​Nursing home residents may benefit from onsite acute care as an alternative to hospitalization, a study funded by the Centers for Medicare & Medicaid Services (CMS) found. Spanning almost a decade of research involving nearly 150 facilities in seven states, the CMS Initiative to Reduce Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents found no indications of harm from onsite care for six conditions:

• pneumonia,
• congestive heart failure,
• chronic obstructive pulmonary disease,
• skin infection,
• dehydration, and
• urinary tract infections.

In fact, researchers concluded in an article published in JAMDA, onsite care may even offer “a possible benefit” for these patients.

That article focuses on the second phase of the Initiative, a large-scale effort to reduce avoidable hospitalizations and the negative health outcomes—as well as the costly Medicare bills—they can incur. In the first phase, researchers introduced a variety of educational and clinical interventions at various facilities. The second phase introduced payment incentives, allowing certain facilities to bill Medicare for onsite care provided to residents with severe enough episodes of any of the six conditions. In some facilities, the payment incentives built on previously introduced clinical interventions; others employed the payment incentives alone.

For proponents of onsite acute care, the results were promising. Comparing 16,974 onsite treatment episodes against 5,907 in-hospital treatments, researchers found that “those treated initially in the hospital were about twice as likely (26.5 percent vs 13.6 percent) to be subsequently treated in-hospital and more than twice as likely (17.0 percent vs 7.8 percent) to die.” Even after they adjusted for observable differences between the two cohorts, they found that hospitalized patients were still more likely to be readmitted.

Ultimately, the researchers wrote, onsite care in a facility with adequate clinical resources “is often the better choice for residents and their health outcomes.”

Familiar Challenges

Notably, the broader Initiative did not find clear evidence that payment incentives alone were effective in reducing avoidable hospitalizations. As the researchers explained in their final report on the project and in comments to Provider, many participating facilities reported that they were effectively paid for processes they already had in place:

• educating direct care staff about the need to treat residents in place,
• using various communication tools to keep facility staff abreast of changes in resident conditions,
• investigating the reasons for avoidable hospitalizations, and
• ensuring the same care workers were consistently assigned to the same residents.

At the same time, many facilities did not even directly receive the financial incentives, which instead went to the offices of their corporate parents.

Facilities encountered familiar challenges as they implemented Initiative-designed interventions. “Nursing homes have high rates of turnover among both direct care staff and leadership, leading to the need to frequently retrain staff about Initiative goals and processes,” researchers Micah Segelman, Mel Ingber, Zhanlian Feng, Galina Khatutsky, and Lawren Bercaw explained in comments emailed to Provider. “In the first phase, in which staff were placed in facilities, insufficient staffing of LPNs and RNs affected [the facility’s] ability to provide in-house care and assess residents. Leadership turnover interfered with initiative implementation and reduced support for the initiative on the ground.”

“Most of the staff in nursing homes are CNAs,” they added. “Most of the nurses are LPNs who cannot formally assess residents and have limitations on the type of care they can provide. There are very few RNs on the floor, which means fewer chances to provide higher level resident care. The initiative hinged on nursing staff’s ability to assess residents for changes in condition.”

That’s not to understate their findings that many residents benefited from onsite treatment, however. Indeed, the Initiative found that clinical and educational interventions resulted in multiple improvements at participating facilities. By using documentation tools like INTERACT, SBAR, and Stop and Watch, facilities improved the quality of their onsite assessments. At the same time, floor staff honed important skills like administering intravenous antibiotics.

“Facilities also reported an increased focus on advance directives and advance care planning, leading to better alignment of clinical care with resident and family wishes,” the researchers wrote in the JAMDA article. “A combination of these efforts supported facilities to provide appropriate treatment of residents on site.”

This echoes their conclusion in the Initiative’s final report: that reducing avoidable hospitalizations depends on a “holistic approach” to care, one that itself rests on “sufficient staffing, appropriate levels of clinical expertise and support, and consistent assignment of nursing staff.” Such an approach may also require the prioritization of onsite care for all residents rather than those with a “limited set of strictly defined specific conditions,” they wrote.

Reconsidering the 3-Day Requirement for Medicare SNF Coverage

In addition to the valuable context it provides to industry-wide conversations about staffing issues and clinical support, the study may also inform a simmering discussion over Medicare requirements for skilled nursing facility (SNF) extended care services coverage.

Under existing rules, Medicare beneficiaries only qualify for extended care in a SNF if they stay in a hospital for at least three consecutive days, not inclusive of their discharge day or any time spent in an emergency room or outpatient setting pre-admission. That requirement was waived during the COVID-19 public health emergency, which ended earlier in 2023. The Initiative’s findings—that appropriately resourced providers can treat residents onsite, in certain cases, as an alternative to hospitalization—lend credence to the argument made by some experts that the three-day requirement is an outdated relic of the past.

One such expert is Toby Edelman, Senior Policy Attorney at the Center for Medicare Advocacy, a nonprofit, public interest law firm. “Health care is so different now from when Medicare was enacted in 1965, when the average length of stay for people over 65 in the hospital was over 13 days,” she told Provider. “Just about anybody who went to the hospital was going to meet that requirement. Now, so many things are done on an outpatient basis; that doesn't mean people don't need rehabilitation and some services in a nursing home. So I think it makes absolutely no sense to have the three-day requirement.”

Asked what she makes of the Initiative’s findings, Edelman stressed the importance of adequate staffing. “What I get from this is that yes, residents for these six conditions can be treated successfully in the nursing home if the facility is appropriately staffed to meet those needs,” she said. “It depends upon having sufficient staff that know what they're doing to provide the care.”

Key Takeaways for Providers

Asked what nursing home leaders should take away from their study, the authors offered a few suggestions:

• Hire nurse practitioners, “on the floors or at least visiting regularly.” They suggested that chains could share traveling NPs.
• Provide staff with the necessary support and resources to reduce turnover.
• Implement consistent assignment practices as much as possible, empowering care workers to “learn residents’ personalities and care needs so that any condition changes are caught quickly.”
• Ensure staff receive the education and skill refreshments they need to provide quality care.
• Improve medication management and communication with hospitals.
• Implement effective telemedicine resources, with the IT infrastructure necessary to support it.
• Assign employees to serve as “champions” for programs designed to reduce avoidable hospitalizations and provide them with the support they need to be effective.
• Educate families about potentially avoidable hospitalizations and why they’re detrimental to residents’ health.