Enhanced Care and Coordination Providers Information

The Centers for Medicare & Medicaid Services (CMS) worked with the following six Enhanced Care and Coordination Providers in both Phase One and Phase Two:

Alabama Quality Assurance Foundation (AQAF) worked with 40 nursing facilities (NFs) across the state in an effort to reduce avoidable transfers and hospitalizations. AQAF implemented an intervention in 19 of these facilities where Registered Nurses (RNs) were 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 promoted 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 served as the liaison for promoting and educating facilities and practitioners on the payment reform model. 

Comagine Health (formerly known as HealthInsight of Nevada) developed the Admissions and Transitions Optimization Program (ATOP), later renamed ATOP2. ATOP2 aimed 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. A total of 13 Nevada NFs received clinical support during Phase Two in addition to technical assistance and education related to payment reform implementation. Payment reform was also implemented in Colorado, where 21 NFs benefited from the new payment model but are not provided additional clinical interventions. ATOP2 provided clinical support (Nevada only), education, and technical assistance to participating NFs.   

Indiana University created a program named "OPTIMISTIC" ("Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care") which included 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 provided direct clinical support, advance care planning, education, and training to NF staff. In addition to employing INTERACT tools, this enhanced staffing model adapted and applied other evidence-based models which have proven to reduce hospitalizations in other settings.

The Curators of the University of Missouri implemented the Missouri Quality Initiative. In this intervention, APRNs were 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 included the use of a mater's prepared social worker who worked 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, facilitated communication among providers and staff. APRNs also focused on root cause analysis and met monthly with the Project Coordinator to review each facility transfer. Customized NF feedback reports on transfers were 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 with demonstrated quality improvement background in using data to drive change. NY-RAH analyzed Medicare claims data for eligible residents to further evaluate the root cause of potentially avoidable hospitalizations related to the six conditions that were 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 created a program named “RAVEN” (Reduce AVoidable hospitalizations using Evidence-based interventions for NFs) in Pennsylvania. This program included facility-based Nurse Practitioners (NPs) to assist with determining resident care plan goals and conduct acute change in condition assessments. RAVEN 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 provided 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.

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