Improving care for nursing home residents: CMS ups support of OPTIMISTIC to $30.3 million

  • March 28, 2016

INDIANAPOLIS -- With the announcement of an additional $16.9 million for a total of more than $30 million of Centers for Medicare and Medicaid Services funding since 2012, Indiana University's OPTIMISTIC project commences the second phase of an innovative endeavor with a goal of improving the health and health care of long-term nursing home residents and ultimately reducing hospital admissions for this growing population.

OPTIMISTIC is an acronym for Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care.

In OPTIMISTIC's four-year initial phase, focused on enhanced clinical care, nurses and nurse practitioners have been embedded in 19 central Indiana nursing homes to provide direct support to long-stay residents as well as education and training to facility staff. These specially trained professionals, who also lead care management reviews of long-stay patients to optimize chronic disease management, reduce unnecessary medications and clarify care goals, will remain in place during OPTIMISTIC's second phase. The second four-year phase adds an additional layer of resources by introducing new Medicare payments to care for sick residents in the nursing home.

Long-stay nursing home residents suffer from high rates of multiple chronic illnesses and dementia. Despite their needs and frailty, their care is often fragmented by potentially avoidable hospitalizations as well as gaps in primary and palliative care, which increase suffering and costs of care.

CMS research has estimated that up to 45 percent 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.

During the upcoming four years of OPTIMISTIC's second phase, the 19 nursing homes that participated in the initial phase plus 25 additional nursing homes, who will be recruited from throughout Indiana, will implement 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.

"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 Project Director for OPTIMISTIC Phase 2, Kathleen Unroe, M.D., MHA, an Indiana University Center for Aging Research and Regenstrief Institute scientist, and an IU School of Medicine assistant professor of medicine.

"There is no mechanism in place for CMS to pay nursing homes for ramping up nursing care and other care services needed when a resident becomes sicker. In phase two of OPTIMISTIC, CMS supports testing to see if unnecessary hospitalizations will decrease if they provide nursing homes incentives to provide care in place," Dr. Unroe said.

The new payment mechanism will support short-term provision of on-site acute care to nursing home residents who have one or more of six conditions linked to approximately 80 percent of potentially avoidable hospitalizations. These conditions include pneumonia (responsible for almost a third of potentially avoidable hospitalizations), urinary tract infections, congestive heart failure, COPD/asthma, skin infection, and dehydration.

All nursing homes participating in OPTIMISTIC will implement the new CMS payment mechanism. However, only the 19 facilities involved in the initial phase will 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.

“OPTIMISTIC continues to be an exciting opportunity to improve care for this vulnerable population. With our academic, state government and nursing home partners, we are working collaboratively to address the root causes for fragmented care,” said Dr. Unroe.

The IU Center for Aging Research, IU Geriatrics, and the Regenstrief Institute are at the forefront in developing, implementing and evaluating interventions to improve care and quality of life for vulnerable older adults.

OPTIMISTIC is one of 6 sites nationwide participating in this CMS Center for Innovations funded nursing home demonstration project.

“CMS is investing in phase 2 for OPTIMISTIC and these other sites because early results from an independent evaluation of the phase I clinical program are already showing very positive results. We’re very excited to have this opportunity to demonstrate the full effect of OPTIMISTIC and see if we can further transform care with better aligning financial payments as well,” said Greg Sachs, M.D., IU Center for Aging Research and Regenstrief Institute investigator and chief of the Division of General Internal Medicine and Geriatrics at the IU School of Medicine. He is the co-project director of the OPTIMISTIC Phase 2 program.

The independent evaluation of the phase I clinical program is available here.

In addition to Drs. Unroe and Sachs, the interdisciplinary OPTIMISTIC project team includes David Bose, M.D., IU School of Medicine (medical director); Monica Tegeler, M.D., IU School of Medicine (assistant medical director); Susan E. Hickman, Ph.D., IU School of Nursing; Ellen Miller, PT, Ph.D., Center for Aging & Community, University of Indianapolis; Jennifer Carnahan, M.D., IU School of Medicine; Nicole Fowler, Ph.D., IU Center for Aging Research, Regenstrief Institute and Center for Health Innovation and Implementation Science; Greg Arling, Ph.D., and Kathleen Abrahamson, Ph.D., RN, of Purdue University; Kathy Frank, Ph.D., IU School of Medicine, and Mary Ersek, Ph.D., University of Pennsylvania. Laura Holtz, B.S., is the project manager and Shannon Effler, MSW and Bryce Buente, MPH are the project coordinators. All three are with the IU Center for Aging Research and the Regenstrief Institute.