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Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

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10/26/15 - Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents page updated.


The Medicare-Medicaid Coordination Office, in collaboration with the Center for Medicare & Medicaid Innovation, established an initiative to help improve the quality of care for people in nursing facilities by reducing potentially avoidable inpatient hospitalizations.  

CMS is supporting organizations that partner with nursing facilities to implement evidence-based interventions that both improve care and lower costs. The Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents is focused on long-stay nursing facility residents who are enrolled in the Medicare and Medicaid programs.


Nursing facility residents often experience potentially avoidable inpatient hospitalizations. These hospitalizations are expensive, disruptive, and disorienting for frail elders and people with disabilities. Nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections.

Many nursing facility residents are enrolled in both the Medicare and Medicaid programs (Medicare-Medicaid enrollees). CMS research on Medicare-Medicaid enrollees in nursing facilities found that approximately 45% of hospital admissions among individuals receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005. More information can be found at the links below:  

Initiative Details

Phase One: Improving Clinical Care

For the past three years, CMS has partnered with seven organizations (referred to as "enhanced care & coordination providers" or "ECCPs") to implement evidence-based clinical and educational interventions that reduce avoidable hospitalizations. These seven organizations (below) each provide on-site services in a group of partner nursing facilities. Five of the organizations focus on direct care, and two focus on staff training.

While each ECCP's intervention has unique features, all include:

  • Employing staff who will maintain a physical presence on site at LTC facilities; 
  • Allowing for participation by LTC facility residents without any need for residents to change providers or enroll in a health plan; and
  • Supplementing (rather than replacing) existing care provided by LTC facility staff.  

On August 28, 2015, the Alabama Quality Assurance Foundation (AQAF) and the Curators of the University of Missouri were awarded performance-based supplemental funds to further enhance the Initiative in their partner facilities. AQAF aims to improve executive leadership competencies and engagement as a strategy to achieve full deployment and sustainability of the AQAF model. The Curators of the University of Missouri seek to disseminate evidence-based practices that can be of help to the general public, nursing home staff and leaders, and public policy makers.

Phase Two: Adding Payment Reform

On August 27, 2015, CMS announced a new funding opportunity to launch the second phase of this Initiative. In this phase currently participating ECCP organizations may apply to test whether a new payment model for nursing facilities and practitioners, will improve quality of care by reducing avoidable hospitalizations while lowering combined Medicare and Medicaid spending.  

The intent of the new payment model is to reduce potentially-avoidable hospitalizations by funding higher-intensity treatment services in nursing facilities for residents who may otherwise be hospitalized upon an acute change in condition. Improving the capacity of nursing facilities to treat common medical conditions as effectively as possible on-site in the facilities, as appropriate, has the potential to improve the residents' care experience at lower cost than a hospital admission. The model also includes Medicare payments to practitioners (i.e., physicians, nurse practitioners and physician assistants) at a level similar to the payments they would receive for treating beneficiaries in a hospital. Practitioners will also be eligible to receive new payments for engagement in multidisciplinary care planning activities. Successful ECCP applicants will implement the payment model with both their existing partner facilities, where they currently provide training and clinical interventions, and in a comparable number of newly recruited facilities. The payment model is slated to run from October 2016 to October 2020.

Successful applicants will also continue the evidence-based clinical and educational interventions from the first phase of the Initiative throughout the second phase. The new payment model will be tested both in the nursing facilities currently participating in the Initiative as well as a comparable set of newly-participating facilities selected by the ECCPs and CMS. 

As of September 9, 2015, all seven ECCPs below submitted Notices of Intent to Apply to this new funding opportunity.   

Participating Sites

From a pool of applicants, seven ECCP organizations were selected for this Initiative:

Alabama Quality Assurance Foundation – Alabama

CHI/Alegent Creighton Health – Nebraska 

HealthInsight of Nevada – Nevada

Indiana University – Indiana

The Curators of the University of Missouri – Missouri 

The Greater New York Hospital Foundation, Inc. – New York City 

UPMC Community Provider Services - Pennsylvania 


On July 1, 2015, CMS released a report entitled, "Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Summary of Evaluation as of December 2014". This summary report presents results of the quantitative and qualitative analysis of data for the seven ECCPs from the first Initiative year, 2013, relative to groups of similar nursing facilities in the seven affected states. 

The report includes promising initial results through 2013, though it is too early to draw any firm conclusions because the ECCPs were phasing in their interventions during this period. The report found that five of the seven ECCPs showed some degree of reduction in hospitalization levels. For three of the ECCPs, the effect estimated could be considered statistically significant but given the transitional status of the intervention in 2013, the reduction cannot be definitely attributed to the Initiative. For hospitalizations determined to be "potentially avoidable" six of the seven ECCPs showed some reductions. For two of the ECCP groups, the effect estimated could be considered statistically significant but whether these reductions were caused by the Initiative is unclear given the transitional status of the intervention. Looking at quality of care outcomes as measured by the Minimum Data Set (MDS) the report found that results were mixed and inconclusive.

Contact us

For more information or questions about this Initiative, email