Coordinated care programs: A lifeline for patients and your facility
If you serve elderly populations in a long-term care or nursing facility, you have my respect — for the compassion you bring to work each day and the challenges you must face.
As a doctor who specialized in geriatric medicine and the former medical director of a long-term care facility, I had the opportunity to work alongside care staff, managers and administrators for many years. I saw how hard these dedicated professionals worked to meet their business mission while serving patients with complex healthcare needs.
The shifting healthcare environment only adds to the challenge. Yet a growing number of facilities are finding ways to achieve their mission and meet stringent new requirements and regulations. These facilities are turning to proven care models such as Optum CarePlus (formerly known as Evercare) to augment patient care, improve occupancy rates and maintain consistently higher revenues.
Reducing hospitalizations, increasing occupancy rates
In the U.S., more than 1,100 nursing and long-term care facilities have chosen to reinforce their own resources by using provider-led clinical care and care management services. When combined with a compatible Medicare Advantage Plan, this extra level of care allows facilities to provide attentive, high-quality care in-place – including skilled nursing care – while being reimbursed for Part A skilled stays.
For patients and families, the coordination of care offered by this early intervention model is a source of comfort and relief during a confusing and stressful time of life. Patients entering a nursing or long-term care facility are in a fragile physical and emotional state; about 40% suffer from dementia. A trip to the hospital is a traumatic and disruptive event.
Yet, frequent hospital admissions and readmissions are a reality for elderly patients. Many suffer from multiple chronic conditions and have lost the continuity of care provided by their primary care physician before their move.
At the same time, many care facilities are challenged to provide patients with an integrated course of care. Facility physicians and nurses are burdened by large caseloads and lack the time or dedicated communications liaison to convey detailed observations regarding the patient's condition to nursing facility custodial or care staff, families or the patients themselves.
Integrated, aligned care
When over-burdened facilities engage with a quality in-facility clinical care program, they often report a remarkable shift — from fast-paced, fragmented care to targeted, individualized care, and from reactive treatment to an integrated and aligned care plan that can help prevent future medical events and health setbacks. The result can be transformative — for patients, families, staff and the facility.
Under this model, nurse practitioners work closely with nursing home staff, patients and family to provide the right care at the right time in the right place, based on each patient's needs. Nurse practitioners are typically dedicated to one or two facilities. They carry a smaller caseload than most physicians, allowing them to spend more one-on-one time with their patients.
Training staff to communicate
Nurse practitioners are also trained in the importance of communicating patient information. They act as a bridge between patients and their families, nursing staff and physicians. They can facilitate advance care planning conversations with patients, and educate nursing homes through formal, in-service training and mentoring. Frequent communication and high-level training result in truly coordinated patient care — and a more informed nursing staff equipped with invaluable skills.
Most importantly, because nurse practitioners get to know their patients and families, they can catch any changes in condition early, often resolving problems or providing treatment before outside care is needed.
Case in point: Mrs. A and Part A revenues
Identifying changes early can — and does — make all the difference in patient outcomes. Consider a situation where staff notices a change in a patient: Mrs. A, a normally outgoing resident, who has diabetes. Lately, she hasn't been interacting with others at mealtime, and seems somewhat lethargic.
The nurse practitioner learns of this behavior change during her regular check-ins with the nursing facility staff. She inquires further into the patient's meal and fluid intake, and then examines her vital signs and patient records — including glucose readings.
The nurse practitioner notes that Mrs. A has had a low-grade fever for several days, which could be important in conjunction with other changes — such as a slight uptick in her blood sugar. These indicators, taken together, cause the nurse practitioner to order lab tests, including a urinalysis — which confirms the patient has an acute urinary tract infection.
The nurse practitioner discusses a treatment plan with the patient's family and physician, and together they decide on antibiotic treatment and fluids. The treatment will be provided by the nurse practitioner, replacing extra care that would have been costly for the nursing home to perform. And, Mrs. A will remain in the nursing facility — where she is most comfortable — while avoiding an unnecessary hospitalization. The nursing facility is reimbursed for the added care costs and retains Mrs. A's occupancy.
In scenarios like these, where proactive treatment is provided in-place, Medicare waives the requirement that patients must spend three days in an acute hospital before the nursing facility is eligible to receive Part A revenue.
Additional incentives and benefits
By providing the right patient care at the right time, nursing facilities also can earn quality incentive payments from health plans. For example, the UnitedHealthcare Nursing Home Plan, formerly known as the Evercare Model, offers dividend and shared-savings programs to participating nursing homes. These payments are made when the nursing facility successfully implements the clinical model and meets predetermined quality metrics.
Optum CarePlus provides an added benefit to nursing facilities by capturing important clinical data, including visits, tests, treatments and conversations between providers, family members and patients. This electronic medical record provides clear documentation that can often eliminate questions or concerns that may otherwise lead to Medicare survey deficiencies or investigations. CarePlus staff members are also available to discuss cases during the survey process, easing the burden on the facility's busy nursing and administrative staff.
Ensuring the well-being of our oldest citizens is an honorable profession — and a difficult job. By engaging in a true partnership with a coordinated care program, facilities can gain the extra layer of care and resources needed to meet new healthcare requirements and sustain vital revenue streams.
Ronald J. Shumacher, M.D., FACP, CMD is the Chief Medical Officer for Complex Population Management at Optum. Dr. Shumacher previously served as Executive Director and Senior Medical Director for Evercare (now called Optum CarePlus) in the Mid-Atlantic market, and Medical Director and Vice President of Clinical Delivery for UnitedHealthcare Medicare & Retirement.