UnitedHealthcare Nursing Home PlanEvercare Clinical ModelTelemedicine InitiativesCathy Lipton, MDSenior Medical Director 03/15/2012
The Evercare Model offers individualized solutionsCurrently:• Complex problems require individual solutions; not just disease –specific programs• Typical Disease Management programs have not demonstrated desired outcomes• Poor communication between providers of care and the delivery system; doctors and nurses don’t get to do what they do bestWith Evercare:• Evercare programs offer individualized and comprehensive care plans• Evercare program results address the systems of care with better quality outcomes and improved satisfactionEvercare Nurse Practitioners / Clinical Support accomplish 3 main objectives:• Increased assessments and proactive medicine to prevent ailments from becoming acute• Facilitate treatment of changes in condition immediately in place• Enhance communication for entire care-plan, disease trajectory, ACP 2 Propriety and Confidential. Do not distribute.
UnitedHealthcare Nursing Home Plan Clinical Features & BenefitsNurse Practitioners as a central part of providing more intensive primary care working in collaboration with nursing home staff and primary care physicians.Physicians who are encouraged to increase their involvement with families and nursing home residents.PCP continued participation rating of 91%Decreased hospital admissions by 50%Year over year family/responsible party satisfaction ratings of greater than 95%.Clinical staff provides both formal and informal education for nursing home staff.Early identification and change in condition programs and tools to promote early clinical intervention and improve outcomes.Annual Clinical Indicator Studies that drive clinical practice guideline development that promotes quality of care. 3 Propriety and Confidential. Do not distribute.
UnitedHealthcare Nursing Home PlanWaiver of 3-day Qualifying Stay – Stable Census – Reduced Bed-Hold Days – Immediate Part A Reimbursement – Skilled Days Outside of MedicareOn-site clinician (NP/PA) at no additional costFocus on ongoing Advance Care Planning with families and staffEnhanced Medical Records (EMR, documentation)Additional Covered Items – Therapy Screenings – Dental and Eyewear Benefits – Blood Glucose Monitoring – Skilled Days Outside of 3-day Qualifying StayAfterhours supportEnhance overall clinical quality 4 Propriety and Confidential. Do not distribute.
Evercare works in partnership with nursing home staff to executethese components:Intensive Delivery of Primary Care – by our clinical team, which includes nurse practitioners collaborating with physiciansOnsite Nurse Practitioner – at no cost to the facility or resident, results in:• Increased visits for residents• Emphasis on proactive care• Early identification of change of condition• Increased communication with residents, families, staff, and physicians• Formal and informal education to nursing staffTreat in Place Model• Frequent visits by Nurse Practitioner• Intensive Collaboration with primary care physician• Ability to initiate skilled benefit without 3-day hospitalization 5 Propriety and Confidential. Do not distribute.
UnitedHealthcare Nursing Home Plan Population ProfileCustodial, permanent stay, frail elderly, no active discharge planAverage age 81+ years old80% female85% Moderate To Severe Dementia75% require assistance with 4+ ADLsMust be long-term resident of SNF, have Medicare A & B, and not enrolled in ESRD programPrimary diagnosis• Dementia• Hypertension• Anxiety and Depression• Vision Impairment• Arthritis< .5% discharged to home 6 Propriety and Confidential. Do not distribute.
The Evercare Clinical Model: How does it work?Apply an individualized, whole-person approach to care of frail, institutionalized elders• Focus on promoting maximum function, comfort, and quality of lifePreventive Care and Early Recognition of Change in Condition• Evidence-based medical care• Frequent monitoring and communication with nursing staff• Rapid response to changes – rapid initiation of treatmentProvide care in a safe but least invasive manner, in the least invasive setting• Provide as much care as possible in the nursing home setting• “Treat in place” philosophy – avoiding complications and trauma of unnecessary hospitalizationsProvide care through a primary care team – partnership of nursing home staff, primary care physician, and nurse practitioner• Clinical support for facility• Access to skilled benefits without hospitalization• Enhanced reimbursement for physician services 7 Propriety and Confidential. Do not distribute.
Why do patients transfer out of Skilled Facilities?Fundamental system issues related to transitions in carePhysician/NP/PA presence in SNFs and coverage issuesSNF technical capabilitiesACP/Family dynamicsStaffingEducation/training in SNFsRegulatory environmentPatient mixFragmentation in system/information systemsOver 50% of admitting diagnoses for avoidable hospitalizations:• Cardiovascular (CHF and chest pain)• Respiratory (pneumonia and bronchitis)• Mental Status Change/Neurological 8 Propriety and Confidential. Do not distribute.
Focused Expert Reviews of Transfers out of Nursing Centersshow….Key facility factors identified when defining “avoidable” hospitalizations:The same benefits could have been achieved at a lower level of careThe SNF should have been able to provide the careAvailability of on-site physician/NP/PA evaluationBetter quality of care in assessing the resident’s change in statusBetter advance care planningThe resident’s overall condition limited his ability to benefit from the hospitalizationKey facility resources helpful in preventing hospitalizations:Examination by a physician, NP or PA within 24 hoursPhysician or physician extender present in the SNF at least 3 days per weekCare by a registered nurse (vs LPN/CNA)Availability of lab tests within 3 hoursAbility of the SNF to initiate and maintain intravenous therapy 9 Propriety and Confidential. Do not distribute.
