Geriatric care approaches in health maintenance organizations

What Do We Know About Nurse Practitioner/Physician Care Models in Long-Term Care: Results of a Scoping Review

OBJECTIVES

Due to the rise of the nurse practitioner (NP) role in long-term care settings, it is important to understand the underlying structures and processes that influence NP and physician care models. This scoping review aims to answer the question, "What are the structures, processes, and outcomes of care models involving NPs and physicians in long-term care (LTC) homes?" A secondary aim was to describe the structural enablers and barriers across care models.

RESEARCH DESIGN AND METHODS

Seven databases were searched. Studies that described NPs and physicians working in LTC were identified and included in the review. We stratified the findings by care model and synthesized using the Donabedian model, which evaluates health care quality based on 3 dimensions: structure, process, and outcome. We then categorized macro, meso, and micro structural enablers and barriers.

RESULTS

Sixty papers were included in the review. The main structural influencers within 5 care models included policies on scope of practice, clarity of role description, and workload. A limited number of papers referred to the process of enabling the development of a working relationship. Thirty-five (49%) studies described resident, staff, and health system outcomes.

CONCLUSIONS AND IMPLICATIONS

Although structural characteristics of NP and physician care models are described in-depth, there is less detail on the processes that occur within the NP and physician care models. We highlight structural barriers and enablers within the care models, allowing for recognition of the importance of organizational influence on the NP and physician relationship. Future work should focus on the processes of the relationships in the models by identifying the drivers and initiators of collaboration between NPs and physicians and how these relationships influence outcomes.

Interdisciplinary collaboration in gerontology and geriatrics in Latin America: conceptual approaches and health care teams

The underlying rationale to support interdisciplinary collaboration in geriatrics and gerontology is based on the complexity of elderly care. The most important characteristic about interdisciplinary health care teams for older people in Latin America is their subjective-basis framework. In other regions, teams are organized according to a theoretical knowledge basis with well-justified priorities, functions, and long-term goals, in Latin America teams are arranged according to subjective interests on solving their problems. Three distinct approaches of interdisciplinary collaboration in gerontology are proposed. The first approach is grounded in the scientific rationalism of European origin. Denominated "logical-rational approach," its core is to identify the significance of knowledge. The second approach is grounded in pragmatism and is more associated with a North American tradition. The core of this approach consists in enhancing the skills and competences of each participant; denominated "logical-instrumental approach." The third approach denominated "logical-subjective approach" has a Latin America origin. Its core consists in taking into account the internal and emotional dimensions of the team. These conceptual frameworks based in geographical contexts will permit establishing the differences and shared characteristics of interdisciplinary collaboration in geriatrics and gerontology to look for operational answers to solve the "complex problems" of older adults.

Outcomes of preventive case management among high-risk elderly in three medical groups: a randomized clinical trial

Preventive case management was implemented by Sharp Healthcare of San Diego with the intention of complementing primary care for geriatric patients enrolled in PacifiCare's Secure Horizons Medicare plan. This article presents patient outcomes after 12 months of participation. The program featured an annual screening questionnaire, appointment monitoring, disease education, and self-management support. It used a prospective design, tracking randomly assigned treatment (n= 1,537) and control patient samples (n = 1,542) for 12 months. Outcomes included physical and mental health status; hospital, ER, and nursing home use; hospital days and expenditures among persons having an inpatient stay; and primary care physician visits. Utilization data were obtained from Sharp Healthcare systems and from screening questionnaires. No statistically significant main effects were found, but persons with three or more independent activity of daily living limitations were about half as likely to have a nursing home admission if they were in case management rather than in the control group.

Kaiser Permanente's Manifesto 2005 Demonstration

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on "unprofitable" populations, for example, those who are chronically ill, poor, and/or disabled.

Outcome and utilization differences for older persons with stroke in HMO and fee-for-service systems

OBJECTIVES

To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems.

DESIGN

Inception cohort stratified by payer and followed for 1 year.

SETTING

Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States.

PARTICIPANTS

A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995.

MEASUREMENTS

Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits.

RESULTS

At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5).

CONCLUSION

Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.

Managed-care research, Part 2: Researching the domain

A review of research pertaining to managed care suggests that little information is known about the impact of the components of managed care on care delivery outcomes. Characteristics of managed-care systems rarely are considered, resulting in uncertainty and confusion about which of the domain components of managed care have contributed to the outcomes seen. In part 1 (JONA November 1999) of this two-part series, we described how the shift to managed care has affected healthcare organizations and healthcare providers. We also identified several research questions relevant to the five domain components of managed care. In this article, we review the research literature concerning managed care and identify where research deficiencies exist within the domain.

The role of the geriatrician in managed care: opportunities and responsibilities

Managed care offers unique opportunities to the geriatrician. Geriatricians in managed care can facilitate the provision of high quality comprehensive care for older populations and do so within reasonable financial limits. With the financial incentives of Medicare Risk contracts, the geriatrician can ensure that care is not rationed inappropriately, nor is it overutilized. As pointed out by Boult in the article on systems of care for older populations, there are several creative possibilities for programs and clinical approaches that can take advantage of the systems in place in managed care. Managed care needs to emphasize integration of multiple programs that focus on the care of the chronically ill older adult and, at the same time, prevent the fragmentation of care that so often occurs in care delivery. With so many organizations merging and the level of complexity of healthcare systems becoming increasingly complex, programs directed specifically toward the older adult must be developed and maintained. Geriatricians must be in leadership positions to ensure this happens successfully. Possible roles for the geriatrician to undertake within a managed care organization and their potential time commitment are shown in Table 1. The assumption is that in most cases each position would not be full time and that the term half-day is defined as 3 to 4 hours in a week that is made up of 10 half-days.

