Improving Care for Individuals in Nursing Homes

Ronald J. Shumacher, MD, FACP, CMD, chief medical officer for Optum Care Services, an integrated community-based care solution for high-risk, chronically ill and medically complex populations across multiple settings, discusses a recent study that looked specifically at inpatient utilization or hospitalization rates, transfers to the emergency department, and skilled nursing use patterns for long-term nursing home residents who were enrolled in a coordinated care program.

Podcast Transcript

My name is Ron Shumacher, and I'm a board-certified internal medicine physician. I serve as the chief medical officer for Optum Care Services.

We provide a number of unique, integrated community-based care models for adults, and particularly for seniors with multiple complex and/or chronic diseases, and typically a variety of special health or social needs.

One of our care models is the subject of a recent study in the American Journal of Managed Care, that was published on September 12 of this year. The study published in American Journal of Managed Care sought to evaluate clinical service use patterns for long-term nursing home residents, who are enrolled in a coordinated care program, such as the Optum clinical delivery model that overlays what's called the UnitedHealthcare Nursing Home Plan.

That happens to be a plan that is an institutional special needs plan (I-SNP). The importance of this study is that, while there's more than 60,000 members enrolled in the UnitedHealthcare Nursing Home Plan, there are others enrolled in institutional special needs plans around the country.

The members in the UHC Nursing Home Plan are receiving an extra layer of care that the Optum model provides to them. Despite all of those people in I-SNP programs, the vast majority of nursing home residents in this country actually don't have the access to this type of care coordination program.

The authors embarked on this observational analysis of institutional special needs plans, or we'll call them I-SNP members, compared to Medicare fee-for-service beneficiaries in nursing homes across the country.

They were looking specifically at inpatient utilization or hospitalization rates, transfers to the emergency department, and they were looking at skilled nursing use patterns.

By doing that, they were able to tell us a lot about the potential to shift the more traditional care paradigms that you see in the nursing homes, and potentially substitute more onsite care in the skilled nursing facility for, what have been in the past, the more costly inpatient episodes. More outpatient or onsite care in the SNF, as opposed to inpatient care, which is what you see a lot of today.

The major takeaway of the study is that there were significant differences in utilization between the study group that received the added support from the Optum care model and the traditional Medicare fee-for-service residents in nursing homes, that in the study were in the same geographic areas.

Even when there were adjustments made for demographics, those results held up. Specifically, there was 51% lower emergency department use, there were 38% fewer hospitalizations, there were 45% fewer readmissions to acute care from the SNF, and the rate of skilled nursing use was actually 112% higher.

I think these findings are critically important for health care professionals, and I think particularly for those who have an interest in care and in health outcomes in the nursing home setting. The Optum care model very clearly is able to augment and enhance the very thinly stretched clinical resources that typically exist in most nursing homes.

The reductions in avoidable hospitalizations and readmissions that we spoke of, really, I think reflect improved quality of care and high satisfaction levels that come with a program that respects every individual's goals and wishes.

There's recent evidence from MedPac, that reports the rate of avoidable hospitalizations and readmissions in nursing homes is dropping, over the past five to seven years. Most stakeholders and most observers in the industry still feel that the rate is too high and that there are huge opportunities still in decreasing the number of avoidable hospitalizations that occur from that setting.

In the AJMC study, the authors actually postulated that, if Medicare fee-for-service beneficiaries exhibited the same utilization patterns that they saw in the I-SNP study group, there would be over a billion dollars in savings for Medicare.

I think that health care professionals and nursing home operators can take this information, and they should be able to put it directly into practice. Nursing homes have lots of options today to adopt onsite care models.

With the growth and the visibility of institutional special needs plans like the United Plan with the Optum overlay, that's very clearly an option, too, for a nursing home to participate in an I-SNP network, or to become part of an I-SNP.

The UnitedHealthcare offering is one potential proven successful approach, that can rebalance the care, as I spoke of earlier, by substituting more on-site care for those costly hospitalizations. Also, I think models like this provide a lot of valuable information for CMS and for policymakers, around the impact of valued-based care models.

My prediction is that we'll continue to see efforts to shift care at a lower cost setting. We're seeing that throughout the health care continuum. Nursing home care models like the Optum model are able to achieve exactly that.

I think it's likely that we'll see more nursing homes implementing similar at-risk models, and investing significantly, and trying to optimize care and outcomes in the SNF. I would anticipate hospitalization trends in long-term care residents, will most likely continue to decline over time as a result of that.

I think that if you look at some of the key components of the Optum care model that are described in the study, these things together help to drive positive results…things like the waiver of the three-day stay requirement to access skilled Medicare benefits, the collaboration — very significant collaboration — between primary care physicians in the SNFs and the SNF operators themselves, and the very model-specific training that's done, training and education that's provided to the clinical staff.

I think those things are going to start to become more of the norm in caring for individuals in nursing homes. That, again, will lead to further reductions in avoidable hospitalizations over time.