Nurse practitioner model improves care for elderly
Proactive approach keeps patients out of the hospital
A nurse practitioner-led care management model has resulted in lower costs, better care, and high patient satisfaction ratings for frail elderly nursing home patients being managed by Inspiris, a Brentwood, TN-based health care management firm.
Inspiris and Mercy Care Plan of Arizona's nurse practitioner care management model was named the best practices award winner in URAC's first Best Practices Consumer Empowerment and Protection Awards program in March.
Medicare managed care plans contract with Inspiris to manage the care of their members in nursing homes. The nurse practitioners visit the patient in person in the nursing home and collaborate with the nursing home staff, the attending physician, and the family.
Patients in the program typically have 300 to 350 hospital admissions per 1,000 compared to a typical Medicare rate of 1,200 to 1,400 admissions per 1,000, says Sarah White, NP, vice president of clinical operations for Inspiris.
In a recent study of the New York market, an analysis of Medicare claims data indicated that the Inspiris CarePlus plan reduced emergency room use by 46% and hospitalizations by 74%.
In Phoenix, one health plan that contracted for the program assigned half of its members and facilities to the Inspiris nurse practitioner care management model and half to the physician-only model.
Over the first eight months of the Phoenix pilot study, acute inpatient hospital admissions for the patients whose care was managed by a nurse practitioner dropped 63% per 1,000 as compared to the control group, White reports. The results were so compelling that the pilot study was dropped and all the patients in the plan were enrolled in the Inspiris program, she adds.
One-on-one care
The program is different from traditional case management and disease management models because the nurse practitioners see their patients in person, rather than relying on telephone calls to manage care
"Telephonic care management doesn't work with patients who are cognitively or functionally impaired or those in a nursing home. Our model represents a major shift in the way health care is being delivered in the long-term care setting," she adds.
The frail elderly population is among the biggest drivers in health care costs, particularly during the last 18 months of their lives, White points out.
"Most health care is delivered in the nursing home through a physician-reactive model. Under fee-for-service Medicare, physicians see the patients only if it's a visit required by Medicare regulations or if it is deemed medically necessary. We see the patients frequently and pick up problems early, revise treatment plans, and deliver care in a timely manner," she says.
The nurse practitioner serves as a case manager and the primary care provider, working with the physician and the nursing home staff.
"The nurse practitioner sees the patients an average of once a week, sometimes with the physician and sometimes alone," White says.
Even subtle changes, such as not eating or sleeping well, can be a sign of failing health in an elderly person, White points out.
"The physicians visit so infrequently that the nurses may forget to tell them about problems. But when the nurse practitioners visit, they specifically ask the nurses about subtle changes and can take proactive steps," she says.
The nurse practitioners usually cover two to three nursing homes, depending on the volume of patients. Their typical caseload is between 80 and 100 patients. They spend their time at the nursing home or in transit and document their findings on a laptop computer.
Patients are enrolled in the Inspiris program through their health plan contract with Inspiris.
Practitioners use an assessment tool that helps them stratify the patients as high, medium, or low risk, based on factors that include the severity of their chronic medical conditions and past medical utilization. The tool includes a cognitive function assessment, fall risk assessment, depression screening, and skin assessment. The nurse practitioner also performs a comprehensive history and physical examination.
The nurse practitioner uses all of the information from the assessment tool and his or her clinical judgment to set the risk level of each patient.
"The nurse practitioner is seeing the patient in person and may pick up something that the tool didn't. The tool is a good indicator of risk, but it doesn't replace the nurse practitioner's professional judgment," White says.
The nurse practitioners meet the family member who is the legal representative for the patient, review the medical record, and talk to the family member about the patient. They talk to the family frequently, sometimes over the telephone and sometimes in person.
"During the introductory visit, the nurse practitioner begins to establish a relationship with the family. A lot of our work involves communication, and when patients can't make decisions for themselves, it's essential to have a good relationship with the family," she says.
The nurse practitioners educate the family members on medical issues, where the loved one is in their disease process, and what their prognosis is.
"We try to give them the big picture and educate them about the trajectories that are part of the aging and disease process," she says.
They work with the family on end-of-life planning and help them make decisions about hospice or palliative care as the patient's condition worsens.
The nurse practitioners visit their patients on a regular basis and work on preventive measures, such as immunization, fall prevention, and pressure ulcer prevention. They work with the nursing home staff to manage multiple chronic and acute conditions.
The company has developed protocols for managing the care of elderly patients with chronic diseases.
"The goal is to be proactive and to create a treatment plan that is appropriate for each patient. We talk to the family and patient to get their input about treatment decisions. We might not treat conditions in this age group as aggressively as we would in a younger population," she says.
With an older patient, palliative care to keep him or her comfortable may be more appropriate than aggressively treating a disease to prevent negative outcomes, White says.
"We examine each treatment decision independently and work with the patient or surrogate to make informed decisions that guide the rest of the protocol," she says.
"The nurse practitioners are in the facility frequently and get to know the staff who are providing care for the patient. They work with a multidisciplinary team that may include nurses, dieticians, social workers, and a consulting pharmacist," she says.
Since they are in the facility regularly, the nurse practitioners can pick up on subtle changes in a patient's condition early on. Often, the facility staff mentions a change to them.
"The facility nurses develop a relationship with the nurse practitioner and will mention that Mr. Smith isn't eating or sleeping well. This is a red flag to the nurse practitioner to begin an in-depth assessment and manage the problem safely in the nursing facility if possible," she says.
The process pays off, even during flu season when the hospitals are often packed with patients, White says.
This year's flu season was particularly rough, and one nurse practitioner with 50 patients in one facility saw many who developed the flu or other respiratory symptoms although only one was admitted to the hospital.
"She managed the rest successfully in the nursing home. She was able to identify the problems early and take steps before the patients got so sick they had to be hospitalized," she says.
If a patient has to go to the hospital, the nurse practitioner calls the hospital or the emergency department and gives them a quick patient history.
"The nurse practitioner reminds the hospital staff that the patient is in a nursing facility that can handle many things like IV antibiotics, therapy, or wound care. This awareness results in a shorter hospital stay," she says.
"We give the family an update at least quarterly and more frequently if there is a change in the patient's condition," she says.
The nurse practitioners follow the patients through the continuum of care, from the nursing home to the hospital and back again.
"Over time, the nurse practitioner gets to know the patient and family really well, and a trusting relationship develops," she says.
The nurse practitioners establish a good working relationship with the health plan case managers, so they can collaborate if issues arise.
For instance, in the case of high-risk, complex patients, since the nurse practitioners see the patients in person, they can give the health plan case managers additional information to take to the plan's medical director when issues of coverage arise.
If a patient is discharged from the nursing home to the community or to a group home or assisted living center, the nurse practitioner coordinates the transfer with the health plan case manager.
A nurse practitioner-led care management model has resulted in lower costs, better care, and high patient satisfaction ratings for frail elderly nursing home patients being managed by Inspiris, a Brentwood, TN-based health care management firm.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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