Medical Homes: Nursing Homes

Medical Homes: Nursing Homes

October 24, 2011, 4-5.30 pm

On the call: Denise Levis Hewson, Randall Best, Polly Welsh, Kim Sturkey, Chris Hermann, Gayla Woody

Introductions, Background and Context to the Grant

This is the Dual Eligible Planning Grant, from Centers for Medicare and Medicaid Services (CMS) with 12 months to develop asintegrated model of delivery for dual eligibles and implementation plan. The grant encompasses primary, acute, and behavioral health care, as well as long term servicesand supports; covering program, policy and payment and deliverables are expected to be developed for submission to CMS in April of 2012. The populations include all dual eligible beneficiaries, adults with intellectual and developmental disabilities, mental health conditions, physical disabilities and older adults.

This is a subgroup of a larger work group- Medical/Health Homes and Population Management. There are three other sub groups to this work group- Need Determination, Palliative Care and Adult Care Homes. The other large work groups are focusing on Long Term Services and Supports, Behavioral Health Integration and Transitions.

The subject of this group is of interest to other work groups who are meeting already. We are trying to focus people on this group on specific topics, these include-

a)How do you bring a medical home to nursing home residents? With one of the goals being to improve the quality and continuity of care and avoid unnecessary hospital stays and Emergency Department (ED) visits

b)Palliative care- importance across all the work groups and especially nursing homes.

c)How do you encourage flow of information, data across settings, providers?

d)Embedding Nurse Practitioners in Nursing homes

e)Discharges to Nursing Homes at End of Life- part A vs. Hospice

What are the needs and the solutions? How do you identify the universal elements that have to be in place, given the differences between rural /urban/ different groups of duals, different providers’ capacity?

For example, if we are talking about putting someone in a nursing home to achieve a medical home, palliative care is an important component, particularly on the question of when to seek hospital admission and when to avoid hospitalization. We are talking about conversations we need to have with family, about the negative side of going to the hospital. This is a discussion with residents’ and family members that needs to happen very early in the admission process.

By the time they come to nursing home everyone has been traumatized- everything cannot be done on the same day. On admission for every dual, have questions about advanced directives. This is a topic best addressed before they even get to the nursing home. When someone is in a nursing home it may be already too late.

You need strong medical leadership- clinical director, so they continue to make that conversation happen.

Chris Hermann:Background on physician practice where, all we do is nursing home support. Have 4500 patients another similar group cares for 6000 residents- managing care in the facilities rather than in an outpatient setting.

Early discussion of advanced directives is important; sometimes discussion is begun and there is no decision, then 6-8 months an event happens and then the conversation is picked up, i.e., a more dynamic approach to the management of these patients.Having clinicians, NPs present in the building. For example, in special needs plan with 300 patients or so found need was for more than half a day a week, rather need PA or NP on-site in the facility 2-3 or even 5 times per week. We have reduced hospital admissions by half and even mortality rate by about 40% less. The presence of clinicians in the building is a key. Physician leadership is key. Having a commitment from the nursing home itself is essential. Improvement has to include the nursing home itself. There is a potential that more work and expense are shifted to the nursing home. The nursing home has to say that we will do the IV here or the mobile x-rays there itself rather than sending them to the ED.
Talking to the family about the pros and cons of keeping the patient in the nursing home itself. If you have administration committed but nurse staff ignore that the fact you cannot control hospital use. The nursing home is the key component to decrease the avoidable hospital utilization.
In NC most often in our practice we offer primary care services to residents.
Many medical practices are willing to give up the management of nursing home residents.
We have 4-5 facilities where we serve about 10% of the patients. At others we cover all patients.
We are the Medical Directors for several facilities. We help these facilities strategize how to handle a variety of issues.
Statewide these types of practices only cover only 20% of nursing home residents.

Polly Welch – Background Role of a NP in the building as an employee of the facility may be another helpful approach.

