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Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents (NFI)

Guidance for Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents (NFI), including overview, background and details.


Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: May 18, 2020





The Medicare-Medicaid Coordination Office, in collaboration with the Center for Medicare & Medicaid Innovation, has undertaken efforts to improve the quality of care for people in long-term care (LTC) facilities by reducing potentially avoidable inpatient hospitalizations.  

The Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, which ran from 2012 to 2020, focused on long-stay LTC facility residents, primarily those enrolled in the Medicare and Medicaid programs. The Initiative supported organizations that partner with LTC facilities to implement evidence-based interventions that both improve care and lower costs.


LTC facility residents often experience potentially avoidable hospital transfers. Unnecessary hospitalizations are expensive, disruptive, and disorienting for frail elders and people with disabilities. LTC 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.

Many LTC facility residents are enrolled in both the Medicare and Medicaid programs (Medicare-Medicaid enrollees). CMS research on this population has repeatedly found that a large number of hospital admissions could have been avoided. More information can be found at the links below:  


Initiative Details

CMS partnered with several organizations, referred to as "enhanced care & coordination providers" or "ECCPs", to implement evidence-based clinical and educational interventions that reduce avoidable hospitalizations.

Learn more about ECCPs

While each ECCP's intervention had unique features, all included:

  • Employing staff who will maintain a physical presence on site at LTC facilities; 
  • Allowing for participation by LTC facility residents without any need for residents to change providers or enroll in a health plan; and
  • Supplementing (rather than replacing) existing care provided by LTC facility staff.  

Phase One: Improving Clinical Care

Between 2012 and 2016, CMS partnered with seven ECCPs, each providing on-site services in a group of partnering nursing facilities. Five of the organizations focused on direct care, and two focused on staff training.

Learn more about Phase One

Evaluation Reports

An independent evaluation found "persuasive evidence of the Initiative's effectiveness in reducing hospital inpatient admissions, ED visits, and hospitalization-related Medicare expenditures."

Learn more about evaluation reports

Phase Two: Adding Payment Reform

In Phase Two, which ran from October 2016 through September 2020, the Initiative tested a new payment model to reduce potentially-avoidable hospitalizations by funding higher-intensity treatment services in nursing facilities for residents who may otherwise be hospitalized upon an acute change in condition. Over 250 LTC facilities were selected to implement this phase of the Initiative.

Learn more about Phase Two


Contact us

For more information or questions about this Initiative, email

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