Specialty practices are the hidden treasures of managed care

Accessibility gives provider secret managed care weapon

Don’t fret if your Medicare patient population becomes a Medicare managed care population overnight and the managed care company invades familiar territory. What many subacute providers perceive as a potential battle over patient control from the managed care company is not even a scrimmage, says one California subacute facility.

A managed care organization (MCO) met with Park Tustin Rehabilitation Center in Santa Ana six months ago to inform them that the MCO’s Medicare managed care patients would be cared for by a specialty physician practice group. But unlike similar programs in which care is contracted to group practices, this practice would send its staff to the facility more frequently. The advantages of the agreement, however, far outweigh the concerns over who’s caring for the patient, says Maryanne Leupold, RN, CCM, case manager at the 99-bed facility, which is part of Regency Health Services.

Park Tustin’s 20-bed skilled nursing unit has more than half of its patients enrolled in the Medicare managed care program, estimates Leupold. The specialty physician care is provided through Costa Mesa-based GeriNet Medical Group, which got its start as a group of specialists within the MCO seven years ago. The practice offers integrated care and specialty services, including wound care, orthopedic services, podiatry, and psychiatric services.

"Working with GeriNet has been nothing but a positive experience for the staff, patients, and myself," says Leupold. The biggest benefit for Park Tustin is the accessibility of the GeriNet staff, she adds. "The GeriNet physician conducts patient rounds more frequently than necessary and is available to talk with patients and families to discuss outcomes and treatment plans."

Physicians are managed care veterans

Second, having a specialty physician in the facility on average four days a week helps the facility work in the confines of managed care, adds Leupold. "The physicians go to bat for a patient if there’s a question of whether the MCO will authorize additional therapy, for example."

"The physicians gained a level of expertise by working in a 99-bed skilled nursing facility [SNF] that was staffed like an acute hospital before creating the specialty practice," says Kim Phan, MBA, vice president of operations for GeriNet Health Services, the management unit that handles administrative and nursing functions for the physicians.

In addition to the availability of staff, GeriNet collects extensive outcomes data that substantiate the level of care provided for many of the chronically ill patients, notes Phan. "We track calls to 911, emergency department visits, and hospital admissions. Most MCOs don’t track custodial patients to the same degree," she adds.

Outcomes data are collected and tracked on GeriNet’s in-house information system. GeriNet collects outcomes data in the following categories:

• acute care length of stay;

• subacute length of stay;

• level of care management;

• cost savings;

• patient satisfaction.

Founded in April 1996, GeriNet did not enroll its first patient until nine months ago. Finding and enrolling patients, however, has not been a problem for the group. GeriNet, for example, contracts with 20 SNFs with subacute units and eight hospital-based transitional care units.

"About 40% of our patients are rehab patients, but the remainder are typical med/surg patients who require IV medications or transfusions," explains Phan. Approximately 75% of GeriNet’s patients are from managed care contracts, and "we’re steadily seeing more Medicare patients," she adds.

Although GeriNet’s services are provided to Medicare patients currently, the same services and care could easily be provided to all subacute patients, says Elise Pirkel, LPN, admissions case manager at Park Anaheim Skilled Nursing in Anaheim, CA.

"Partnering with GeriNet has helped us become more managed care savvy. Their staff helps us determine when a patient should be transferred to acute care and when they can return. This program is the forerunner of what care delivery will be like. I think a change will occur in the overall care provided in the skilled nursing and subacute facilities over the next couple of years," predicts Pirkel.

Harbinger of the future

Providing medical and surgical services within the long-term care setting will become more commonplace as managed care incorporates more long-term care providers into an integrated network, notes Phan. "The future of health care is moving toward empowering the patient. Acute care in the future will be the equivalent of today’s intensive care unit. Everything else will be provided in the nursing home."

Goal is 15-minute response time

GeriNet’s staff consists of four physicians, three nurse practitioners, and one part-time physician assistant. The staff is divided into three medical teams covering geographic regions of southern California. In addition, eight physicians are employed by the group as subcontract employees, says Phan.

While staff are not based within a health care facility, the goal is to respond to a provider or patient’s call within 15 minutes, says Phan. GeriNet’s medical and nursing staff instead work from their homes and have "virtual offices," notes Phan. (To find out about how GeriNet got started, see the related story, above.)

Patient referrals come from a variety of sources, including acute care case managers, long-term care nursing directors, and HMO case managers. "Some family members in the nursing homes we serve see our staff and find out how to obtain our services for their family member," adds Phan.

Phan sees patient and family education as one of the biggest benefits for patients so far. "We can spend more time with the patients than their regular primary care physician or, in some cases, the facility’s nursing staff. In cases where the patient has a chronic condition, they benefit from the increased communication and the services provided by our case manager," adds Phan.

And facilities with GeriNet patients benefit as well, Phan adds. "Our nurse practitioners are working with the nursing home nursing staff to enhance their skills. It’s important to have the right nurse assess a patient. That’s where we can help the director of nursing find the right staff by being partners," she says.

Inservice training helpful

Nursing staff at Park Tustin, for example, have benefited from inservice training on blood levels and understanding the signs and symptoms of diseases affecting elderly patients, says Leupold.

There was a certain level of animosity from patients’ primary care physicians initially, but now the physicians see the benefit of working with GeriNet, says Phan. "Many of these patients’ physicians were untouched by managed care, and as more of their patients enroll in Medicare managed care plans, the physicians realized that they needed to comply with managed care policies," she explains.