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Katherine Tardiff is a gerontological nurse practition-er, and all her patients reside at a long-term care facility in Marlborough, Mass. As their care coordinator, Tardiff visits each of them at least once a month for a routine check of physical condition, medications, treatment plan and general well-being. If needed, she writes orders for specialty care at the patient's bedside.
Tardiff also conducts yearly physical exams and other visits required by Medicare. And since she's at the facility almost every day, Tardiff is immediately available to provide acute care when the need arises. If she's not available, her patients can receive acute care in the nursing home from the NP on call, who has all necessary records on hand. After each visit with a patient, Tardiff confers with the facility nurses and the patient's family.
Tardiff works for Evercare, a division of the health insurance giant UnitedHealth Group. Evercare is a care coordination program for people who are older or have chronic illness or disabilities. Evercare enrollees live in long-term care facilities such as nursing homes or assisted living facilities, as well as in the community.
Evercare's guiding principle is that patients have better outcomes - and the system saves money - when care isn't fragmented among providers and venues, when patients receive preventive care, and when families are kept informed and involved. And, the company believes, nurse practitioners are the ideal professionals to lead each patient's health care team.
The Idea
With Evercare's focus on NPs, it's not surprising that the program was the brainchild of two nurse practitioners. Jeannine Bayard and RuthAnn Jacobson were classmates in the adult-geriatric NP program at the University of Minnesota in the 1970s. Their paths crossed again at Share Health Plan in Minneapolis in 1987. The HMO had recently been acquired by UnitedHealth, and the restructured entity was entertaining ideas for new subsidiaries and products.
At the time, Bayard was the vice president of planning and development at Share, and Jacobson was vice president for the medical delivery division. They had become experts on Medicare programs and patients, and they saw a pressing problem with a subset of Medicare patients: frail older adults.
When older patients, even those with long-standing primary care relationships, became ill, it was the family who arranged nursing home care. This often required the patient to move to another community and to leave the patient's established primary care provider.
And once in a nursing home, a stable patient could see his or her own provider only once every 30 days; physicians weren't reimbursed for further visits. For any acute episode, the patient was sent to an unfamiliar provider in the emergency department, who ordered multiple tests. "So the system was built to incur huge costs," Bayard says.
"The cost to these people - not just financial, but emotional and physical - was very great because they'd be bounced in and out of the hospital, and their families would be upset because there would be no continuity," Bayard recalls.
So Bayard and Jacobson pitched a business plan that would offer integrated care for patients and cost savings for UnitedHealth. "The plan outlined an approach to reduce the cost of care for the most expensive Medicare beneficiaries by having experienced experts in medical management of the elderly providing their care as opposed to the hit or miss that we were seeing for this population," Jacobson explains.
Championed by Robert Ditmore, then president of UnitedHealth, the Evercare plan was approved. Jacobson reactivated her nurse practitioner credentials, and the two nurse practitioners began hammering out the details.
Challenges
Their first challenge was attracting physicians to the program. Bayard and Jacobson convinced the only geriatrician in the Twin Cities to sign on. "He was very supportive of NPs," Jacobson remembers.
But other physicians were reluctant to work with nursing home residents. "Remember, this was back in 1987, and geriatrics was just beginning. There were a lot of doctors who didn't even believe that it was a specialty," Jacobson says.
And nursing home care isn't glamorous. The patients rarely get better, Bayard points out.
Bucking conventional wisdom in managed care, Bayard and Jacobson turned to academic physicians for support. There was interest in the Evercare model, and a few agreed to accept some nursing home patients with nurse practitioner care management. "That was a breakthrough for nursing homes, really," Jacobson says, "to get those positions out of the halls of ivy and into the nursing home halls."
With their employer on board, Jacobson as NP and a handful of physicians and patients, Bayard and Jacobson tackled their biggest challenge: convincing nursing homes.
Nursing Home Care Circa 1987
In the beginning, there was great skepticism about Evercare in the long-term care industry. Bayard believes the first problem was clinical. Long-term care facilities were providing the best care they could, and they were defensive about being told it could be done better.
But the bigger problem was financial. "That was in the days of contract negotiations, and the history between managed care and long-term care was bumpy, to say the least," Jacobson explains. "The nursing homes felt that managed care took advantage of them and didn't understand them."
Between Medicare regulations and the way managed care organizations worked at the time, many long-term care facilities were having trouble getting paid, Bayard and Jacobson discovered. Billing procedures were opaque, and after continually being denied payment, nursing homes just stopped submitting claims.
