Restrictions on what Medicaid and Medicare will cover for nursing home patients can often lead to unnecessary hospitalizations – an estimated $8 billion in unnecessary hospitalizations each year, in fact.
For example, a nursing home patient would be hospitalized for a common ailment such as pneumonia or a skin ulcer in order to have their treatment covered. In that case, Medicaid and Medicare will pay extra for hospital visits, but not nursing home care. But a program through the University of Pittsburgh Medical Center and Centers for Medicare and Medicaid aims to cut down on those unnecessary hospital visits.
The program, called RAVEN, actually launched in 2012 with UPMC employees working in 18 area nursing homes to offer expertise to each facility.
The next phase of the program just kicked off, offering federal reimbursements for nursing home care. It also allows doctors, nurse practitioners and physician assistants who provide the care to bill at the same rate they would if the patient were in the hospital, which is 50 percent more than if they see the patient in the nursing home.
“In essence, trying to take away what is a perceived potential increase in revenue if you see somebody in the hospital versus the nursing home,” said RAVEN Co-director April Kane who stresses that hospitalization will always be an option for patients who need the extra care.
The program includes treatment for congestive heart failure, dehydration, urinary tack infection, COPD asthma, pneumonia and skin ulcers.
Kane said Centers for Medicare and Medicaid officials believe those six conditions account for 80 percent of the avoidable hospitalizations among nursing home patients.
“(Hospitalization for) these very common conditions often times puts them at risk for other things,” Kane said. “Not only the disruption of them moving from their home, but also putting them at risk for infection and things of that nature.”
Fifteen of the original 18 nursing homes involved in phase one will continue in phase two, receiving clinical support and additional reimbursements. An additional 20 nursing homes were added for phase two. Those facilities will only receive the additional payments. A third control group that will receive neither will also be tracked.
The pilot program runs through 2020 with annual evaluations of patient outcomes and cost savings by an independent third party.
Two-thirds of all nursing home residents are covered by either Medicare or Medicaid, according to Kane.