Phase Two

Project Structure

For Phase Two, GNYHA Foundation will continue to partner with the Icahn School of Medicine at Mount Sinai (Mount Sinai) to employ the Registered Nurse Care Coordinators (RNCC) that serves as educators and consultants to the 27 nursing facilities that participated in Phase One, also known as Group B nursing facilities. Group A nursing facilities will not have a RN Care Coordinator provided by the NY–RAH project; they will instead test payment reform initiatives to treat six clinical conditions in place at the facility as well as provide care conferences. Group B nursing facilities will also be eligible for these payment reform incentives.

The goal of Phase Two is to test the different care models to determine which provides the highest quality of cost-effective care. Research Triangle Institute, the evaluation contractor for CMS in Phase One, will continue to evaluate the following care models:

Clinical & Quality Improvement Only Clinical & Quality Improvement
+ Payment Reform
Payment Reform Only Standard Care Equally as Effective
  • Phase One
  • 29 Facilities
  • February 2013–September 2016
  • Phase Two
  • 27 Facilities
  • October 2016–October 2020
  • "Group B"
  • Phase Two
  • 31 Facilities
  • October 2016–October 2020
  • "Group A"
  • Comparison Group Facilities
  • 2013–2020
  • Blinded
Facility Payment Incentives
Facility Payment Tools

Research shows that six conditions are linked to approximately 80% of potentially avoidable hospitalizations among LTC facility residents.

  • Pneumonia
  • Dehydration or Fluid/Electrolyte Disorder
  • Congestive heart failure (CHF)
  • Urinary tract infection (UTI)
  • Skin ulcers or cellulitis
  • COPD or asthma

To create an incentive for facilities to invest more time and resources than is currently required to furnish services and treat beneficiaries in-house without transferring to the hospital, the first component of the model is a new code category billable by the skilled nursing facility under Medicare Part B for the treatment of the above six conditions only.

Facility Chart Audit Tool
Facility Chart Audit Tool

NY-RAH encourages all facilities use the chart audit tool to retroactively review a sample of charts and proactively use prior to billing all conditions to ensure all of the clinical criteria and documentation has been met. Please read through the instructions tab carefully to understand how to use the tool.

For UTI - if the Urine C&S returns negative, the tool will state you can bill for days prior to the return of the C&S if the dates are entered correctly under billing dates for the episode.

The project management team strongly encourages you to provide any feedback you have while using the tool to allow us to enhance the tool over time. If you have questions regarding the tool, please contact Faiza Haq, Project Manager for Payment Reform, at or 212-506-5421.

Practitioner Payment Tools
Practitioner Payment Incentives

This model tests a new payment under the Medicare physician fee schedule that can be billed by a practitioner for an initial visit to treat an acute change in condition in the long term care (LTC) facility. Payment for the service would be based on the condition of the resident rather than whether the service is furnished in a hospital or LTC facility setting. In other words, when a practitioner sees a beneficiary in the LTC facility for an acute change in condition, the practitioner would be paid for the service at the equivalent of an acute hospital initial visit code.

In addition, to increase practitioner involvement in person-centered care coordination with beneficiaries (and/or engagement with the individual(s) authorized to make health care decisions on their behalf), this model also includes a payment to create an incentive for practitioners to participate in nursing facility conferences that engage in care coordination discussions with beneficiaries, their caregivers, and the LTC facility interdisciplinary team.

Case Studies