Affordable Care Act Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents

Under this Initiative, the Centers for Medicare & Medicaid Services (CMS) selected eligible organizations to test a series of evidence-based clinical interventions.

The goal of these interventions is to improve the health and health care among long-stay nursing facility residents and ultimately
reduce avoidable inpatient hospital admissions.

Successful applicants are implementing such interventions that will have the following objectives:
• Reduce the frequency of avoidable hospital admissions and readmissions;
• Improve resident health outcomes;
• Improve the process of transitioning between inpatient hospitals and nursing facilities; and
• Reduce overall health care spending without restricting access to care or choice of providers.


Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Office - None.

Not Applicable.


Program Accomplishments

Not Applicable.

Uses and Use Restrictions

Under the Cooperative Agreements, CMS funded "enhanced care & coordination providers" to implement an intervention that meets the objectives of the Initiative.

All interventions must include the following activities:
• Hire staff who shall maintain a physical presence at nursing facilities and who shall partner with nursing facility staff to implement preventive services and improve recognition, assessment, and management of conditions such as pneumonia, congestive heart failure, chronic obstructive pulmonary disease and asthma, urinary tract infections, dehydration, skin ulcers, falls, and other common causes of avoidable hospitalizations;
• Work in cooperation with existing providers, including residents primary care providers, nursing facility staff, and families to implement best practices and improve the overall quality of nursing facility care, focusing on quality improvement activities that most directly relate to avoidable hospitalizations;
• Facilitate residents transitions to and from inpatient hospitals and nursing facilities, including facilitating timely and complete exchange of health information among providers and providing support for residents and nursing facility staff to support successful discharge to the community as appropriate;
• Provide support for improved communication and coordination among hospital staff (including attending physicians), nursing facility staff, residents primary care providers and other specialists, and pharmacies; and
• Coordinate and improve management and monitoring of prescription drugs to reduce risk of polypharmacy and adverse drug events for residents, including inappropriate prescribing of psychotropic drugs.



All interventions must also:
• Demonstrate a strong evidence base;
• Demonstrate strong potential for replication and sustainability in other communities and institutions;
• Supplement (rather than replace) existing care provided by nursing facility staff;
• Coordinate closely with State Medicaid and State survey and certification agencies and State public health and health reform efforts, including other CMS demonstrations and waivers; and
• Allow for participation by nursing facility residents without any need for residents or their families to change providers or enroll in a health plan.

(Residents will be able to opt-out from participating, if they choose.)

The enhanced care & coordination providers must collaborate with State Medicaid and State survey and certification agencies and participating nursing facilities, with each enhanced care & coordination provider implementing its intervention in at least 15 Medicare- and Medicaid-certified nursing facilities in the same State.

In addition to implementing the interventions and executing other activities outlined in the Initiative funding opportunity announcement, enhanced care & coordination providers must also participate in ongoing learning and diffusion activities and cooperate with operations support and evaluation efforts, including adapting models based on needed mid-course corrections.

The following standard requirements apply to applications and awards under the Initiative funding opportunity announcement:
• Specific administrative requirements, as outlined in 2 CFR Part 225 and 45 CFR Part 92 and OMB Circulars A-87, A-102, A-110, and A-133 apply to cooperative agreement awarded under this announcement.


• All awardees under this project must comply with all applicable Federal statutes relating to nondiscrimination including, but not limited to:
o Title VI of the Civil Rights Act of 1964,
o Section 504 of the Rehabilitation Act of 1973,
o The Age Discrimination Act of 1975,
o Hill-Burton Community Service nondiscrimination provisions, and
o Title II Subtitle A of the Americans with Disabilities Act of 1990.
• All equipment, staff, other budgeted resources, and expenses must be used exclusively for the project identified in the awardee s original cooperative agreement application or agreed upon subsequently with HHS, and may not be used for any prohibited uses.
Prohibited Uses of Cooperative Agreement Funds
• To match any other Federal funds.
• To provide services, equipment, or supports that are the legal responsibility of another party under Federal or State law (e.g., vocational rehabilitation or education services) or under any civil rights laws.

