Is managed care in your future? - benefits of health maintenance organization's provision of health care through nursing homes according to John Hopkins School of Medicine professor Richard G. Bennett

Nursing Homes, August, 1999 by Linda Zinn

Highlights from a presentation by Richard G. Bennett, MD, at the 1999 Annual Meeting of the American Geriatrics Society/American Federation for Aging Research, Philadelphia.

Managed care offers a unique opportunity for nursing homes - as well as presenting a few pitfalls that must be foreseen and eliminated in order for managed care to be successful in that setting - according to Richard G. Bennett, MD, associate professor of medicine at Johns Hopkins School of Medicine and medical director for EverCare-Maryland, a special Medicare HMO program for nursing home residents offered by the managed care company United HealthCare.

In his presentation, "Managed Care in Nursing Homes," Dr. Bennett said, "Managed care provides, up front, the resources needed to deliver care before it is actually delivered. However, facilities must make certain that they are prepared and equipped to provide the level of care they promise. A nursing home administrator might think it's great that a managed care company will pay $400 per day for the care of a resident with pneumonia, but the managed care company is going to expect a certain level of services and staffing for that money."

Dr. Bennett's comments were centered on the care of long-stay nursing home residents and did not address short-say subacute patients. He asserted that for long-stay residents, decreased hospitalization - as a result of treating certain acute illnesses in the nursing home rather than in the hospital - can have a tremendous impact on the success of managed care in a nursing home. He cautioned, however, that preparing for such an upgrade of services takes time - from five to seven years, in his experience. But, because hospitalizations are responsible for approximately 50% of all Medicare dollars spent, upgrading services to provide more acute care is worthwhile. It is the first area, said Dr. Bennett, where Medicare HMOs can look for savings and, at the same time, improve quality of care.

"Many residents are sent to the hospital with a 102 [degrees] fever and no other problem" Dr. Bennett said, "when they could be treated safely in the nursing home where they live - and receive better care than they would in a hospital. It's not all about money. Residents in a well-run managed care program receive better care because they are seen more frequently by physicians and fewer hospitalizations. Strategies are needed for managing common, acute illnesses that physicians and nurse practitioners (NPs) can comfortably handle and that staff can carry out."

Dr. Bennett described four models for managed care of nursing home residents:

* dedicated nursing home physician

* midlevel practitioners (NP/PA)

* midlevel practitioners/MD teams

* RN care managers

No data are available as yet to show whether any of the above approaches is superior to any of the others, according to Dr. Bennett. He gave three examples of special Medicare HMO programs operating in nursing homes in the United States that are using these approaches: EverCare, ElderHealth and Optage (see Table 1). (Dr. Bennett pointed out that, unlike these examples, most of the 350 Medicare HMOs in the United States focus on managing care for enrollees who reside in the community and not in nursing homes. Furthermore, most of these HMOs have no targeted approach for nursing home residents.)

EverCare began as part of United HealthCare's Medicare HMO in Minneapolis 10 years ago and was initially conducted by a group of NPs. The project's success was the springboard for EverCare, a for-profit program that now employs 150 NPs and operates in seven states: Arizona, Colorado, Florida, Georgia, Maryland, Massachusetts and Minnesota. EverCare's expansion to New York and New Jersey is planned.

ElderHealth is a Baltimore-based, privately held company that operates in four locations: Maryland, Florida, the District of Columbia and Pennsylvania. Most of its 1,800 nursing home enrollees reside in Maryland and Florida. ElderHealth employs NP/RN Case Manager/MD teams, and the company partners with existing HMOs. ElderHealth uses customized, office-based, medical-record software for clinical management and quality improvement. In addition to its nursing home residents, ElderHealth's enrollees include dually eligible, community-based individuals.

Minnesota-based Optage, which operates under an HMO risk contract, moved away from its earlier NP/PA (physician's assistant) approach in favor of employing RN Case Managers.

According to Dr. Bennett, managed care case management in nursing homes encompasses four key components: resident/family education, acute illness management, chronic disease management and preventive health (see Table 2). Chronic disease management is a primary area of concern, he emphasized, saying, "We can care for people with chronic diseases if we are equipped and prepared to do some simple things well - for example, using an on-site pulse-oximeter, having staff who are trained to initiate hydration, and having the appropriate selection of antibiotics on hand." Other simple but essential measures include proper vaccination of residents and taking care that they aren't being overmedicated - a very real possibility, considering that residents receive an average of 12 drugs per day, he said.