Applying managed care techniques in traditional Medicare

Medicare has lagged behind the private sector in its reliance on managed care, which, properly done, has the potential to restrain budget growth and enhance quality. This paper addresses how the Medicare fee-for-service program--traditional Medicare--might apply managed care techniques. It first discusses the institutional constraints Medicare faces in implementing managed care techniques and then presents options for applying these techniques. I propose elements of an overall strategy to incorporate managed care in the fee-for-service program.

Is managed care good or bad for geriatric medicine?

This article uses clinical vignettes to examine the simultaneous dangers and opportunities that managed care brings to geriatric medicine. While the complex multifactorial syndromes prevalent in older adults might at first glance seem poorly handled under capitation, we argue that the incentives provided under existing delivery systems can be equally perverse. These improper incentives have arisen from (1) the fee-for-service payment mechanism itself, which has spawned a subspecialty culture ill-equipped to deal with the primary care needs of older adults and (2) the fragmentation of funding sources for geriatric care into two major payers (Medicare and Medicaid), encouraging providers to focus on cost shifting rather than the logical integration of services. The result has been a delivery system that provides little impetus to maximize functional status, the central goal of modern geriatric medicine. Because physicians may assume financial risk under global capitation, and because the cost of caring for a frail older adult is inversely related to functional status, managed care offers the potential to align the goals of cost containment with the goals of modern geriatric medicine. Physicians should have a substantive voice in the design and implementation of these systems.

Resident selection in a Connecticut nursing home. A view from within

Using data from a year of participant observation, this study provides a detailed description of resident selection procedures in a for-profit Connecticut skilled nursing facility. A system of multiple payers for nursing home services created a hierarchy of admission preferences that privileged those who could pay and denied access to the least profitable and the sickest individuals. Prescreening and waiting list juggling were strategies employed by the home to maximize the selection of private-paying residents and residents requiring the least care.

Rationale and design of a multi-center randomized trial of comprehensive geriatric assessment consultation for hospitalized patients in an HMO

OBJECTIVE

To describe the evaluation of an interdisciplinary comprehensive geriatric assessment (CGA) consultation program for targeted hospitalized patients.

DESIGN

Multi-center randomized clinical trial (RCT) at four hospitals where patients were randomly assigned to CGA consultation or usual care by the attending physician, and a non-equivalent control group (NCG) at two hospitals.

SETTING

Six hospitals in a multi-specialty group practice model health maintenance organization (HMO).

PARTICIPANTS

3593 patients age 65 years or older meeting at least one of 13 inclusionary criteria at admission.

INTERVENTION

Screening by hospital staff and standardized CGA consultation conducted by a nurse practitioner, social worker, and geriatrician at the four RCT hospitals.

MAIN OUTCOME MEASURES

Functional and health status, mortality, rehospitalization, and cost-effectiveness of the CGA program at 1 year post-randomization; validation of targeting (inclusionary) criteria that identify subgroups of patients deriving benefit from CGA; and physician contamination (learning from CGA and changing treatment provided to control patients).

CONCLUSIONS

A number of methodological issues need to be considered when conducting effectiveness trials of CGA. The concurrent design of a multi-center RCT, coupled with the NCG to determine physician contamination, is an innovative approach intended to determine more precisely the cost-effectiveness of CGA for frail hospitalized elderly persons. The large and heterogeneous patient population and the broad array of inclusionary criteria will permit the evaluation of the benefit of CGA for subgroups. All these features are intended to enhance the generalizability of study results.

Integrating acute and long-term care

Advocates of health system reform are striving to assure that a valuable new benefit for home- and community-based long-term care is included. Yet in many legislative proposals, a long-term care benefit is kept separate from the rest of the benefit package. Experience from the social health maintenance organization (social HMO) demonstration shows that for the elderly at least, community long-term care can be integrated with acute care, at a manageable cost. Acute and chronic disease and disability are experienced concurrently. Moreover, disability is not confined to a small group of permanently disabled persons but affects many other persons for short periods. Integration of long-term and acute care in a managed care model serving a broad population may promote more effective acute care and more efficient and affordable long-term care.

Projecting the need for physicians to care for older persons: effects of changes in demography, utilization patterns, and physician productivity

OBJECTIVE

To determine the influence of differing assumptions of population growth, visit rates, prevalence of functional impairment, physician productivity, and hospitalization rates on projected need for physicians to provide medical care for older persons.

DESIGN

Sensitivity analysis of a manpower model.

MAIN RESULTS

The factors that appear to have the most impact on projections of physician need are related to physician productivity, especially delegation to mid-level providers, and case-mix. Other factors, such as the variability of census projections and per capita visit rates, are likely to have less effect on overall physician supply needs.

CONCLUSIONS

Although case mix and delegation to mid-level providers may both substantially affect the need for physician supply to care for older persons, only the latter can be directly affected by health policy decisions. Consideration should be given to increasing the supply of mid-level providers and providing incentives for patients and physicians to receive and provide care in delivery systems that utilize mid-level providers extensively.