Treating patients at nursing home cuts hospital stays by 58%
Costs reduced by 30%
A managed care program aimed at delivering more primary and preventive care to long-term nursing home residents is reducing the number and length of hospital stays, as well as slashing total medical costs for its elderly participants.
EverCare is a medical model for permanent nursing home residents that emphasizes intensive on-site care for patients and offers financial incentives that encourage physicians to manage care from the nursing home whenever possible, says Marcia Smith, MSN, president of EverCare, a subsidiary of United Healthcare Corp., based in Minnetonka, MN.
As the movement toward Medicare HMOs and other managed care programs intensifies, discharge planners are finding that such programs' emphasis on providing care in the nursing home and avoiding hospitalization is beneficial for frail elderly patients.
Medical costs for the 1,600 Minneapolis-area patients participating in the program in 1995 have been reduced by 30%, and hospital days have been reduced by 58% since the program began in 1987. Hospital lengths of stay in 1995 averaged 4.7 days -- nearly one-third lower than the national average for people in the same age bracket as EverCare members, Smith says. From 1987 to June 1995, admissions to the hospital were cut in half for EverCare participants, she adds.
Based on those results, the Baltimore-based Health Care Financing Administration (HCFA) has given EverCare approval to establish demonstration programs in up to nine more locations. Those sites -- where EverCare contracts directly with HCFA to provide care -- are in Atlanta, where membership in the program has grown to 300 in three months, and Baltimore and Boston, where the programs are just getting under way.
At two other sites -- in Tampa, FL, and Phoenix -- EverCare has contracted with other managed care entities to provide care for institutionalized Medicare patients. Those entities -- in Tampa, EverCare's own sister company, United HealthCare, and in Phoenix, an HMO operated by Maricopa County -- in turn contract with HCFA, Smith says.
United Healthcare Corp. plans to take the EverCare program into three more geographical areas by the end of 1996, and eventually will expand to all 20 areas where it has HMOs with Medicare risk contracts, Smith says.
Long-term residents of nursing homes, including those on Medicaid, in an EverCare service area are eligible to enroll in EverCare. Any permanent resident of a nursing home is eligible if the resident:
* has Medicare Part A and B, or Part B only;
* does not have end-stage kidney disease;
* has not elected Medicare hospice coverage;
* lives in one of the 10 metropolitan areas where EverCare is offered.
Virtually all medical costs are covered by EverCare, from routine checkups to eye and hearing exams to hospitalizations. EverCare coordinates all insurance requirements for its members -- there is no annual deductible, no copayment, and no complicated paperwork, Smith points out. Members must continue to pay their Part B Medicare premium.
At no extra charge, EverCare gives nursing home residents benefits they might otherwise get only through supplemental Medicare policies, such as some wellness care, physician co-insurance unpaid by Medicare, and hospital deductibles, Smith says.
Another plus is that there are no claims forms involved, and the patient never gets a bill, she adds.
"There is no balance billing," Smith says. "We just cover in full according to the fee schedules. The patient never gets a bill or a claims form, so it's simpler for the family. [Care is given by] a provider or network, who has agreed to accept our payment as payment in full."
The ideal scenario for enrolling a patient in the EverCare program is for a discharge planner to call the EverCare office in advance and say he or she has a patient who is going to be permanently institutionalized, Smith says, noting that most of the time discharge planners know when this will be the case.
The EverCare program aims at averting hospital admissions by keeping patients as healthy as possible, and by catching problems early enough to keep them from developing into acute conditions, she says.
"This is preventive care in the context of the very frail, medically complex patient," explains Ruth Ann Jacobson, MPH, NP, EverCare's vice president of operations. "It is more maintenance of chronic illnesses and management of acute episodes."
EverCare's approach differs from the traditional Medicare approach to nursing home care in that physicians are reimbursed for unlimited visits to the nursing home if they will see the patient there rather than in the hospital, Jacobson says.
Medicare traditionally has reimbursed physicians for only one visit per month to a nursing home, she says. EverCare, on the other hand, reimburses physicians "very adequately" if they will, for example, go to the nursing home on a weekend to see a patient rather than have that patient transferred to a hospital emergency department.
EverCare even reimburses physicians for the time they spend in conferences with patients' families, Smith points out.
Although EverCare contracts with physicians, it generally employs the nurse practitioners who make up the other half of the primary care team, Smith says. The nurse practitioners -- who can write prescriptions, write orders, and initiate treatment plans -- are readily available by pager to the patients under their care, Smith adds.
"Not having ready access to medical care is one of the big frustrations of nursing home administrators," Smith says.
In cases where the nursing home staff otherwise might speak to a physician by phone and be told to send a sick patient to the emergency department, an EverCare nurse practitioner often can make an on-site visit and deal with the problem there, Smith says.
The nurse practitioner, who is trained in providing medical care for the frail elderly, can spot early signs of disease in the patients before they exhibit more pronounced symptoms, she says.
"The symptoms of these patients differ from what you and I might have," Jacobson adds. "A symptom [of pneumonia] might be that they stop eating. The nurse practitioner can treat the pneumonia with oral antibiotics before the patient develops symptoms that require hospital care."
As an example, Smith cites an incident that occurred when she was making rounds with an EverCare nurse practitioner.
"We walked into the nursing home, a staff member approached [the nurse practitioner] and said, 'Will you check on Bertha? She seems to be coughing when she wakes up,'" Smith recounts. "The nurse practitioner listened to Bertha's lungs, which sounded different than seven days ago, even though Bertha was smiling and happy. She said there were some rattles, and prescribed antibiotics, as she said the condition probably would have proceeded to pneumonia."
Another function of the EverCare nurse practitioner is to act as a care manager, bringing together all the people or agencies that need to be involved in the patient's care to eliminate fragmentation and duplication, she says.
Representatives of EverCare are actively meeting with discharge planners to let them know the program is in their areas, and then work with them to prevent hospitalization whenever possible, Smith says.
"We work closely with discharge planners at the hospital on the idea that we already have a bed [at the nursing home] and will work to continue the IVs or whatever there," Smith says. "If there is a hospitalized member, we work with the discharge planner to get [him or her] back in the nursing home as quickly as possible." *
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