Potential hospital patients get care in familiar place

‘Program is much more flexible than Medicare’

Avoiding a two-week acute care hospital stay and, instead, spending only 48 hours in the hospital followed by subacute rehab care for two surgeries is now possible. In fact, that’s just one example of how a resident of the Hebrew Home of Greater Washington is benefiting from a new program designed to avoid unnecessary hospitalizations.

And most residents of the 558-bed skilled nursing facility (SNF) in Rockville, MD, are sold on the program. More than 300 residents joined the program called EverCare when it was offered in October. EverCare is for long-term care Medicare patients and is sponsored by Blue Bell, PA-based United HealthCare Corp. EverCare received funding for the demonstration project through the Health Care Financing Administration (HCFA) in Baltimore three years ago after its initial success in Minneapolis.

Although Hebrew Home already had existing specialty subacute programs such as wound care and rehabilitation, the program now allows the facility to readmit these patients sooner, says Sandi DuPaul, director of admissions. DuPaul also served as chairperson of the facility’s EverCare implementation task force.

"What we’re doing might be atypical for some nursing homes, but we were providing these subacute services already, and that’s why we were a good fit for the EverCare program," explains DuPaul.

Enrollment in EverCare is voluntary and designed for patients who choose to make the Hebrew Home their residence. Long-term residents then receive as much care as possible within the nursing home setting, including subacute services following surgery. "It’s not for a short-stay rehabilitation patient," adds Marilyn Feldman, director of public relations for the facility.

Enrollees have no deductibles, copayments, or premiums in the program. Unlike Medicare’s reimbursement rate of 80% of the cost of services, EverCare offers 100% reimbursement for services. The required three-day hospital stay for Medicare patients also is eliminated in the program, notes Feldman.

Subacute stay in SNF is name of game

EverCare’s primary goal is to prevent unnecessary hospitalizations that cause patients to temporarily leave their familiar surroundings in an SNF environment. But when patients require hospitalizations, they can return to the SNF for subacute services sooner, says Judith W. Ryan, PhD, CRNP, clinical director for EverCare’s Maryland division.

"The project is demonstrating that subacute services typically provided in the hospital can now be provided in the nursing home. The goal is to better manage the episode of illness and have the patients stay in their own rooms. The technology, equipment, and expertise is now available in the nursing home," she adds.

For most frail elderly patients, hospitalizations are the result of an acute episode of a chronic condition, says Marcia Tinsley, business development manager at EverCare’s Maryland office.

Going to the hospital is disorienting, and patients often come back in worse shape physically and are vulnerable to falls and bone breaks during their subacute rehabilitation period, notes Feldman.

"The EverCare point of view is to provide care in the nursing home instead of the hospital. The decubitus patient who avoided the two-week hospital stay was able to stay at our facility [after being discharged 48 hours after surgery] because EverCare arranged for a special bed to be brought to the facility," explains Feldman.

"EverCare did everything," adds DuPaul. The nurse practitioner coordinated with the hospital for the patient’s discharge, communicated with the physician, and provided additional wound care training to the staff RNs, she notes.

"The program is much more flexible than Medicare. There is a different method of cost reporting where Medicare doesn’t seem to be set up as effectively," explains DuPaul.

Nurse practitioners as case managers

Both preventive and subacute care for EverCare patients are provided at the Hebrew Home by three nurse practitioners working full time at the facility.

Employed by EverCare, the nurse practitioners work alongside the medical and nursing staff of the Hebrew Home and serve as cross-continuum case managers for the patients. "Typically, a Medicare resident with pneumonia would go to the hospital for five days and return to the facility. With EverCare, the nurse practitioner administers the IV here and coordinates the care with the physician, and Hebrew Home gets a reimbursement rate for the skilled services provided," explains DuPaul.

"The nurse practitioners manage the patient’s care and provide communication to patients and family members for the physician. They visit the patient at least once a month and report any signs or symptoms to the patient’s physician," explains Tinsley.

The most important requirement for the EverCare program’s success is that it be a partnership between the nurse practitioner and the nursing home staff, stresses Tinsley. "It needs to be a working relationship among the nurse practitioners, medical staff, nursing staff, and nursing home administration," she adds.

Although staff nurses still provide patient care, the nurse practitioner is available for consultation on high-tech care patients, especially during the subacute phase following surgery, notes Ryan. For example, the nurse practitioners provided inservice sessions for staff on wound care when the decubitus patient came back from the hospital, recalls DuPaul. "The staff nurses like having the additional nurse consultation available," she adds.

Nurse practitioners are assigned to about 100 patients as a general rule. "We’ve found that 100 patients is about as high as a provider can go," adds Tinsley. After enrolling, patients undergo baseline evaluations of their general health status. A plan of care is developed in conjunction with a patient’s physician, the nursing home medical director, and nursing home nursing staff.

The nurse practitioners are considered part of the care team and write progress notes and document in the patient’s medical record, says Tinsley.

Another benefit provided by EverCare is patient and family education. The nurse practitioner consults with patients and family members individually to discuss the patient’s disease and possible changes in diet and activities, says Tinsley.

The EverCare program benefits the nursing home in administrative resources as well. "Since the nurse practitioner is at the facility full time, she can conduct staff inservice sessions and community outreach programs. The nurse practitioners also work with the hospital discharge planner when patients do require hospitalization," says Tinsley.