Dedicated Med Director, - saved money, reduced hospital visits, and decreased Medicaid days- CCNC pilot.
Currently have a nursing home seeing if they can employ a physician-
When residents are send back to hospitals it’s mostly about liability.
Who employs the nurse practitioner? Should the NP be an employee of the physician- in terms of reporting requirements?
We envision NP role that supports the nursing staff and helps develop the knowledge base. NP mentors the nurses and makes them better communicators. It does not make any difference which entity employs the NP. The embedded NP will work great if it is a facility which is operating at a high level of quality- if a site has low quality and operating with low qualified professionals then it’s not going to make a difference.
How do you incentivize a facility to improve the quality- ? Motivation will come from non payment for conditions acquired after admission to facilities. Nursing homes are next in line for non-payment by Medicare – Requirement from Affordable Care Act-
Like reductions being implemented in hospitals e.g. no payment for readmissions within 30 days for conditions like hospital-acquired diseases.
In facilities below the margin, experience is that if there is a facility in duress- culturally known to have a bad ways- than the only way to come out of that is to have a strong administrative team and change the culture, takes more than medical professionals. Strong medical component can be helpful but we may need to earmark those facilities with large numbers of dual eligible residents.
If we are talking about medical homes for nursing facilities there should be a PMPM that goes with that facility-based medical support.

Who should get the PMPM? - The physician, there needs to be something for the nursing homes as well –.Challenge is how to arrange for facilities with multiple physicians - group buy in

What are the elements that go with that PMPM?Documentation of advanced directives, DNR (currently only 50 % of residents in specialized practice group have DNR).Is there a mechanism to refer to social services or something else to open up the conversation- training sessions, open communication, what language to use etc? Social workers help with conversation in some facilities – and help set up discussion to fill out the MOST form. It’s going to take a different kind of Social worker who is able to do this. Social workers are important;

Nursing supervisors and care managers are very important and capable of having this conversation. Western part of the State has been successful in implementing the MOST form- although at least half of the time the event happens and the family changes their mind.
Another incentive to reduce ED visits- nursing home nurses do not like residents going to the ER - too often bad things start to happen- skin breakdown, another pill gets added on, dehydration. It’s a great incentive for them not to go unless when they really have to go.
Assign a payment code that goes into the physicians’ check- for having the MOST form filled out- and to have the documentation.

** If folks could think of and send to us what are the minimum items to have in place for designation as a medical home – and for PMPM payment to occur that would be helpful. What are the best practices for a nursing home medical home? It can be compiled and send back out, what needs to be in place to get a medical home payment.

Quality: Evidence based metrics that need to be in place- say, or care of residents with memory loss. What needs to be in place to support a person with memory loss in a nursing home?Other examples are the % of patients discharged from the facility to a lower level of care, patients readmitted; did it occur within 30 days of the previous admission?

Each nursing home has a finger print. Very high on hospitals or very high on everyone goes home.
Are there any quality indicators (QIs)from the Minimum Data Set (MDS) that could help? Problem with those is you can control the quality measures if you can control whom you admit. Use some consistent measures.
One strong indicator is s patient and family satisfaction- that is quality. Especially high ratings often are associated with the natural end of life progression.
Other indicators might include length of stay and discharge to the community; every patient is different from the next one. Are there any system level indicators? For example for the primary care medical home one indicator is if a referral is made the PC has to get the information back from the referral.

** What are the things that make a difference and make them our quality metrics for making a medical home in a nursing home?

If leadership style is key, then what is being done that could be an expectation for every facility that is a medical home? A satisfaction assessment for its employees and its patients – the fact that it is being done in itself may be a quality measure.

The Quality First Initiative? This is embedded or is similar to the work on Quality Assurance and Performance Improvement (QAPI).

May be ideas from tools developed as INERTACT II ( from Emory)

If folks can think about the issues discussed and get back to us or if there are other issues

Next meeting date for this group: Nov 14th at 4 pm- A meeting notice will be send out along with a call in number closer to the date.