Health Reform's Anniversary Stirs LTC Initiatives

Abstract

Maybe it was inspired by the new beginnings of spring, but whatever it was, the Centers for Medicare & Medicaid Services rained “initiatives” like blossom petals on long-term care providers in March. Not to make light of any of them – they dealt with the weighty topics of antipsychotic medication prescribing in nursing homes, reducing avoidable hospitalizations, and training more advanced practice nurses to address the health care workforce shortage. The antipsychotics initiative was one with an unusual kickoff. The agency announced long in advance that it would launch its “Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes Residents” on March 29 in a web-only video broadcast. Even beforehand though, the agency gave these provocative details: “As part of the initiative, CMS is developing a national action plan that will use a multidimensional approach including public reporting, raising public awareness, regulatory oversight, technical assistance/training and research. The action plan will be targeted at enhancing person-centered care for nursing home residents, particularly those with dementia-related behaviors.” As several AMDA leaders made clear in featured presentations at the annual AMDA meeting in San Antonio, antipsychotic prescribing to dementia patients will continue to be a hot topic in Washington. AMDA Board of Directors member Dr. Susan Levy, CMD, medical director at Levindale Hebrew Geriatric Center and Hospital in Baltimore, was scheduled to present part of the broadcast. The other big March CMS initiative addresses another topic always high on the LTC agenda, hospital admissions of nursing home residents. The agency announced that it has $128 million to spend on “evidence-based interventions” to “reduce costly and avoidable hospitalizations among nursing facility residents.” The money in the “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents” will go to organizations independent of nursing homes that will, however, partner with the facilities and send in professionals with strategies for keeping residents there and safe. Eligible organizations “can include physician practices, care management organizations, and other public and not-for-profit entities,” according to the CMS announcement. Hints in the announcement at what kinds of efforts might win funding included: “For example, past demonstrations have reduced avoidable hospitalizations by deploying nurse practitioners in nursing facilities to manage residents' medical needs on the spot, when possible. Others have implemented quality improvement and communication tools to identify, assess, communicate, and document changes in resident status.” The agency said that its research has found that about 45% of hospital admissions of Medicare and Medicaid nursing home beneficiaries “could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.” Those are numbers that catch the attention of people concerned about health care spending – and they did. Nearly simultaneously with the CMS announcement, the Medicare Payment Advisory Commission (MedPAC) called on Congress to institute rehospitalization penalties for skilled nursing facilities (SNFs) of the type about to go into effect for hospitals. “SNF patients who are rehospitalized raise Medicare spending and are exposed to hospital-acquired infections and disruptive care transitions. Beginning in October 2012, a readmission policy will penalize hospitals with high readmission rates for certain conditions. A rehospitalization policy for SNFs would create comparable policies for SNFs and hospitals, thereby encouraging providers in both settings to work together to better manage the transitions between them …. A rehospitalization policy that penalizes facilities with high riskadjusted rates over multiple years would target providers with aberrant patterns of rehospitalization, recognize that some rehospitalizations are appropriate, and reduce the incentive to selectively admit beneficiaries with specific characteristics.” The full MedPAC report (which also repeated the commission's plea for an end to the Sustainable Growth Rate formula for Medicare fees) is available at www.medpac.gov/documents/Mar12_EntireReport.pdf. Information and application requests for the CMS hospitalization initiative are available at www.innovation.CMS.gov/initiatives/rahnfr. And, the Obama administration happened to note that the effort on resident hospitalizations was developed by the Center for Medicare & Medicaid Innovation and the Medicare-Medicaid Coordination Office, both of which “were created by the Affordable Care Act.” Health reform also happened to be the genesis of a CMS initiative to “bolster the primary care workforce” by offering $200 million over 4 years to medical centers willing to train more nurse practitioners and other advanced practice registered nurses and send them out to nonhospital settings. Maybe it was just coincidence that so many health and long-term care initiatives were rolled out around the second anniversary of the health reform act (March 23). You know, the one that most Republicans pledge to repeal in their campaign materials.