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The Case for Small Reforms within Long-Term and Post-Acute Care

While major reforms of the Affordable Care Act, such as those proposed by the Trump administration and Republican leaders in Congress are sure to have an impact on the post-acute and long-term care industry–if passed–by dedicating all our attention to the big “what ifs”, we may be ignoring the trees for the forest.

This commentary offers a few examples of successful healthcare delivery pilot studies designed to lower cost and improve outcomes for seniors. Regardless of what happens to federal healthcare reform, they have demonstrated evidence of success and offer best practices that operators can incorporate today without needing a grant from the Centers for Medicare & Medicaid Services (CMS) or a research institution.

Following some of these best practices could help your organization adapt to the ever-changing healthcare delivery landscape. In a value-based payment world, these practices could go a long way to saving money while keeping residents happy and healthy.

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

Study: Program evaluation of a CMS pilot study

Publication Source: Health Affairs

Program Design: Seven Enhanced Care and Coordination Provider (ECCP) models in seven states partnered with 143 nursing homes to develop and implement strategies to lower hospitalizations among long-stay residents. The ECCP models were required to hire on-site staff focused on care coordination and communication. The seven ECCP models also hired nursing staff that either provided direct services or training at participating facilities, and employed some elements of the Interventions to Reduce Acute Care Transfers (IMPACT) system. All programs included an emphasis on end-of-life. Facilities did not receive incentive payments based on participation or outcomes.

Best Practices:

  • Give new techniques time to work. The positive impacts of this pilot were more palpable in the second year of implementation for some states, indicating that such pilots need sufficient time for phase-in before results can be realized.
  • Invest in education, utilize free online tools. Even in states where the model only emphasized educational support to partner facilities, some improvement was observed, though the impact was more significant when ECCP model staff provided clinical care. The IMPACT tools used in the model are available to the public.
  • Reduce staff turnover. Staff turn-over at participating facilities impeded the efforts of ECCP model staff, negatively impacting outcomes. However, where ECCP model staff developed good relationships with facility staff, resident outcomes were better.


Quality Improvement Interventions Designed to Prevent Hospital Readmission

Study: Original investigation of several pilot studies

Publication Source: Journal of the American Medical Association

Study Design: Researchers examined 50 unique pilots aimed at reducing hospital readmissions. Half of the studies considered heart failure patients, while most of the other studies included general populations. The investigation aimed to determine if interventions that target hospital readmissions save health systems money.

Best Practices:

  • Focus on specific conditions. The analysis concluded that interventions designed to reduce rehospitalizations for heart failure patients were twice as successful as interventions designed for general readmission reduction. Savings to the health system were significantly higher in this group compared to general populations as well.
  • Involve patients, caregivers. Among the various interventions considered, those that included patient and caregiver involvement had the greatest effect on reducing readmission risk.


Aerobic Exercise and Dementia

Study: Independent study

Publication Source: British Journal of Sports Medicine

Program Design: Older adults diagnosed with vascular cognitive impairment participated in aerobic exercise three times per week for six months. Study participants completed a functional MRI (fMRI) at the beginning and end of the trial to determine if the addition of exercise resulted in improvements. Patients in the test group were compared to a control group based on their performance on a cognitive test at baseline and at the end of the trial period. Vascular cognitive impairment is the second-most common form of cognitive dysfunction.

Best Practices:

  • Make aerobic exercise available to residents with dementia. The study concluded that aerobic training improved performance on the Eriksen Flanker test, which tests inhibition and selective attention. The fMRI scans indicate a physiological explanation for improved test scores because of the aerobic exercise intervention. Improvements in inhibition and attention can lead to improved resident safety.


Comprehensive Unit-based Safety Program

Study: Program evaluation of Agency for Healthcare Research and Quality (AHQR) Safety Program for Long-Term Care pilot

Publication Source:

Program Design: The Health Research & Education Trust, a research arm of the American Hospital Association, designed an evidence-based process for nursing home staff to follow for residents with catheters. The process was designed to reduce catheter-related infections and other acquired infections. Over 400 nursing homes participated in the pilot study, which included training on the CAUTI Intervention process. Staff were instructed to reduce catheter use, increase hand-washing, use catheters properly, and employ behavioral interventions to improve incontinence care. Participating nursing homes had access to webinars, regular coaching calls, and training sessions.

Best Practices:

  • Time bathroom breaks, wash your hands. The CAUTI interventions resulted in more than 50% fewer catheter-associated urinary tract infections, which are dangerous to patient health and can lead to unnecessary hospitalization and decreased quality of life. Two of the interventions were directly related to staff behaviors: emphasis on hand-washing and proper hygiene, and focus on resident bathroom break timing to preempt an incontinence episode.
  • Check in regularly to see if a new technique is working. As part of participation in the pilot, nursing home staff held regular check-ins to evaluate the intervention and adjust techniques as needed. Results improved over time.

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