NURSING HOMES: Healthplan Assesses Managed Care Models

      The March/April issue of Healthplan looks at the new model for the provision of primary care services to nursing home residents. The provision of primary care in a nursing home setting is becoming more important: among those who were age 65 in 1990, 43% could expect to spend some time in a nursing home. Of those, 55% will stay for at least a year, and 21% for five years or longer. Researchers from the UCLA School of Medicine and RAND recently conducted case studies of three managed care plans "that have developed innovative programs to provide primary care to nursing home residents." Each of the three emphasized the use of physician assistants or nurse practitioners -- serving a median of 115 patients -- to augment physician care, and stressed managing acute problems in the nursing home setting. The first model, or "dedicated team" approach, relied on a "cadre of four physicians whose responsibilities are limited to nursing home, hospice and home care," paired with four full-time nurse practitioners or physician assistants. A physician and an assistant were assigned to each of 50 homes where health plan members live, with each team caring for between 100 and 140 patients. The second model, or "augmentation" model, involves physicians with more traditional responsibilities, in which one doctor is assigned to each nursing home within the health plan's purview, overseeing care for all members there. Only the doctors with the largest patient loads have the benefit of a nurse practitioner to assist them. The final model combines elements of both alternatives. In all cases, "physicians named coordination of care as one of the strengths," as well as the presence of nurse practitioners, which "reduces calls and reassures physicians that patients are being seen." Physicians listed as weaknesses a heavy workload, lack of transportation for patients to outside services, a lack of skilled nurse practitioners and the need for better information flow. Nurse practitioners cited similar pros and cons. Nursing home administrators liked the frequency of visits "and the ability to react to acute problems." However, nursing homes had to "absorb many of the costs," programs "were difficult and slow with authorizations, and paid inadequate compensation for nursing home services."

But How is the Care?
      Under the managed care models, health plan members received more primary care visits per month (including those by assistants) than did residents who had fee-for-service Medicare. Under the dedicated team model, health care utilization, such as hospitalization rates, were lower than under fee-for-service Medicare, while rates were about the same under the augmentation model. Under the combination plan, "implementation failed to meet targeted goals because of the loss of a nurse practitioner." Satisfaction levels did not differ among plans (Reuben, March/April 99 issue).