About 25% of the hospitalizations for dual eligible beneficiaries in 2005 were potentially avoidable. Medicare and Medicaid spending for those potentially avoidable hospitalizations or rehospitalizations, was almost $6 billion, or about 20% of total spending on inpatient care for the dual eligible. Research has shown that the highest potentially avoidable hospitalization rates were skilled nursing facility and nursing facility residents. Furthermore, Illinois ranked 5th highest overall, behind Louisiana, Kentucky, Pennsylvania, New Jersey and Ohio for these rates.

The leading potentially avoidable hospitalizations were congestive heart failure, chronic obstructive pulmonary disease, asthma, pneumonia, dehydration and urinary tract infections. For skilled nursing facilities and nursing facilities, pneumonia was the leading cause of hospitalization.

On March 15, 2012, Centers for Medicare & Medicaid Services (CMS) issued an informational bulletin announcing their “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents”. This initiative will test whether providing nursing facility residents with enhanced on-site services and support can reduce avoidable hospitalizations, improve quality of care and reduce costs. CMS is committing up to $128 million to support a variety of evidence-based interventions through this effort. This initiative supports the goals of two other initiatives, to reduce rehospitalizations 20% by 2013 and the Million HeartsTM campaign, a national initiative to prevent one million heart attacks and strokes over the next five years.

Currently twenty-five Hospital Engagement Networks are working closely with hospitals to improve quality of care, provide more intense resident education on their disease, and provide hospital patients with a post-hospital plan that includes future medical visits, pre-arranged appointments, diet and activity restrictions, and pharmacy reports on medications and stopped medications. Increased communication with community health services, including nursing care facilities is another element in the plan to improve quality transfers for the promotion of quality of care. In Illinois, Joint Commission is guiding hospitals in Project RED (Re-Engineered Discharge). Morris Hospital is one such participant, with Walnut Grove Nursing Home being one of their community nursing facilities.

As an incentive for improved quality of care and the reduction of potentially avoidable hospitalizations, nursing homes and other providers for dual eligible recipients will be included in a bundled pay package for services rendered. Reducing the number of rehospitalizations, which can be for any reason, not just the initial reason or one of the primary reasons will reduce the amount spent on hospitalizations. Coordinating health care with other providers, especially hospitals and physicians will be imperative to receiving pay for services.

Nutrition Care Systems can provide each of our clients with the best nutrition recommendations possible. Our dietitians will work closely with facility team members to incorporate nutrition interventions for residents that will optimize their health and promote the highest quality of care. Through the course of this initiative, a provider may want to determine their own potentially avoidable hospitalization rate and focus sights on reducing them in their own facility. Our company will be happy to assist with nutritional concepts intended to help facilities reach their goals.

Visit www.cms.gov for more information on these initiatives.