Such legal responsibilities include, but are not limited to, modifications of a workplace or other reasonable accommodations that are a specific obligation of the employer or other party.
• To supplant existing State, local, or private funding of infrastructure or services, such as staff salaries, etc.
• To be used by local entities to satisfy State matching requirements.
• To pay for the use of specific components, devices, equipment, or personnel that are not integrated into the application.
• To pay for construction or alteration and renovation of real property (A&R).


• To pay for information technology (IT) equipment exceeding 10 percent of the total award.

Any equipment, which includes IT, over $5,000 must be approved by CMS.
• To pay States for the use of any of their data made available for this Initiative.



Eligibility Requirements

Applicant Eligibility

Applicants eligible to be enhanced care & coordination providers included, but were not limited to:
• Organizations that provide care coordination, case management, or related services;
• Medical care providers, such as physician practices;
• Health plans (although this initiative will not be capitated managed care);
• Public or not-for-profit organizations, such as Aging and Disability Resource Centers, Area Agencies on Aging, Behavioral Health Organizations, Centers for Independent Living, universities, or others;
• Integrated delivery networks, if they will extend their networks to include unaffiliated nursing facilities.

Nursing facilities, entities controlled by nursing facilities, or entities for which the primary line of business is the delivery of nursing facility/skilled nursing facility services were excluded from serving as enhanced care & coordination providers under this cooperative agreement.

Legal Status: To be eligible, an organization must have been recognized as a single legal entity by the State where it is incorporated, and must have had a unique Tax Identification Number (TIN) designated to receive payment.

The organization must have jhad a governing body capable of entering into a cooperative agreement with CMS on behalf of its members.

Beneficiary Eligibility

The primary target population for the clinical interventions is fee-for-service Medicare-Medicaid enrollees in nursing facilities, but fee-for-service long-stay residents who are not yet Medicare-Medicaid enrollees will also benefit (i.e., Medicare beneficiaries not yet eligible for Medicaid, or Medicaid beneficiaries not yet eligible for Medicare but who represent similar opportunities for inpatient reductions).

Credentials/Documentation

Seven (7) organizations, which fulfilled these requirements (below), have already been selected for this Initiative.

All applications shall attach letter(s) of support from the State Medicaid director and State survey and certification director from each State in which the applicant is proposing to implement the intervention. They shall also describe Medicare- and Medicaid-certified nursing facilities that have agreed to participate in this initiative and attach letters of intent (LOIs) from partnering nursing facilities. All applications must include LOIs from a minimum of 15 Medicare- and Medicaid-certified nursing facilities in the same State with an average census of 100 residents or more per facility. CMS will only review applications that include these letters of support from the State and LOIs from nursing facilities. All applications shall also include other required forms: standard forms, Tables 1-3 (in the funding opportunity announcement) outlining characteristics of nursing facility partners, and Monthly Financial Plan (which includes Tables 4-7 in the funding opportunity announcement).
In addition to this documentation, the application is expected to address how the applicant will implement the cooperative agreement program, including how it will meet the clinical intervention requirements, and ultimately, meet the objectives of this Initiative. OMB Circular No. A-87 applies to this program.

Aplication and Award Process

Preapplication Coordination

This program is excluded from coverage under E.O.

12372.

Environmental impact information is not required for this program.

This program is excluded from coverage under E.O.

12372.

Application Procedures

OMB Circular No. A-102 applies to this program. This program is excluded from coverage under OMB Circular No. A-110. Not Applicable

Award Procedures

Seven (7) organizations, which completed the review process as outlined below, have already been selected for this Initiative.

