Life In The Slower Lane

Here is the standardised PICO analysis for the CMS Initiative article you provided:

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Full Title

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned

Authors: Denise A. Tyler, Zhanlian Feng, David C. Grabowski, Lawren Bercaw, Micah Segelman, Galina Khatutsky, Joyce Wang, Angela Gasdaska, Melvin J. Ingber

Journal: The Milbank Quarterly, December 2022; 100(4): 1243–1278  

Type of Study

Mixed-methods policy-evaluation study combining:

1. Qualitative interviews and site-visits (2013–2020) with participating nursing homes and Enhanced Care & Coordination Providers (ECCPs)
2. Quantitative difference-in-differences analyses of Medicare claims and Minimum Data Set (MDS) data

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PICO Summary

Population (P)

• Long-stay residents of skilled nursing facilities (SNFs) in seven U.S. states (AL, IN, MO, NE, NV, NY, PA) from 2014 to 2019
• Residents were fee-for-service (FFS) Medicare beneficiaries with ≥ 101 days stay and no hospice enrolment  

Intervention (I)

Three sequential arms over two phases:

1. Clinical-Only (Phase 1, 2012–16): On-site placement of nurse practitioners (NPs) or RNs by ECCPs, plus staff education, communication tools (e.g. INTERACT), and coordination support
2. Clinical + Payment (Phase 2, 2016–20): Continued clinical interventions plus a Medicare Part B payment incentive for on-site treatment of six qualifying conditions (pneumonia, CHF, COPD/asthma, fluid/electrolyte disorders, skin infection, UTIs)
3. Payment-Only (Phase 2, 2016–20): Medicare payment incentive without the original ECCP-placed clinical staff or intensive education  

Comparison (C)

• Clinical-Only vs. non-participating (“within-state”) SNFs in the same states, matched by propensity scores
• Clinical + Payment vs. national FFS Medicare SNFs (excluding Initiative states)
• Payment-Only vs. same national comparison group

Outcomes (O)

Quantitative (per resident-year):

• Utilisation:
  • All-cause hospitalisations & potentially avoidable hospitalisations (PAHs)
  • All-cause and potentially avoidable ED visits
• Medicare expenditures: total, hospitalisation-related, ED-related
• Quality measures (MDS-based): falls with injury, pressure ulcers, UTI, pain, ADL decline, antipsychotic use

Qualitative (implementation):

• Facilitators/barriers: staff retention & leadership stability; leadership & staff buy-in; provider engagement (visualised in the thematic coding of interview data)  

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Key Findings

• Clinical-Only intervention (Phase 1) was associated with significant reductions in all-cause hospitalisations (–2.6 pp; –9.5 %), PAHs (–2.0 pp; –17.0 %), ED visits, and related expenditures.
• Adding payment incentives (Clinical + Payment) did not yield further reductions; trends were neutral or unfavourably increased.
• Payment-Only homes saw no consistent improvements in utilisation or costs.
• Implementation success depended on stable leadership, ongoing NP/RN presence, and engaged physicians for on-site treatment and billing.

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