Reducing Avoidable Hospitalizations and Improving Quality in Nursing Homes With APRNs and Interdisciplinary Support: Lessons Learned

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REDUCTION in avoidable hospitalizations of nursing home residents is a major concern to health care providers as well as payers.1 Not only are hospitalizations costly but also hospitalized nursing home residents experience functional and physical decline as a result of hospital transitions that can result in worsening health conditions or death.2 In 2012, the Missouri Quality Initiative (MOQI) was funded by the Centers for Medicare & Medicaid Services (CMS) Innovations Center and Medicare-Medicaid Coordination Office as a part of a national demonstration, Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. While avoiding hospitalizations is important for both short- and long-stay nursing home residents, the CMS initiative focuses on long-stay residents. The CMS funded 7 sites across the United States with the purpose for each site to test the effectiveness of evidence-based clinical and educational interventions in reducing potentially avoidable hospitalizations for long-stay residents—an important aspect of improving care and quality of life.
The MOQI team recruited 16 nursing homes in the St Louis regional area, an area of the country with high rehospitalization rates. The homes met the base criteria established by the CMS: (a) serve Medicare and Medicaid beneficiaries, (b) have high hospitalization and rehospitalizations rates for long-stay residents, (c) have a track record of providing good quality of care, and (d) be willing to implement the MOQI intervention model as fully illustrated in a prior publication.3 The key components of the intervention include advanced practice registered nurses (APRNs) working full-time within each home with an interdisciplinary MOQI intervention team to support each APRN and nursing home in the initiative. Other key components include implementing INTERACT II (Interventions to Reduce Acute Care Transfers) processes and tools,4 an emphasis on end-of-life care,5 and health information technology (HIT).6
Within the first 3 years of implementation, 2012-2015, MOQI experienced the most positive results of the 7 sites across the country participating in the CMS demonstration.7,8 Specifically, MOQI resulted in statistically significant reductions in all key outcomes of the demonstration as analyzed and reported by an independent evaluation team.7 After controlling for baseline differences, the 16 MOQI facilities achieved the following: (a) 40% reductions in all-cause hospitalizations (P < .001); (b) 57.7% reduction in avoidable hospitalizations (P < .001); (c) 54.1% reduction in all-cause emergency department (ED) visits (P < .001); and (d) 65.3% reduction in avoidable ED visits (P < .001).
Medicare expenditures were significantly reduced in all categories for MOQI versus a comparison group that the evaluation team selected.7 MOQI had significant reductions of the following: (a) 10.4% in total Medicare expenditures by −$2066 per resident (P = .034); (b) 33.6% reduction in spending on all-cause hospitalizations by −$1369 per resident (P < .001); (c) 45.2% reduction in avoidable hospitalizations by −$577 per resident (P < .001); (d) 50.2% reduction in all-cause ED visits by −$86 per resident (P < .001); and (e) 59.7% reduction in avoidable ED visits by −$29 per resident (P < .001).
According to Ingber and colleagues,8 the MOQI intervention was associated with “consistent and significant” reductions in outcome measures, as reductions were larger in 2015 than in 2014. These data support the substantial impact of MOQI and the value of adding a full-time APRN and an interdisciplinary support team to the facilities involved. Key findings of lessons learned from implementing the MOQI intervention are shared to help others as they consider strategies to reduce avoidable hospitalizations of long-stay nursing home residents.
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