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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 has implemented an intervention in which RNs are deployed in the partnering nursing facilities to implement the Interventions to Reduce Acute Care Transfers (INTERACT) tools, morning huddles, medication management, advance care planning, consistent staffing, and quality assurance and performance improvement (QAPI). Additionally, the intervention staff will work with each facility to adopt and measure consistent assignment as defined by the Advancing Excellence in America's Nursing Homes campaign. The goals of AQAF and consistent assignment include reducing staff turnover and increasing awareness of residents' status and needs, which would improve the staff's ability to implement care plans and notice changes in residents' health. 

HealthInsight of Nevada has implemented an intervention, named the "Nevada Admissions and Transitions Optimization Program" or "ATOP." ATOP includes the creation of pods that consist of a physician extender (nurse practitioner or physician's assistant) and two registered nurses (RNs) who will be physically on-site at nursing facilities. Each one of the five pods provides enhanced care and coordination to residents in four or five facilities. Additionally, the intervention will include INTERACT tools and use a resident risk assessment program whereby each beneficiary receives the appropriate level of enhanced care and attention based on their individual risk level. HealthInsight of Nevada has also implemented a medication management program to reduce polypharmacy and the inappropriate use of antipsychotics.   

Indiana University has created a program called "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 nursing facilities, allowing for enhanced recognition and management of acute change in medical conditions. RNs and APNs provide direct clinical support, education, and training to nursing facility 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, advanced practice RNs (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 nursing home residents. Additionally, the intervention includes the use of social workers who will closely with each facility's social worker, the residents' primary care providers, nursing facility staff, and APRNs to assure consistent communication about resident's needs and preferences. APRNs increased focus on root cause analysis and met monthly with the Project Coordinator to review each facility transfer. The APRNs created customized reports on transfers and use the information to target education and work with facility quality improvement committees. 

The Greater New York Hospital Foundation, Inc. has implemented a program, New York Reducing Avoidable Hospitalizations (NY-RAH), whereby RNs are deployed in the partnering nursing facilities to train, but not provide direct clinical care, to the nursing facility staff on INTERACT tools. Additionally, RNs identify root causes for potentially avoidable hospitalizations and review and modify its policies and procedures to prevent such hospitalizations. NY_RAH is also focusing on palliative care education and the implementation of electronic solutions for nursing facilities. 

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

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