Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

This initiative is possible through the collaboration of the CMS Innovation Center and the CMS Medicare-Medicaid Coordination Office.

Recent Updates:

09/27 - Announced: 7 organizations participating in this Initiative.
06/01 - Application Guidance Document posted under "Additional Information" section below.
05/30 - Updated Frequently Asked Questions document posted under "Additional Information" section below.


This new effort aims to improve the quality of care for people residing in nursing facilities.

CMS will support organizations that will partner with nursing facilities to implement evidence-based interventions that both improve care and lower costs. The initiative is focused on long-stay nursing facility residents who are enrolled in the Medicare and Medicaid programs, with the goal of reducing avoidable inpatient hospitalizations. This initiative supports the Partnership for Patients' goal of reducing hospital readmission rates by 20% by the end of 2013.

Participating Sites

From a pool of applicants, 7 organizations were selected for this Initiative:

Alabama Quality Assurance Foundation – Alabama

Alabama Quality Assurance Foundation will implement an intervention in 23 facilities in Alabama. In this intervention, RNs will be deployed in the partnering nursing facilities to implement the INTERACT tools. Additionally, the proposal includes the implementation of “EMPOWER” (Enhancing My Profession and Organization with Empathy and Respect), which is a training program to help nursing facility staff enhance their skills for managing workplace demands and professional relationships. Additionally, the intervention staff will work with each facility to adopt and measure consistent assignment as defined by the Advancing Excellence in America’s Nursing Homes campaign. The goals of EMPOWER and consistent assignment include reducing staff turnover and increasing awareness of residents’ status and needs, which would improve the staff’s ability to implement care plans and notice changes in residents’ health.

Alegent Health – Nebraska

Alegent Health will implement an intervention in 15 nursing facilities in Nebraska. Alegent Health will deploy nurse practitioners in the partnering nursing facilities to enhance care by implementing INTERACT tools and a program to improve medication management based on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. An innovative aspect of this program is the use of a dentist and dental hygienist to improve oral care for beneficiaries. This type of care is typically not provided in the nursing facility environment and contributes to better overall health, while also working to prevent other conditions that lead to avoidable hospitalizations.

HealthInsight of Nevada – Nevada

HealthInsight of Nevada will implement an intervention in 25 nursing facilities in Nevada. The intervention, named the “Nevada Admissions and Transitions Optimization Program” or “ATOP,” includes the creation of pods that consist of a physician extender (nurse practitioner or physician’s assistant) and two registered nurses (RNs) who will be physically on-site at nursing facilities. Each one of the five pods will provide enhanced care and coordination to residents in five facilities. Additionally, the intervention will include INTERACT (INTErventions to Reduce Acute Care Transfers) tools and use a resident risk assessment program whereby each beneficiary will receive the appropriate level of enhanced care and attention based on their individual risk level. HealthInsight of Nevada will also implement a medication management program to reduce polypharmacy and the inappropriate use of antipsychotics.

Indiana University – Indiana

Indiana University will implement an intervention in 20 nursing facilities in the Indianapolis region of Indiana. This organization has created a program called “OPTIMISTIC” (“Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care”) which includes the deployment of RNs and advanced practice nurses (APNs) to be on-site at the nursing facilities, allowing for enhanced recognition and management of acute change in medical conditions. RNs and APNs will coordinate with nursing facility staff and residents’ primary care providers. In addition to employing INTERACT tools, this enhanced staffing model will adapt and apply other evidence-based models which have proven to reduce hospitalizations in other settings.

The Curators of the University of Missouri – Missouri

The Curators of the University of Missouri will implement an intervention in 16 nursing facilities in Missouri. In this intervention, advanced practice RNs (APRNs) will be assigned to facilities to provide direct services to residents while mentoring, role-modeling, and educating the nursing staff about early symptom/illness recognition, assessment, and management of health conditions commonly affecting nursing home residents. Additionally, the intervention includes the use of social workers who will work closely with each facility’s social worker, the residents’ primary care providers, nursing facility staff, and APRNs, to assure consistent communication about resident’s needs and preferences. Finally, RNs will implement INTERACT and QIPMA (Quality Improvement Program for Missouri), programs that have demonstrated positive results in the nursing facility environment.

The Greater New York Hospital Foundation, Inc. – New York City

The Greater New York Hospital Foundation, Inc. will implement an intervention in 30 nursing facilities in the New York City metropolitan region. In this program, RNs will be deployed in the partnering nursing facilities to train the nursing facility staff on INTERACT tools and the American Medical Director Association Clinical Practice Guidelines on Acute Change in Condition. The project will also implement the use of an eINTERACT system to eliminate the need for the paper-based format and provide real-time access to beneficiary information to all providers across the continuum of care.

UPMC Community Provider Services - Pennsylvania

UPMC Community Provider Services will implement an intervention in 16 nursing facilities in the western region of Pennsylvania. UPMC Community Provider Services has created a program called “RAVEN” (Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing facilities in western Pennsylvania). This program will include facility-based nurse practitioners to assist with determining resident care plan goals, and conduct acute change in condition assessments. It will also implement evidence-based clinical communication tools such as INTERACT and others recommended by the American Medical Directors Association to assist in structuring and standardizing clinical assessments and recommendations. The intervention will also provide support from innovative telehealth and information technologies to connect participating nursing facilities into the Western PA Health Information Exchange.


Nursing facility residents often experience potentially avoidable inpatient hospitalizations. These hospitalizations are expensive, disruptive, and disorienting for frail elders and people with disabilities. Nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections.

Many nursing facility residents are enrolled in both the Medicare and Medicaid programs (Medicare-Medicaid enrollees). CMS research on Medicare-Medicaid enrollees in nursing facilities found that approximately 45% of hospital admissions among those receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.


Initiative Details

Through this initiative, CMS will partner with eligible, independent, non-nursing facility organizations (referred to as “enhanced care & coordination providers”) to implement evidence-based interventions that reduce avoidable hospitalizations. Eligible organizations can include physician practices, care management organizations, and other entities. Both for-profit and not-for-profit organizations are eligible to apply.

The enhanced care & coordination providers will collaborate with States and nursing facilities, with each enhanced care & coordination provider implementing its intervention in at least 15 partnering nursing facilities.

Applicants will propose an intervention that meets the objectives of the initiative, which those selected will then implement. Interventions will be evaluated for their effectiveness in improving health outcomes and providing residents with a better care experience.

Applications for this initiative were due June 14, 2012 by 3:00 p.m.


Addition Information


If you have additional questions on this Initiative, please e-mail us directly at Programmatic questions submitted after May 31, 2012 are not guaranteed a response. For more information on this initiative, including archived information, visit the Medicare-Medicaid Coordination Office page.