Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative

Abstract

Background/objectives: Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated.

Design: We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status.

Setting: Participating NFs during fiscal years 2017 to 2018.

Participants: There were 47,202 long-stay NF residents from 260 facilities in seven states.

Intervention: CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform.

Measurements: Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions.

Results: Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital.

Conclusion: Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Keywords: Medicare; ambulatory care sensitive conditions; avoidable hospitalizations; nursing facilities.