Managed Medicare & Assisted Living: The Evercare Experience

The number of assisted living facilities (ALFs) has increased dramatically over the past 20 years, with the number projected to reach 1.9 million by 2030.¹ The goal of assisted living is to support older individuals who are unable to live alone but do not need nursing home placement. However, there is an increasing recognition that some individuals residing in ALFs have significant health problems, disabilities, and functional impairments. For example, studies have compared residents who reside in ALFs to individuals living in nursing homes. In general, ALFs are serving older residents who require less nursing care and who are less functionally and cognitively impaired than nursing home residents.² While part of this may be attributed to admission criteria, those who leave an ALF do so because of the need for a higher level of care.³ Dementia and psychotic disorders are common but may not be recognized and treated.⁴

In terms of healthcare costs, ALF residents incur Medicare costs of approximately $4800 annually. However, similar to other Medicare populations, 15% of ALF residents account for 75% of total Medicare costs in the ALF populations.⁵ Recent trends suggest that both managed Medicare programs as well as state Medicaid agencies are interested in developing relationships with ALFs. Both programs see the opportunity for managed care to integrate long-term care (LTC) services for dual eligibles and other Medicare beneficiaries using ALFs as a resource for members in the need of a supportive living facility with services. This article presents the experience of one managed Medicare program in providing services for ALF residents.⁶

Evercare

In terms of background, Evercare is a managed Medicare program within the Ovations division of the UnitedHealth Group. The Evercare programs initially focused on nursing home care. Nurse practitioners (NPs) followed a caseload of 90-100 LTC residents each, providing frequent visits and identifying early changes in clinical conditions. As a result, acute illnesses were treated in the nursing home, reducing acute care hospitalizations by 40-50%.^7,8 Evercare also serves a growing community population. Its programs include:

▪ Long-term Medicaid and nursing home deferment program
▪ Integrated Medicare/State Medicaid demonstration programs
▪ Medicare Advantage (MA)

Special Needs Plans (SNPs) for members who are permanent nursing home residents, beneficiaries with Medicare and Medicaid, as well as Medicare beneficiaries with chronic illnesses, including end-stage renal disease Evercare’s clinical care model includes risk stratification, comprehensive assessment, and an interdisciplinary care plan that focuses on prevention, self-management, care coordination, and patient-centered care. Measured outcomes for these community programs have included a 20-30% reduction for dual eligibles and emergency room and hospital utilization, as well as LTC savings of $70 million in Harris County, Texas.⁹

Evercare programs now serve individuals living in ALFs in Minnesota, Arizona, and Florida. In Minnesota, Evercare provides services in both traditional MA programs and with dual-eligible individuals in the Minnesota Senior Health Options (MSHO) program. In the MA programs, members are followed by a NP/primary care physician (PCP) team, who provide on-site care. This care includes routine primary care, urgent visits, diagnostic lab and x-ray services, as well as specialty care services. Dual-eligible members receive telephonic case management and are followed primarily by their community PCP. Services made available include personalized emergency medication kits for the highest-risk members. Additionally, direct admissions to a skilled nursing facility unit on a continuing care retirement community campus are available in lieu of acute hospital care.

The hospital admission rate for members followed by the NP/PCP team is 65% lower than those cared for by the community PCP. This reduction is attributed to the provision of care on-site by the NP/PCP team. In Arizona, as many as 2500 individuals in the Arizona Long-Term Care System (ALTCS) live in ALFs or boarding homes. A pilot program in two ALFs provides an interdisciplinary team—PCP, NP, and RN care manager—on-site. The NP serves as a clinical consultant and coach for the clinical care manager. There has been a marked improvement in advanced care planning and family communications. Hospitalization rates have been reduced by 60-70% as compared to members residing in other ALFs. The experience in Florida has been different. Evercare’s two Medicaid programs provide coordinated care in three regions: Orlando, Tampa, and Miami, with 550 members residing in ALFs. However, few facilities have ten or more residents. While members receive care management and custodial services, no additional clinical support services are provided on-site. If needed, skilled clinical support services could be provided through the member’s Medicare program. Acute hospitalization rates remain high, although nursing home placement rates are low, with 70% of the members remaining in the community.¹⁰ Evercare’s experience represents some of the challenges that managed Medicare and SNPs may encounter when considering enrolling members who reside in ALFs. These include:

▪ Needing a significant number of enrollees in a facility for a program or provider to offer additional clinical support services on-site
▪ Providing effective care management for residents who are cared for by multiple providers within the community
▪ Staffing issues in the ALF, particularly shortages of clinical staff (RN, CNAs, LPNs); the absence of 24/7 coverage may limit the opportunity for clinical interventions, such as treatment of acute illness or acute exacerbations of chronic illness on-site
▪ Absence of PCPs to establish a clinical presence (ie, office on-site at the ALF)

Hoping to address these issues proactively, in 2005 Evercare joined forces with Erickson Retirement Communities and the Centers for Medicare and Medicaid Services to develop a continuing care retirement community-based demonstration program. The Erickson Retirement Communities system includes a closed medical staff model at each site, a medical center, on-site primary and specialty care physicians, mental health clinical specialists, case management, rehabilitation, home health, and supportive services. Under this strategic partnership, Evercare provides specific MA products including MA SNPs tailored to the needs of this frail population. The goals of the demonstration are to improve clinical outcomes and members’ quality of life, and reduce avoidable medical expenses. While the demonstration program is only in its second year, early data suggest that clinical outcomes may be improved when compared with traditional MA and fee-for-service programs. For example, hospital admission rates appear lower, and the average hospital length of stay is less than four days (M. Narett, oral communication, May 2008). This demonstration program should help identify opportunities to improve clinical quality outcomes within LTC settings. Areas of potential improvement include:

▪ Assessment and management of geriatric syndromes—dementia, depression, falls, incontinence—as well as chronic illness prevalent in the ALF setting¹
▪ Identification of members at highest risk for avoidable hospitalizations and providing proactive care management
▪ Assessment of members at risk for polypharmacy, on high-risk medications, as well as drug/disease interactions
▪ Fostering improved comprehensive and continuous advanced care planning
▪ Identification of the most appropriate clinical quality measure for an ALF population (such as the Assessing Care Of Vulnerable Elders [ACOVE] guidelines)¹¹

Summary

Medicare Advantage plans and SNPs need to work closely with ALFs, facilitating timely and appropriate medical care services, and enhancing the provision and quality of medical care. The result should be a LTC setting in which members reside in comfort, and in the least restrictive environment, with appropriate support of their mental and physical needs.

The author reports no relevant financial relationships.