RTI International.
Harvard Medical School.
Milbank Q. 2022 Dec;100(4):1243-1278. doi: 10.1111/1468-0009.12594. Epub 2022 Dec 27.
Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone.
In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).
Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.
Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.
Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.
医疗保险和医疗补助之间的激励措施不匹配可能导致长期居住在养老院的居民住院治疗。为养老院提供临床工作人员，如执业护士，比仅提供医疗保险激励措施更能有效减少居民住院治疗。
2012 年，医疗保险和医疗补助服务中心实施了减少养老院居民可避免住院治疗的倡议。在第一阶段（2012 年至 2016 年），临床或基于教育的干预措施（仅临床）旨在减少长期居住在养老院的居民住院治疗。在第二阶段（2016 年至 2020 年），该倡议还包括医疗保险支付激励措施，用于治疗养老院中某些条件的居民。参与第一阶段的养老院继续实施以前的干预措施并获得激励措施（临床+支付），而其他养老院仅获得激励措施（仅支付）。
采用混合方法确定该倡议的有效性，并探讨参与的养老院在实施过程中面临的促进因素和障碍。我们使用电话和面对面访谈调查实施情况的各个方面，并使用差异中的差异回归模型框架比较参与和未参与养老院的居民，以确定该倡议对利用、支出和质量衡量标准的影响。
成功实施该倡议需要三个关键组成部分——人员保留和领导稳定、领导和员工支持以及提供者参与和支持。缺乏这三个组成部分之一或多个组成部分的养老院面临更大的挑战。第一阶段的仅临床干预措施成功减少了住院治疗。我们没有发现临床+支付或仅支付干预措施成功减少住院治疗的证据。
减少养老院居民的住院治疗取决于是否有临床工作人员以及这些工作人员是否能够提供持续的教育，为养老院的直接护理人员提供支持，以及提供实际护理。仅使用医疗保险支付激励措施来鼓励在现场治疗居民不足以减少住院治疗。除非养老院有足够的人员配备来治疗有急性护理需求的居民，否则将难以进一步减少住院治疗。
