RAVEN (Reduce Avoidable Hospitalizations using Evidence-based interventions for Nursing Facility Residents)

The Issue

Hospitalizations are disruptive and disorienting for the frail elderly, and nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections.

Research conducted by the Centers for Medicare and Medicaid Services (CMS) found that 45% of hospitalizations among Medicaid and Medicare enrollees receiving care at either Medicare skilled nursing facilities or Medicare nursing facilities could have been avoided. About two-thirds of nursing facility residents are enrolled in Medicaid, and most also are enrolled in Medicare, which represented more than 300,000 potentially avoidable hospitalizations at the time of the study.

At the same time, studies have estimated that 30% to 67% of hospitalizations among nursing facility residents could have been prevented with well-targeted interventions.

The Solution

JHF is the lead education partner for the RAVEN initiative, which is funded by a grant to UPMC Community Provider Services, its Aging Institute, and the Palliative and Supportive Care Institute to improve the quality of care and reduce avoidable hospitalizations among long-stay nursing facility residents in western Pennsylvania. The award was made through a joint initiative of the Center for Medicare and Medicaid Innovation and the Medicare-Medicaid Coordination Office.

UPMC, JHF, and its RAVEN partners are working with nursing facilities in western Pennsylvania to improve nursing facility resident outcomes, improve the transitions of care between hospitals and nursing facilities, and reduce overall health spending while ensuring access to care and choice of providers.

Within these facilities the RAVEN team is implementing evidence-based interventions that have proven to be successful in other communities and facilities, including having nurse practitioners on-site to work with existing nursing staff to provide preventive services, improve the assessment and management of residents’ medical conditions, and provide advance care planning as well as support and treatment for those who choose palliative care at end-of-life.

Other interventions include having nurse educators customize tools to help improve communications about residents’ changing medical conditions among nursing facility, staff, on-site practitioners, and physicians; training on a number of issues, including geriatric syndromes, dementia care, palliative care, and advance care planning; specialists improving management of residents’ prescription drugs to reduce the risk of medication-related complications; and using telemedicine to enhance around-the-clock communications among facility nursing staff, physicians, acute care clinicians, and nurse practitioners.

Measure of Success

The RAVEN initiative is focused on long-stay nursing facility residents who are enrolled in the Medicare and Medicaid programs, with the goal of improving care and reducing avoidable inpatient hospitalizations. JHF’s role in RAVEN is to lead, provide, and have primary responsibility for supporting the education elements of the RAVEN initiative within the participating skilled nursing facilities participating in RAVEN.

Results to Date

Since the initiative began in October 2012, JHF has conducted site visits and developed individual education plans for facilities, and delivered frontline education on team-building, problem-solving, communication, palliative care, dementia care, and lean quality improvement. In addition, RAVEN sites have received extensive training on implementing INTERACT in their facilities. INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of nursing facility residents.

In 2016, the project’s evaluator reported that 18 RAVEN sites in western PA lowered avoidable hospitalizations among long-stay nursing facility residents by 24%, readmissions by 22%, and ER visits by 41%. Combined, these improvements resulted in an almost 12% reduction in Medicare spending and helped countless frail nursing home residents avoid the trauma of a hospital transfer and stay.

CMS renewed the RAVEN initiative through 2020, with JHF once again serving as the education lead during the second phase of the grant. Nursing facilities that participated in phase one of the grant will receive enhanced payment and continued interventions from the RAVEN model. New participants will pilot a new payment model, and will take part in a learning collaborative that JHF created on Tomorrow’s HealthCareTM, the Foundation’s online learning, communication, and leadership platform.

Nancy D. Zionts, MBA
Chief Operating and Program Officer