The review process will include the following:
• Applications will be screened to determine eligibility for further review using the criteria detailed in this solicitation. Applications received late or that fail to meet the eligibility requirements as detailed in the solicitation or do not include the required forms will not be reviewed.
• Applications must include the required letters of support from State Medicaid and State survey and certification directors and at least 15 letters of intent from nursing facilities in the same State with an average census of 100 residents per facility. If an application includes these required letters and includes all other required forms (standard forms, Tables 1-3 (in the funding opportunity announcement) outlining characteristics of nursing facility partners, and Monthly Financial Plan (in the funding opportunity announcement), the proposal will be reviewed in the technical review process outlined below. If not, the applicant s submission will not receive further consideration and will not be eligible for award.
• A team consisting of staff from HHS and other outside experts will review the applications. The review panel will assess each application to determine the merits of the proposal and the extent to which the proposed program furthers the purposes of the program. CMS reserves the option to request that applicants revise or otherwise modify their proposals and budget based on the recommendations of the panel. Applications will be scored with a total of 100 points available. The following criteria will be used to evaluate applications received in response to this solicitation. More information about each criteria domain can be found in the Initiative funding opportunity announcement.
• Proposed Approach (45 points)
• Organizational Capacity and Management Plan (25 points)
• Budget, Budget Narrative, and Monthly Financial Plan (15 points)
• Evaluation and Reporting (15 points)
• The results of the objective review of the applications by qualified experts will be used to advise the approving HHS official. Final award decisions will be made by an HHS program official. In making these decisions, the HHS program official will take into consideration: recommendations of the review panel; diversity in the clinical models; diversity in enhanced care & coordination providers; strength of partnerships with nursing facilities and States; number of nursing facility partners and size of target population; the geographic diversity of locations; feasibility of evaluating the proposed interventions; the reasonableness of the estimated cost to the government and anticipated results; likelihood that the proposed project will result in the benefits expected; and availability of funding.
• Successful applicants will receive one cooperative agreement award issued under this announcement.

Deadlines

Jun 14, 2012: The period of performance is September 24, 2012 through September 23, 2016. Seven (7) organizations, which fulfilled these requirements, have already been selected for this Initiative.

Potential applicants were required to submit a non-binding Notice of Intent to Apply by April 30, 2012, 3:00 p.m. Eastern Standard Tim in order to be eligible for a funding award. Applications were due by June 14, 2012, 3:00 p.m. Eastern Standard Time.

Authorization

Affordable Care Act, Public Law 111-148, section 3021.

Range of Approval/Disapproval Time

Cooperative agreement awards were made on September 24, 2012.

Appeals

None.

Renewals

Not Applicable.

Assistance Considerations

Formula and Matching Requirements

Statutory formulas are not applicable to this program.
This program has no matching requirements. No. This program has no matching requirements.
MOE requirements are not applicable to this program.

Length and Time Phasing of Assistance

The project period of performance is 48-months and is expected to last from September 2012 to September 2016. No restriction is placed on the time permitted to spend the money awarded. See the following for information on how assistance is awarded/released: Awards were made through cooperative agreements.

Post Assistance Requirements

Reports

The seven (7) award recipients must comply with the report requirements as outlined below:

Enhanced care & coordination providers will be funded based on their ability to execute their proposed work plan.

The components of the work plan include, but are not limited to:
• Meeting proposed milestones and deliverables as outlined in the work plan and communications plan;
• Satisfying all Enhanced Care & Coordination Provider Activities, including a) submitting quarterly progress reports as scheduled and providing complete and accurate information for all required data fields in those reports and b) submitting timely, complete, and accurate semi-annual funding reports that show efficient use of cooperative agreement funds;
• Participating in ongoing learning and diffusion activities, including those offered through the CMS Learning Community; and
• Cooperating with operations support and evaluation efforts, including adapting models based on needed midcourse corrections.
CMS will regularly monitor operations.

Awardees will be required to cooperate in providing the necessary data elements to CMS.

CMS will contract with independent entities to assist in monitoring the programs and to conduct an independent evaluation.

The seven (7) award recipients must comply with the report requirements as outlined below:

The enhanced care & coordination provider must submit a semi-annual electronic SF 425 via the Payment Management System.

The report identifies cash expenditures against the authorized funds for the cooperative agreement.

Failure to submit the report may result in the inability to access funds.

