For years, providers have focused on readmissions and their relationships with hospitals.

While that remains important, skilled nursing facilities would also be wise to keep their patients in their homes and out of the hospital completely. That’s why it was intriguing to hear of the model of the Provider Partners Health Plan, a Medicare Advantage HMO plan for beneficiaries who reside in long-term care facilities.

Bruce R. “Rick” Grindrod Jr., president and CEO of Provider Partners Health Plan, told me his company’s goal is to increase and improve the clinical capabilities in a skilled nursing facility to handle acute flare-ups of chronic disease among residents.

The PPHP care model involves nurse practitioners who meet daily with residents and staff. They learn of any changes in conditions with a goal to halt problems that can multiply. By applying the same clinical principles that we’ve used around reducing readmissions, facilities can catch a disease earlier, reducing the need for a hospitalization at all.

“For example, a long-term care patient has a little cough or a little bit of a weight gain. If there’s no nurse practitioner the nursing staff may or may not pick up on that subtle change in the patient’s condition,” Grindrod said. “The fact they have congestive heart failure is buried in their chart.  … We do an assessment and see if there’s a little bit of a cough or a weight gain. We treat the patient with a diuretic and avoid hospitalization three days later.”

When facilities can decrease the need for repeat hospitalizations, both overall costs go down and the patient benefits. Of course, many administrators tell me that by the time the resident has an infection or a fever, the family is demanding a hospitalization. That’s why the nurse practitioner who can notice the slight change earlier can mitigate this push-pull over the emergency room.

PPHP has more than 15 nurse practitioners on its team, but the model is not dependent on PPHP-employed nurse practitioners, Grindrod said.

“If a facility wants to create their own nurse practitioner team, or a primary care team has nurse practitioners who work with the providers, we have seen those models work well,” he said. “What’s important is that in many circumstances where there have been nurse practitioners, they are focused on the post acute population.” It’s important to align economic incentives “so that nurse practitioners and care models are focused on the resident and not just post-acute patient,” he added.

As more members engage in the plan, the membership costs go down per member, Grindrod explained. So far, PPHP has enrolled more than 1,000 members in 22 long-term care facilities in Maryland and Pennsylvania. Among these is Lorien Health Services, which operates nine nursing facilities in four counties in Maryland. PPHP provides its Institutional Medicare Advantage Special Needs Plan to Lorien’s long-term care residents.

“Our partnership with PPHP provides new resources to further improve our already market-leading quality of care,” said said Lou Grimmel, CEO of Lorien Health Systems.  We are very careful with whom we choose to partner and PPHP has demonstrated its ability to run a high-quality organization that truly cares about patients.”

I’m sympathetic to how difficult it is to try to navigate Medicare Advantage options, or partnerships. But as patients become sicker, it would be worthwhile to examine whether it’s possible to steadily drop residents from landing on an uncomfortable hospital bed.

Follow Senior Editor Elizabeth Newman @TigerELN.