Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

This initiative is possible through the collaboration of the CMS Innovation Center and the CMS Medicare-Medicaid Coordination Office.

This effort aimed to improve the quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations.

CMS supported organizations that each partnered with a group of LTC facilities to implement evidence-based clinical and educational interventions that both improved care and lowered costs. The initiative was focused on long-stay LTC facility residents who were enrolled in both the Medicare and Medicaid programs, with the goal of reducing potentially avoidable inpatient hospitalizations. This initiative was launched in 2012.

A second phase of this Initiative was announced on August 27, 2015, and new cooperative agreements were announced on March 24, 2016.

Map of Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents sites.

From a pool of applicants, 7 organizations were selected for phase one of this Initiative:

Alabama Quality Assurance Foundation – Alabama 

Alabama Quality Assurance Foundation has implemented an intervention in 23 facilities in Alabama. In this intervention, RNs will be 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.

CHI/Alegent Creighton Health – Nebraska

CHI/Alegent Creighton Health has implemented an intervention in 14 nursing facilities in Nebraska. CHI/Alegent Creighton Health has deployed nurse practitioners in the partnering nursing facilities to enhance care by implementing 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.

HealthInsight of Nevada – Nevada

HealthInsight of Nevada has implemented an intervention in 24 nursing facilities in Nevada. The intervention, named the “Nevada Admissions and Transitions Optimization Program” or “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 (INTErventions to Reduce Acute Care Transfers) tools and use a resident risk assessment program whereby each beneficiary will 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 – Indiana

Indiana University has implemented an intervention in 19 nursing facilities in the Indianapolis region of Indiana. This organization 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 – Missouri

The Curators of the University of Missouri have implemented the Missouri Quality Initiative in 16 nursing facilities in Missouri. 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 work  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 APRN 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. – New York City

The Greater New York Hospital Foundation, Inc. has implemented an intervention in 29 nursing facilities in the New York City metropolitan region. In this program, New York Reducing Avoidable Hospitalizations (NY-RAH), RNs are deployed in the partnering nursing facilities to train, but not to provide direct clinical care, to the nursing facility staff on INTERACT tools. Additionally, RNs identify root cause 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 - Pennsylvania

UPMC Community Provider Services has implemented an intervention in 15 nursing facilities in the western region of Pennsylvania. 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 implemented  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.



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

Many LTC facility residents are enrolled in both the Medicare and Medicaid programs (Medicare-Medicaid enrollees). CMS research on Medicare-Medicaid enrollees in LTC 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.

Initiative Details

Under the initial phase of the Initiative, CMS partnered with seven Enhanced Care and Coordination Provider (ECCP) organizations to improve care for long-stay LTC facility residents. In aggregate, the ECCPs collaborated with 143 LTC facilities across seven states to provide on-site staff for training and to provide preventive services and improve the assessment and management of medical conditions to reduce avoidable hospitalizations.

The ECCPs collaborated with States and LTC facilities, with each ECCP implementing its evidence-based interventions in at least 14 partnering LTC facilities over a four-year period (2012-2016). The interventions in the first phase of the Initiative reached about 16,000 beneficiaries each month.

Interventions were evaluated for their effectiveness in improving health outcomes and providing residents with a better care experience.

Applications for this Initiative were due June 14, 2012.


Latest Evaluation Report

Prior Evaluation Reports

Additional Information

If you have additional questions on this Initiative, please e-mail For more information on this initiative, including archived information, visit the Medicare-Medicaid Coordination Office page.


Where Health Care Innovation is Happening