The Centers for Medicare and Medicaid Services (CMS) Innovation Center and Medicare-Medicaid Coordination Office created an initiative in 2012 to reduce avoidable hospitalizations among nursing facility residents. CMS partnered with seven Enhanced Care and Coordination Providers (ECCPs) across the U.S. to improve care for long-term care (LTC) facility residents. Each ECCP chose a different approach to improve nursing home care, and each was evaluated for its effectiveness in improving health outcomes and providing residents with a better care experience.
The OPTIMISTIC program, one of the original seven ECCPs to receive funding, was born from research conducted by clinicians from Indiana University, the Regenstrief Institute, and the University of Indianapolis. The four-year trial project, started in September 2012, was directed by Dr. Greg Sachs and Dr. Kathleen Unroe, and received a $13.4 million award from the CMS Innovation Center. Then, in 2015, the project received an additional grant of $621,697 from the John A. Hartford Foundation to prepare for the expansion and dissemination of the program.
OPTIMISTIC’s strategy to keep elderly patients out of the hospital involved placing 19 geriatrics-trained RNs in nursing homes across central Indiana. These RNs helped administer care to patients, but they also worked to support, educate, and train facility staff to hone their skills and to improve the quality of geriatric medical practice and palliative care.
The phase one work had a significant impact. Compared to our blinded control group, OPTIMISTIC:
- Reduced relative risk of potentially avoidable hospitalizations by 32.6%.
- Reduced all-cause hospitalizations by 19.3%.
- Reduced relative spending for avoidable hospitalizations by 24.9% per resident.
- Produced net savings of $3.4 million in Medicare expenditures.
In 2016, OPTIMISTIC received another $16.9 million award from CMS to continue its research and capitalize on the phase one success. Phase two of the program aimed to test and implement a new payment model in the 19 phase-one LTC facilities, as well as 25 additional homes recruited from across Indiana. The new CMS payment model incentivized nursing facilities, as well as their medical staffs, to provide higher levels of care on site rather than sending residents to the hospital. Facilities using the phase two model accepted payments under Medicare Part B for qualifying conditions linked to unnecessary hospitalizations, including pneumonia, urinary tract infections (UTI), congestive heart failure (CHF), dehydration, skin ulcers (cellulitis), chronic obstructive pulmonary disease (COPD), and asthma.
The Future of OPTIMISTIC
While the OPTIMISTIC team continues the phase two research under the CMS initiative, it actively pursues commercialization efforts, with the goal of introducing a market-ready, evidence-based model of care to be available in 2017. At that time, independent long-term care facilities, health systems, and affordable care organizations across the U.S. will be able to license the OPTIMISTIC model and begin implementation.