based clinical communication tools such as INTERACT and others recommended by the American Medical Directors Association (AMDA) to assist in structuring and standardizing clinical assessments and recommendations. The intervention also provides support from innovative telehealth and information technologies to connect participating NFs to NPs.

During Phase One, CMS also worked with CHI/Alegent Creighton Health, which implemented an intervention in 14 NFs in Nebraska. CHI/Alegent Creighton Health deployed NPs in the partnering NFs to enhance care by implementing INTERACT tools, improving communication, and providing education to NF staff. An innovative aspect of this program was the use of a dentist and dental hygienist to improve oral care for beneficiaries. This type of care is typically not provided in the NF environment and contributes to better overall health, while also working to prevent other conditions that lead to avoidable hospitalizations.

Page Last Modified:
06/25/2019 01:26 PM