By Niall Brennan, Director of the CMS Office of Enterprise Data and Analytics, and CMS Chief Data Officer; and, Tim Engelhardt, Director of the Federal Coordinated Health Care Office at CMS
Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents
For long-term care facility residents, avoidable hospitalizations can be dangerous, disruptive, and disorienting. Keeping our most vulnerable citizens healthy when they are residents of long-term care facilities and reducing potentially avoidable hospital stays has been a point of emphasis for the Centers for Medicare & Medicaid Services (CMS).
Over the last several years, with the help from the Affordable Care Act, Medicare and Medicaid have worked with other federal government agencies, states, patient organizations, and others to identify and prevent those health conditions that have caused long-term care residents to be unnecessarily hospitalized. Because of these efforts, we have seen a dramatic reduction in avoidable hospitalizations over the last several years, according to below analysis released by CMS today.
In 2001, the Agency for Healthcare Research and Quality (AHRQ) first identified a set of measures designed to identify hospitalizations that could potentially be avoided with appropriate outpatient care. They include hospital admissions for largely preventable or manageable conditions like bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, and chronic obstructive pulmonary disease. More recently, CMS’s own Office of Enterprise Data and Analytics found that instances of these potentially avoidable hospitalizations (PAH) were disproportionally high among some of our nation’s most vulnerable people, those dually eligible for Medicare and Medicaid living in long-term care facilities.
Treating conditions before hospitalization and preventing these conditions whenever possible would not only help long-term care facility residents stay healthy, but may also save Medicare and Medicaid money. After carefully examining this problem, CMS and others focused on reducing the instances of potentially avoidable hospitalizations from these facilities.
In 2015, Medicare fee-for-service (FFS) beneficiaries living in long-term care facilities had a total of 352,000 hospitalizations. Of this number, Medicare beneficiaries eligible for full Medicaid benefits living in long-term care facilities (LTC Duals) accounted for 270,000 hospitalizations. And, almost a third (approximately 80,000) of these hospitalizations were caused by six potentially avoidable conditions: bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, chronic obstructive pulmonary disease or asthma, and skin ulcers.
Through the concerted effort by CMS and many other to address these potentially avoidable conditions, real progress has been made to improve the health and wellbeing of some of our country’s most vulnerable citizens. In recent years, the overall rate of hospitalizations declined by 13 percent for dually eligible Medicare and Medicaid beneficiaries. But we have seen even larger decreases in hospitalization rates for potentially avoidable conditions among beneficiaries living in long-term care facilities. Specifically, between 2010 and 2015, the hospitalization rate for the six potentially avoidable conditions listed above decreased by 31 percent for Medicare and Medicaid dually-eligible beneficiaries living in long-term care facilities.
In 2010, the rate of potentially avoidable hospitalizations for dually-eligible beneficiaries in long term care facilities was 227 per 1,000 beneficiaries; by 2015 the rate had decreased to 157 per 1,000. This decrease in potentially avoidable hospitalizations happened nationwide, with improvement in all 50 states. The reduced rate of potentially avoidable hospitalizations means that dually-eligible long-term care facility residents avoided 133,000 hospitalizations over the past five years.
Percent Change in Medicare Hospitalization Rates Since 2010
Note: FFS (fee-for-service), LTC (long-term care facility), PAH (potentially avoidable hospitalization)
Potentially Avoidable Hospitalization Rates for Dual-Eligible Beneficiaries Living in Long-Term Care Facilities, by State
Note: Labeled states contain facilities in the CMS “Initiative to reduce avoidable hospitalizations among long-term care facility residents”, discussed below.
This success would not be possible without the committed work by those who directly serve older adults and people with disabilities. We also should consider the range of other contributing factors, including:
- An initiative launched in 2011 by the Medicare-Medicaid Coordination Office, CMS Innovation Center, and other partners to reduce avoidable hospitalizations among nursing facility residents in seven sites across the country. This initiative aimed at keeping dually-eligible long-term care residents healthy by focusing on preventable conditions that lead to hospitalizations.
- The AHRQ Safety Program for Long-Term Care significantly reduced catheter-associated urinary tract infections in hundreds of participating long-term care facilities nationwide, which helped prevent a recognized cause of hospitalizations in residents of these facilities.
- This work is in addition to the many other efforts and initiatives, including the Hospital Readmission Reduction Program, and systemic efforts to reduce readmissions through the Partnership for Patients;
- The efforts to align care with quality through Accountable Care Organizations, the Bundled Payments for Care Improvement models, and other delivery system reforms;
- And, finally, the countless other industry-led initiatives focusing on quality improvement and specifically reducing hospitalization rates among long-term care facility residents.
This success shows that a sustained commitment to smarter spending across the entire health care system can yield dramatic results and improve the lives of vulnerable Americans. These results are also consistent with other ongoing collaborative efforts to improve the quality of care patients received through preventing hospital-acquired conditions where approximately 125,000 fewer patients died due to hospital-acquired conditions and more than $28 billion in health care costs were saved from 2010 through 2015.
Finding the best possible long-term care facility care for a loved one is one of the most difficult decisions family members can make. Family members want to be assured that their loved one will receive the highest quality of care in a healthy environment. And thanks to efforts across the health care industry, and with tools from the Affordable Care Act that allow CMS to improve quality and test innovative strategies, these residents are living in safer, healthier environments.
Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress
 Analysis includes residents living in nursing homes or nursing facilities. It does not include residents receiving skilled nursing facility services paid through the Medicare program.
 The population of dual-eligible beneficiaries living in long-term care facilities consists of Medicare FFS beneficiaries with full Medicaid benefits residing in long-term care facilities but not receiving skilled nursing facility services. The number of days that beneficiaries met this criteria was annualized so that 365 days was equivalent to one beneficiary. Hospitalizations of long-term care residents were counted as potentially avoidable if the primary diagnosis of the admission was bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, chronic obstructive pulmonary disease or asthma, or skin ulcers.
 The seven sites were: Nevada, Nebraska, Missouri, New York, Pennsylvania, Indiana, and Alabama. Note that six of these sites have continued into “Phase II” of the Initiative, which launched in October 2016.
 For more information, see the Initiative website at: https://innovation.cms.gov/initiatives/rahnfr/