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.

Eligible organizations will partner with long-term care (LTC) facilities and practitioners to implement and test a new payment model
with the goal of improving the health and health care among LTC facility residents and ultimately reducing avoidable hospital admissions.

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 will implement the payment model along with interventions that will have the following objectives (consistent with Phase I):
? 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
University Of Missouri System $ 19,824,271   2016-03-212021-09-30
Trustees Of Indiana University $ 16,545,692   2016-03-212021-04-30
Alabama Quality Assurance Foundation $ 17,613,674   2016-03-212021-04-23
Greater New York Hospital Foundation, Inc $ 22,752,586   2016-03-212020-12-31
Comagine Health $ 3,419,757   2020-03-102020-10-23
Upmc Community Provider Servies $ 20,201,716   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 (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 had 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

Six (6) organizations, which fulfilled these requirements (below), have already been selected for this Initiative. LTC facilities must execute a participation agreement with the ECCP prior to participating in the payment model. This agreement must also attest or state the LTC facility?s commitment to meeting and maintaining the above criteria through the end of the Initiative (we note that a facility?s ability to meet the demographic criteria of an average daily census of greater than 80 residents with greater than 40% of the total LTC facility census as long-stay Medicare enrollees in traditional FFS Medicare, may be outside of the facility?s control and may fluctuate throughout the period of performance. CMS will address these fluctuations on a case by case basis). Executed agreements between LTC facilities and ECCPs for this phase of the Initiative may be submitted in lieu of a Letter of Intent (executed agreements preferred). For LTC facilities partnering with ECCPs for phase one of the Initiative, agreements for phase two should not supersede the existing agreements for phase one. Rather, these new agreements should supplement what has already been agreed upon. 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. 2 CFR 200, Subpart E - Cost Principles applies to this program. 2 CFR 200, Subpart E - Cost Principles 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

2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards applies to this program. Not Applicable

Award Procedures

Seven (6) organizations, which completed the review process as outlined below, have already been selected for this Initiative. The review process included the following: (1) An independent, objective review of applications will be conducted. The CMS review panel will assess the application based on the review criteria outlined in section V.1 above to determine the merits of the application and the extent to which it furthers the purposes of the Initiative. The review panel comments and recommendations will be condensed into a summary statement that will assist CMS in making the final award decision. CMS will use the information to judge the likelihood that the project will be successfully implemented and will have tangible, beneficial outcomes. (2) A program integrity screening of the applicant, its affiliates, or any other relevant individuals or entities to determine if prior investigations, CMS administrative actions, or claims analysis indicate these entities present a high risk for fraud and abuse under the Initiative. (3) Applications determined to be ineligible, incomplete, and/or non-responsive based on the initial screening may be eliminated from further review. However, the CMS/OAGM/GMO, in his or her sole discretion, may continue the review process for an ineligible application if it is in the best interest of the government to meet the objectives of the program.

Deadlines

Mar 21, 2016 to Oct 23, 2020: The period of performance is September 24, 2012 through September 23, 2016. Six (6) 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 September 9, 2015. Eastern Standard Tim in order to be eligible for a funding award. Applications were due by October 29, 2015, 5:00 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 six (6) 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: There will be a separate work plan for Group A and Group B.

Each work plan will identify key milestones, tasks, interdependencies, and the responsible parties for each, as well as a related timeline.

Each work plan should contain, at a minimum, target dates for the following: ? In consultation with CMS, finalizing a list of LTC facilities to target for recruitment for Group A (this list should be large enough to form an adequate pool of prospective LTC facilities from which to screen and propose a final list of Group A LTC facilities to CMS).

Confirming a primary and secondary contact at each prospective participating LTC facility.

? Educating the targeted list of LTC facilities on all aspects of the Initiative ? Educating and finalizing the list of respective practitioners at each LTC facility for both groups (can be different target dates for each group).

? Completion of the recruitment of prospective LTC facilities for Group A.

? Completion of screening of practitioners to confirm eligibility to participate and for final submission to CMS (for both groups).

? Completion of the screening and prioritization of the list of LTC facilities to propose and submit to CMS for Group A.

? For both groups, assessing LTC facilities? current status as compared to the readiness review requirements (can be different target dates for each group).

This will be tracked using a Readiness Review Tracker (see Appendix D for sample template).

? For both groups, completion of requirements in order to pass the readiness review.

? For Group B, a plan to implement any changes to the clinical intervention necessary to address any challenges identified to date, improve performance and to better coordinate the clinical intervention with the introduction of facility and practitioner payments.

? Obtaining executed agreements for participation from each partnering LTC facility.

Target dates proposed should align with the deliverables described in this FOA.

However, ECCPs may choose to propose earlier dates (e.g., obtain primary and secondary contacts for LTC facilities prior to the submission of an application for this FOA).

The work plan will be reviewed regularly, as frequently as bi-weekly, and updated and provided to CMS, as needed.

CMS may also share it with the State Medicaid agency and State survey and certification agency. 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 six (6) 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)six (6) 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 six (6) 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 six (6) 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 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 2 CFR 200, Subpart F - Audit Requirements, non-Federal entities that expend financial assistance of $750,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Non-Federal entities that expend less than $750,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in 2 CFR 200.503. Not applicable.

Records

The seven (6) 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 16 $5,799,630; FY 17 est $28,152,584; and FY 18 est $28,367,101

Range and Average of Financial Assistance

The seven (6) organizations which received funding are: Alabama Quality Assurance Foundation ? Alabama, 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

Nicole Perry 7500 Security Blvd., Baltimore, Maryland 21214 Email: Nicole.Perry@cms.hhs.gov Phone: 410-786-8786

Criteria for Selecting Proposals

See Award Procedures (093).


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