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

Another key to the success of managed care in the nursing home, Dr. Bennett said, is communicating the program's philosophy to residents and their families - they need to know what the goal of treatment is and be warned about the risks and limits of hospitalization, for example.

Dr. Bennett also presented four strategies for operating a nursing-home-based managed care program: a preauthorization process, physician-related programs, nursing-home- related programs and development of care teams (see Table 3). He said that in EverCare, preauthorization has generally been limited to enteral feeding, because the long-term healthcare system tends to be incentivized toward this costly measure. He cautioned, however, that nursing homes and managed care have to be alert to practitioners who try to "take advantage of the system" in other procedural areas, as well, citing as examples inordinately frequent vision exams and the practice of subjecting every resident in a nursing home to a psychiatric exam. "You must have mechanisms in place to prevent such abuses," he said.

Table 1. Profiles of Three Special Medicare HMO Programs

Company         Enrollment    Management Approach

EverCare          12,000      MD/NP teams
ElderHealth        2,000      NP/RN Case Manager/MD teams
Optage             1,000      RN Care Managers

The physician and NP/PA recruitment and education processes are also important pieces of the puzzle. Dr. Bennett said that EverCare focused its recruitment efforts on busy physicians who were in active primary care practices and were caring for 30 to 40 nursing home residents as part of their practices (though the "ideal physician" for nursing home managed care has yet to be identified, he added). The important thing is that the physician understands the facility's care management model, as opposed to the hard-to-break habit of quickly admitting to the hospital everyone who becomes ill. NPs and PAs might also have to reorient themselves to case management, he added. Once involved, a good, experienced NP/PA might be able to handle 100 to 120 nursing residents in a nursing home managed care program, said Dr. Bennett, while a new NP/PA might be overtaxed with 75.

When discussing the development of care management teams, Dr. Bennett emphasized the need to be sure physicians and nursing staff have excellent relationship skills. He said that all too often, physicians are viewed as "that white-coated person who writes in the residents' charts and doesn't talk to anyone." He warned that medical directors should not assume that physicians have relationship skills.

Dr. Bennett described several possible limitations of care management that need to be addressed. First, the MDs', NPs' and PAs' experience might run counter to the managed care program's goals, and re-education is needed to overcome their previous training. Education is also needed for the facility's nursing staff, who might be conditioned to simply call 911 when a resident becomes ill. Families' concerns about the care management approach must be addressed, especially because it might be new to them, and administrators' support for care management enlisted. Finally, care must be taken to ensure that care management does not compromise the facility's regulatory compliance.