What can happen as a result of hospitalization? New physical or Conflicting Outpatient (clinic) chemical information visits get scheduled Altered functional restraint given to family Increased when not necessary status/weakness or appropriate confusion-‘out of sorts’ Pressure Sores Psychiatric Lost teeth,Over sedation/lethargy exacerbation hearing aids Eccymosis from IV/lab and glasses sticks Decline in Relocation Physically unkempt ADL’s Trauma Incontinence UTI’s secondary to catheterMRSA and or VRE Relocation Fecal Impaction Weight loss/ Loss of Broken bones from Trauma appetite falls in hospital Initial problem not fully investigated/resolved Advance Directives NOT followed Increased anxiety/agitation Lost equipment: Confusion from the Decreased (splints/braces) Activity Phlebitis hospitalization that can take a long time to clear Bad memories/waiting in ER for up to 18 hours Resident not a Lack of discharge summary and priority to acute 10 info related to hospitalization Heel ulcers care staff Death or poor quality death Propriety and Confidential. Do not distribute.
Reduction In Unnecessary HospitalizationsThe University of Minnesota School of Public Health found that the incidence of hospitalizations among nursing homepopulations was twice as high in control residents as in Evercare residents. Members in the control group were also twiceas likely to go to the Emergency Room than Evercare members. Evercare had ½ the hospitalizations compared to fee-for-service Medicare (Control 1 & 2). Effect of Evercare on Hospital Use 80 70 60 Admits per 50 1000 Enrollees 40 30 20 10 0 Evercare Control 1 Control 2 Evercare Control 1 Control 2 Hospital Emergency Room Admissions Visits Source: Dr. Robert Kane et al, University of Minnesota, 2003 11 Propriety and Confidential. Do not distribute.
It’s not just good geriatric care…One in 4 Medicare patients admitted to skilled nursing facilities from hospitals is readmitted to the hospital within 30 daysUp to 2/3 of hospital transfers are rated as potentially avoidable by expert long-term care health professionalsHealth Care Reform requirement: “Hospital Readmissions Reduction Program” becomes fully effective October 1, 2012Medicare is putting in place financial incentives to reduce potentially avoidable hospital transfers through pay-for-performance, bundled payments, and other strategies First phase: Heart Attack, Heart Failure, Pneumonia Second phase: COPD, CABG, PTCA, Other vascular conditionsThe OIG considers unnecessary hospitalizations during a nursing home stay a compliance priority in its 2011 and 2012 work plansBudget plans for similar reductions in skilled nursing facility reimbursement as of 2015 for high rates of preventable hospital admissions 12 Propriety and Confidential. Do not distribute.
Proposed Telemedicine PilotWork in Ethica Health centers in conjunction with Georgia Partnership for TelehealthTarget buildings that have the Evercare model in place and still have continued high rates of transfersUse existing telemedicine equipment with the Evercare NPs and PAs as “end users”Overlay Evercare’s existing 24-7 on call systemOne year pilot proposedGoals:• Improve “face-to-face” communication with staff and families• Enhance treatment in place• Reduce transfer ratesReplicate across our shared nursing centers and expand beyond to underserved and geographically remote centers 13 Propriety and Confidential. Do not distribute.
UnitedHealthcare Telemedicine/Telehealth ActivitiesGoal to enhance use of telehealth in rural areas: 1. Expand broadband connectivity to enable growth of telemedicine adoption. 2. Improve and align reimbursement approaches across payers to encourage greateruse of telemedicine across rural settings. 3. Encourage physicians to incorporate telemedicine into their practice. 4. Use telemedicine to build primary care capacity in rural areas. 5. Increase access choices for rural beneficiaries. 6. Raise patient comfort levels with telemedicine technology and encourage its usein rural care models. 7. Update regulations associated with technologies and professionals. 8. Improve care coordination and patient safety in rural areas. 14 Propriety and Confidential. Do not distribute.
Bringing Primary Care and Specialty Services to the Navajo Nation UnitedHealthcare serves 24,000 special needs children in the Arizona Medicaid program. Obtaining pediatric specialty services in rural parts of the state is a significant challenge for many children. In 2010, UnitedHealthcare generated a Title V grant for the expansion of telemedicine into Tuba City on the Navajo Nation in Northeastern Arizona. Access to specialty medical care on the Navajo Nation is extremely limited. Children and their families typically must travel 200 miles to Phoenix, the closest urban center, to see a specialist. The Navajo telemedicine program utilizes high-definition technology through an established T1 network that provides hub site services (at regional clinics) to patients presenting from remote locations on the Navajo Nation. Financial support for travel and individual service plans are helping underserved tribal members gain access to needed primary care and specialty services in the most remote areas of Northeastern Arizona. 15 Propriety and Confidential. Do not distribute.
OptumHealth’s Connected Care Delivery of Telehealth Technologyand Services Connected Care delivers telehealth services in low-access rural and urban areas using a combination of advanced telecommunications technologies, health care delivery expertise and scalable operations. Through the provision of telemedicine equipment and operational assistance, Connected Care enables communication among existing medical communities, providing the technology and professional support necessary to implement telemedicine. This includes everything from equipment, software and support services, to coordinating scheduling systems, training, facility design and reimbursement analysis. All equipment — video gear, stethoscopes, etc. — is telemetry-enabled. Connected Care improves access to care by reducing travel time to see specialty providers and making it easier to provide follow-up care in a local setting. It serves rural populations in collaboration with local providers and remote specialists, including Critical Access Hospitals, Rural Health Clinics and larger hospital systems. 16 Propriety and Confidential. Do not distribute.
Thank You! 17 Propriety and Confidential. Do not distribute.