RAVEN (Reduce Avoidable Hospitalizations using Evidence-based Interventions for Nursing Facilities in Western Pennsylvania)

About the RAVEN Project

The Aging Institute of UPMC Senior Services and the University of Pittsburgh has been awarded a $19 million grant from the Centers for Medicare and Medicaid Services (CMS) as part of a comprehensive initiative to improve the quality of care and reduce avoidable hospitalizations among nursing facility residents in western Pennsylvania.

The project is a 4-year collaboration between:
  • UPMC Community Provider Services (through the Aging Institute and its sister organization, UPMC Palliative and Supportive Institute)
  • Excela Health
  • Heritage Valley Health System
  • Jewish Healthcare Foundation
  • Robert Morris University

The Goals of RAVEN

RAVEN project aims to:
  • Improve nursing facility resident outcomes
  • Improve the transitions between hospitals and nursing facilities
  • Reduce overall health spending while ensuring access to care and choice of providers
UPMC and six other organizations nationally have received CMS Innovation Awards to reduce hospitalizations among nursing facility residents.
In western Pennsylvania, 19 nursing facilities have committed to making changes to improve care and reduce avoidable hospitalizations.
Those changes include:
  • Having nurse practitioners on-site to work with existing nursing staff providing acute care interventions and preventive services
  • Improving the assessment and management of residents’ medical conditions
  • Providing advance-care planning
  • Supporting and treating those who choose palliative care as end-of-life approaches
Other interventions include:
  • Implementation of tools for quality improvement and enhanced communication about residents’ changing medical conditions among the resident-care team
  • Training conducted by education partners about geriatric syndrome
  • Palliative care and advance care planning
  • Specialists improving management of residents’ prescription drugs to reduce the risk of pharmacy-related complications
  • Using telemedicine to enhance communications among facility nursing staff, physicians, acute care clinicians, and nurse practitioners

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