Medicare-Medicaid Coordination Office: Evaluation
Guidance for evaluation reports on Phase I and Phase II of the Initiative to reduce avoidable hospitalizations in Nursing Facility Residents
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: May 18, 2020
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Latest Report - Phase Two
The fourth annual evaluation report for Phase Two was released on March 17. 2021.
Similar to the previous reports (see below), this report found no evidence of favorable reductions in hospital-related utilization or Medicare expenditures in fiscal year 2019, relative to a national comparison group. Analysis indicates that the on-site treatment to residents for qualifying conditions generally did not represent substitution for avoided hospitalizations.
Prior Reports - Phase Two
The third annual evaluation report for Phase Two was released on December 16. 2019.
Unlike previous reports (see below), this report did not find evidence that payment reforms led to a consistent pattern of improved outcomes in newly-recruited facilities for Fiscal Year 2018. Facilities that participated in an earlier phase of the Initiative did not show further improvements beyond what was expected based on the trends established during that phase. For both groups, additional years of data and analysis should provide more definitive insight about Initiative effects.
The second evaluation report for Phase Two was released on March 20, 2019.
Early findings in the report are preliminary and should not be considered conclusive. Nevertheless, the evaluation found some promising evidence that payment reforms have led to a consistent pattern of improved outcomes in newly-recruited facilities. Facilities that had participated in Phase One did not show further improvements beyond what was expected based on the trends established during that phase. For both groups, additional years of data and analysis will provide more definitive insight about Initiative effects.
The first evaluation report for Phase Two was released on February 16, 2018. This report explains how the Payment Reform phase of the Initiative will be evaluated and presents some early qualitative findings from the first year of the Initiative.
Final Report - Phase One
The final independent evaluation report for Phase One was released on October 20, 2017.
The evaluation determined that all seven sites reduced hospitalizations, with six of the seven achieving statistically significant improvement in either all-cause hospitalizations, potentially avoidable hospitalizations, or both. Total Medicare expenditures were reduced in six of the seven sites, with statistical significance in four. If the intervention cost is taken into account, four of the seven sites achieved Medicare expenditure reductions in excess of costs, though overall the difference was not statistically significant.
The report found the strongest improvements in both cost and quality at the intervention sites with a full-time nurse at each facility providing direct care to residents. These models demonstrated greater changes in facility culture, greater support for the need to reduce avoidable hospitalizations, and greater overall buy-in to the Initiative from facility staff, resulting in stronger intervention effects. Intervention sites where nurses did not provide direct care, or where nurses rotated across multiple facilities, showed less consistent effects.
According to the report, "Overall, these findings provide persuasive evidence of the Initiative's effectiveness in reducing hospital inpatient admissions, ED visits, and hospitalization-related Medicare expenditures."
Prior Reports - Phase One
On March 6, 2017 the Centers for Medicare & Medicaid Services released an evaluation report demonstrating promising results for this Initiative. The report analyzed Medicare expenditures, utilization measures, and MDS-based quality measures through the end of 2015 and included qualitative findings through mid-2016.
For the second year in a row, partnering long-term care (LTC) facilities at all seven sites collectively showed a decline in all-cause hospitalizations and potentially avoidable hospitalizations, relative to a comparison group. Five sites show statistically significant reductions in at least one of the hospitalization measures. Six of the seven sites also collectively showed reductions in Medicare expenditures relative to a comparison group, with statistically significant declines in total Medicare expenditures at four sites.
Once again, the MDS-based quality measures do not show any pattern of change related to the Initiative, suggesting that lower hospitalization rates are not generally leading to a decline in quality of care for LTC facility residents.
The Year 3 report, published on January 19, 2016, presented early results for this Initiative. This report analyzed Medicare expenditures, utilization, and MDS-based quality measures through the end of 2014 and included qualitative findings through mid-2015.
According to the analysis, all seven sites showed reductions in overall Medicare expenditures relative to a comparison group, with statistically significant declines in total Medicare expenditures at two sites. All sites also showed a decline in all-cause hospitalizations and potentially avoidable hospitalizations, with four sites showing statistically significant reductions in at least one of the hospitalization measures. The MDS-based quality measures do not show any pattern of change related to the Initiative, suggesting that lower hospitalization rates are not generally leading to a decline in quality of care for LTC facility residents.
An earlier evaluation report presented results of the quantitative and qualitative analysis across the first two years of the Initiative. That report described promising initial results including estimated reductions in hospitalization and potentially avoidable hospitalization levels, though at the time it was too early to draw any firm conclusions because the ECCPs were phasing in their interventions during this period.
Contact Us
For more information or questions about these reports or the Initiative as a whole, please email NFI@cms.hhs.gov.
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