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.



Selected Recipients for this Program


RecipientAmount Start DateEnd Date
Greater New York Hospital Foundation, Inc $ 22,752,586   2016-03-212020-12-31
Comagine Health $ 3,419,757   2020-03-102020-10-23
Alabama Quality Assurance Foundation $ 17,613,674   2016-03-212020-10-23
Upmc Community Provider Servies $ 20,201,716   2016-03-212020-10-23
University Of Missouri System $ 19,824,271   2016-03-212020-10-23
Trustees Of Indiana University $ 16,545,692   2016-03-212020-10-23
Healthinsight Of Nevada Inc $ 12,932,530   2016-03-212020-03-10
Alegent Creighton Health $ 5,205,431   2012-09-242017-09-23
Healthinsight Of Nevada Inc $ 12,543,765   2012-09-242017-09-23
Trustees Of Indiana University $ 13,471,938   2012-09-242017-09-23



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