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GNYHA Foundation Receives Award from CMS to Reduce Preventable Hospitalizations in Nursing Homes

On September 27, the Centers for Medicare & Medicaid Services (CMS) announced that GNYHA Foundation is one of seven organizations to receive a cooperative agreement award for an initiative to reduce avoidable hospitalizations among long-stay nursing facility residents. The four-year project will be conducted in New York State’s downstate region, where there are high Medicare costs, high hospital readmission rates, and where Medicare-Medicaid “dual eligible” enrollees account for a high percentage of nursing facility residents.

As an “enhanced care and coordination provider,” GNYHA Foundation will place registered nurse (RN) care coordinators at 30 participating nursing homes in the metropolitan New York region to provide enhanced on-site services. The initiative will use an evidence-based toolkit of interventions that includes INTERACT (Interventions to Reduce Acute Care Transfers) and evidence-based care paths and communications protocols, such as the American Medical Directors Association (AMDA) Clinical Practice Guidelines on Acute Change Condition and AMDA’s medication management manual. The toolkit also contains a training program in early intervention and follow-up on palliative care practices.

The RN care coordinators will be trained on using the above toolkit, assessing care coordination capacities, and developing and implementing an action plan for improving care coordination. Through the guidance of a Clinical Intervention Advisory Committee, GNYHA will work with key clinical staff from member hospitals to which the participating nursing homes typically discharge long-stay residents. GNYHA Foundation will also work closely with the New York State Department of Health. The CMS initiative is being run collaboratively by the CMS Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation, both of which were created by the Affordable Care Act.

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