Avoidable Hospitalization and Therapy Services Discussed at SNF Open Door

CMS provided an overview of the Initiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents during an open door forum for skilled nursing facilities (SNF) on January 16, 2014.  After the review of the initiative, providers asked questions on the use of the  change of therapy (COT) Other Medicare Required Assessment (OMRA), and the types of staff that can provide therapy for a resident who is on a maintenance plan.

Avoidable Hospitalizations 

The Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents was designed to help improve the quality of care for SNF residents while reducing costs to CMS at the same time.  During the open door forum, CMS reported that there are currently 1 million dual eligible beneficiaries in 15,000 SNFs across the country of which 45 percent will be admitted to a hospital.  CMS estimates that 314,000 of the 450,000 hospitalizations could be avoided, saving $2.6 billion in Medicare expenditures.

The initiative uses independent organizations known as  enhanced care and coordination providers (ECCPs) to implement interventions at SNFs to reduce hospitalizations. The ECCPs are testing several models of intervention. An ECCP must partner with at least 15 SNFs to be a part of the initiative. There are seven ECCPs currently working with 147 facilities in seven states, CMS reported.  These ECCPs are providing services to 16,000 dual eligible beneficiaries.

The demonstration began in 2012 and is to last for four years, until September 2016.  At that time a full evaluation of the various models being tested by the ECCPs will be conducted to determine the success of each model at reducing hospitalizations.  The two main models being tested are models that educate and train SNF staff to observe the signs of conditions that can be treated at the facility before hospitalization is required, and a model that uses nurse practitioners to provide additional hands-on care. In Nebraska, the ECCP is providing oral care to SNF residents, as better oral care has been linked to a reduction in pneumonia. During the open door forum CMS said that it has received significant anecdotal evidence of success in the reduction of hospitalizations for urinary tract infections and  medication management.

The initiative is being overseen by the Medicare-Medicaid Coordination Office, which was created by section 2602 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Its purpose is to improve the quality of care received by dual eligible beneficiaries by eliminating regulatory conflicts between Medicare and Medicaid, improving the continuity of care between the two programs, eliminating cost shifting, and improving the quality of performance of providers and suppliers.

Questions on Therapy Services

CMS clarified that assistants can provide physical therapy to SNF residents who are on a maintenance program following the agreement reached in the Jimmo v Sebelius case.  For a short period of time, the SNF provider manual said that assistants could not provide the therapy. For home health agencies and outpatient rehabilitation facilities (ORFs) this is the case, and CMS applied the rule to  SNFs in an effort to be consistent.  Upon further review, it was discovered that the SNF regulations specifically allow for assistants to provide physical therapy,  although the regulations governing in home health  care or at ORFs do not. CMS has recently corrected the SNF manual to be consistent with the regulations.

Several providers had questions about the use of a COT OMRA.  A COT OMRA  is required if a resident does not receive the therapy as indicated by the  resource utilization group (RUG-IV) classification level provided by the patient’s last assessment.  Particularly providers had questions about when to complete a COT OMRA for a resident who simply took a break from therapy for any number of reasons. A resident can be reclassified back into rehabilitation group prior to the discontinuation of therapy services by using a COT OMRA, CMS said.  Prior to fiscal year 2012 SNFs would have to wait until the next scheduled comprehensive assessment to get a resident back into the level of therapy from which they took a break.

The next SNF open door forum is scheduled for March 6, 2014.