The seven (7) award recipients must comply with the report requirements as outlined below:

Enhanced care & coordination providers will be measured and funded based on their ability to execute their proposed work plan.

The components of the work plan include, but are not limited to:
• Meeting proposed milestones and deliverables as outlined in the work plan and communications plan;
• Satisfying all Enhanced Care & Coordination Provider Activities, including a) submitting quarterly progress reports as scheduled and providing complete and accurate information for all required data fields in those reports and b) submitting timely, complete, and accurate semi-annual funding reports that show efficient use of cooperative agreement funds;
• Participating in ongoing learning and diffusion activities, including those offered through the CMS Learning Community; and
• Cooperating with operations support and evaluation efforts, including adapting models based on needed midcourse corrections.
CMS will regularly monitor operations.

Awardees will be required to cooperate in providing the necessary data elements to CMS.

CMS will contract with independent entities to assist in monitoring the programs and to conduct an independent evaluation.

The seven (7) award recipients must comply with the report requirements as outlined below:

The enhanced care & coordination provider shall detail how cooperative agreement funds were used for each six-month period.

This information shall be provided to CMS using the SF 424A form and the Monthly Financial Plan template (Appendix D of the funding opportunity announcement).

CMS will use this information, in addition to quarterly progress reports, to monitor operations.

Within 30 calendar days of the end of each six-month period, the enhanced care & coordination provider shall provide the completed SF 424A and relevant table from the Monthly Financial Plan.

The seven (7) award recipients must comply with the report requirements as outlined below:

Enhanced care & coordination providers will be measured and funded based on their ability to execute their proposed work plan.

The components of the work plan include, but are not limited to:
• Meeting proposed milestones and deliverables as outlined in the work plan and communications plan;
• Satisfying all Enhanced Care & Coordination Provider Activities, including a) submitting quarterly progress reports as scheduled and providing complete and accurate information for all required data fields in those reports and b) submitting timely, complete, and accurate semi-annual funding reports that show efficient use of cooperative agreement funds;
• Participating in ongoing learning and diffusion activities, including those offered through the CMS Learning Community; and
• Cooperating with operations support and evaluation efforts, including adapting models based on needed midcourse corrections.
CMS will regularly monitor operations.

Awardees will be required to cooperate in providing the necessary data elements to CMS.

CMS will contract with independent entities to assist in monitoring the programs and to conduct an independent evaluation.

Audits

In accordance with the provisions of OMB Circular No. A-133 (Revised, June 27, 2003), "Audits of States, Local Governments, and Non-Profit Organizations," nonfederal entities that expend financial assistance of $500,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Nonfederal entities that expend less than $500,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in Circular No. A-133. Not applicable.

Records

The seven (7) award recipients must comply with the report requirements as outlined below:

Enhanced care & coordination providers must track data required for quarterly progress reports and semi-annual funding reports.

Financial Information

Account Identification

75-0522-0-1-551.

Obigations

(Cooperative Agreements) FY 12 $26,262,112; FY 13 est $25,762,828; and FY 14 Estimate Not Available

Range and Average of Financial Assistance

The seven (7) organizations which received funding are:
Alabama Quality Assurance Foundation - Alabama,
Alegent + Creighton Health - Nebraska,
HealthInsight of Nevada - Nevada,
Indiana University - Indiana,
The Curators of the University of Missouri - Missouri,
The Greater New York Hospital Foundation, Inc. - New York City, and
UPMC Community Provider Services - Pennsylvania.

The awards ranged from: $5 million to $25 million to cover a four-year period of performance.

Regulations, Guidelines, and Literature

The background provided in the funding opportunity announcement describes relevant literature. A list of references is also included.

Information Contacts

Regional or Local Office

None. Not Applicable.

Headquarters Office

Melissa Seeley 7500 Security Blvd, Baltimore, Maryland 21214 Email: Melissa.Seeley@cms.hhs.gov Phone: 212-616-2329

Criteria for Selecting Proposals

See Award Procedures (093).



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