With a cooperative claims department at UnitedHealth, the two nurse practitioners set out to change the system. Since managed care works under capitation - Medicare provides a lump sum for each patient, and the managed care organization decides how to reimburse providers and facilities - Bayard and Jacobson were free to create a new fee schedule based on the needs of the nursing homes and health care providers.
"And that's how we began to get them to think differently about how they were delivering care to these people," Bayard explains. "We would pay physicians and nurse practitioners to just talk to the family about advance directives; they'd never been paid for that. And we paid physicians and nurse practitioners to go out on emergency visits; they'd never been paid for that."
By paying generously for more care in the nursing home, Evercare avoided paying even more for unnecessary care in the ED. Administrators and staff were thrilled that patients spent less time in the hospital.
The Halo Effect
Jacobson emphasizes that Evercare served its enrollees well right from the beginning- "because we really ran a lot of interference and made sure that the program ran well."
But over time, the program came to benefit even nursing home residents not covered by Evercare.
For example, Medicare would provide funds for 100 days per patient for nursing home care. But in the mid-1980s, Congress mandated that certain patients, such as those on enteral feeding, receive care for as long as their condition persisted. So managed care organizations would receive a limited payment but were required to pay for unlimited care.
"We began to look at [patients being tube fed] in a new light to see if we could get them off tube feeding," Bayard recalls. After conducting swallowing studies and trying new therapies, some of their patients returned to eating by mouth. "Sometimes administration and financial issues led us to identify care issues," she offers.
And these processes could be applied to all nursing home patients. Bayard calls it the "halo effect." A large part of the Evercare NP's role is educating the nursing home staff, both formally and informally.
"They'll bring the RNs in with them. They'll support them so that they will then carry the knowledge they have to other patients," Bayard explains.
Success
The Centers for Medicare and Medicaid Services approved Evercare as a Medicare pilot program in 1987 and, based on the program's success, allowed it to expand to other markets in 1994 and awarded it federal Medicare demonstration project status in 1995.
But Jacobson measures its success differently: "I remember the first day a physician, a very good geriatrician, called the nursing home she was serving and said, 'I will only accept new patients if they enroll in Evercare.' I remember in those early years the first time a nursing home started to say to people who were new in the facility, 'You really ought to take a look at the Evercare program.'"
Jacobson says she never doubted that Evercare was the right model for patient care. But it's also had a halo effect for nurse practitioners. "Our role was to create the opportunity for NPs, and just the sheer volume of NPs in these roles had a huge impact on [Medicare] regulation even if it lagged behind what NPs [outside nursing homes] were doing," she observes.
Katherine Tardiff agrees: "I really love my job. It's been a great opportunity working with Evercare. ? Since it was founded by NPs, you just have a wonderful support network of nurse practitioners who are passionate about geriatrics, which is so important to bring to long-term care facilities."
-Jill Rollet is the senior associate editor. Reach her at jrollet@merion.com.
Evercare NPs
Today, Evercare employs more than 500 nurse practitioners in patient care and management
positions who serve more than 120,000 enrollees nationwide.1
NPs spend about 35% of their time on direct patient care - about 42 minutes per patient on a given day.2
NPs spend another 26% of their time on indirect patient care - about 20 minutes per patient on a given day.2
Of the time spent on indirect care, 46% is spent with nursing home staff, 26% with patient families and 15% with physicians.2
About 20% of an NP's time is spent on administrative tasks.2
Among patient families of Evercare enrollees in nursing homes, 97% rate Evercare NPs as good or excellent.3
Of nursing home staff members, 92% report satisfaction with the amount of time Evercare NPs spend with residents.4
Of nursing home administrators, 94% report overall satisfaction with Evercare NPs, and 92% report satisfaction with NPs' relationships and communication with physicians.
The Evercare Scholars program provided five $20,000 scholarships during the 2006-2007 school year for graduate nursing students at the Hartford Centers of Geriatric Nursing Excellence, located at five schools across the country.5
Sources:
1. Evercare Web site, www.evercarehealthplans.com.
2. Kane RL, et al. How EverCare nurse practitioners spend their time. J Am Geriatr Soc. 2001; 49:1530-1534.
3. Evercare. Overview: Evercare institutional plans responsible party satisfaction survey. Based on 2,600 responses to survey conducted from July 25 through Aug.14, 2005.
4. Evercare. Overview: 2004 Evercare institutional plans nursing home staff satisfaction survey. Based on 250 interviews conducted by Strategic Resources Partners in the fall of 2004.
5. Evercare donates $100,000 to fund scholarships at the John A. Hartford Foundation Centers of Geriatric Nursing. [press release] Minneapolis, Minn.: Evercare. Aug. 17, 2006.
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