OPTIMISTIC Study of New CMS Model Expands Implementation

The OPTIMISTIC study (Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care), by Indiana University, has added 25 additional facilities across Indiana as it expands its efforts to improve the health and health care of long-term nursing home (NH) residents. An overview and preliminary analysis of this transition model was published in the Annals of Long-Term Care: Clinical Care and Aging. (2016;24[7]:31-36).

All NHs participating in OPTIMISTIC have implemented the new Centers for Medicare and Medicaid Services (CMS) payment mechanism. However, only the 19 facilities involved in the initial phase have embedded OPTIMISTIC nurses and nurse practitioners, allowing the OPTIMISTIC project team to identify specific effects of the clinical innovations and the new payment method.

Over the next 4 years, the 19 central Indiana NHs that participated in OPTIMISTIC’s initial phase, plus the 25 additional NHs from across the state, are implementing a new CMS payment model, which incentivizes nursing facilities, as well as their medical staffs, to provide higher levels of care on site rather than sending residents to the hospital.

OPTIMISTIC’s 4-year initial phase focused on enhanced clinical care. Nurses and nurse practitioners were embedded in 19 central Indiana NHs to provide direct support to long-stay residents as well as education and training to facility staff. These specially trained professionals also lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications, and clarify care goals. These nurses and nurse practitioners will remain on-site in Phase I facilities during OPTIMISTIC’s second phase.

The new payment strategy supports short-term provision of on-site acute care to NH residents who have one or more of six conditions linked to approximately 80% of potentially avoidable hospitalizations. These conditions include pneumonia (responsible for almost a third of potentially avoidable hospitalizations), urinary tract infections, congestive heart failure, chronic obstructive pulmonary disease/asthma, skin infection, and dehydration.

“Under the current CMS payment system, nursing facilities do not receive additional reimbursement to provide the care needed by residents who become sicker, unless the nursing home sends them to the hospital and then readmits them to the nursing home under the Medicare post-acute care benefit,” said Director for OPTIMISTIC Phase II, Kathleen Unroe, MD, MHA, Indiana University Center for Aging Research, in an Indiana University news release.

CMS research has estimated that up to 45% of hospitalizations of nursing facility residents could be prevented with well-targeted interventions. In 2005 this could have accounted for 314,000 potentially avoidable hospitalizations and an estimated $2.6 billion in Medicare expenditures.
—Amanda Del Signore