Patients living in skilled nursing facilities (SNFs) are a small subset of Medicare beneficiaries. But these clinically complex individuals generate nearly two times the average medical expense for all Medicare members, according to The Henry J. Kaiser Family Foundation. By promoting more intense attention to this institutional population, health plans can drive better care and outcomes, as well as reduce costs. The Optum® CarePlus Institutional program allows health plans to identify and close gaps in care, which in turn helps prevent many costly and unnecessary hospitalizations and ER visits.
Permanently institutionalized Medicare beneficiaries tend to be older and more physically and mentally fragile than their counterparts residing in the community. They frequently have eight or more chronic conditions. The average age of CarePlus enrollees is 84 years old, with 75 percent being female and 64 percent with some degree of dementia.
CarePlus advanced practice clinicians have relatively small caseloads, which enables them to capably manage all enrolled members in each nursing facility. They are able to identify early signs and symptoms of a significant change in condition. As a result, they can coordinate customized care plans to address the root cause.
For example, a CarePlus advanced practice clinician might be helping to care for a patient with severe cognitive impairment who develops difficulty swallowing, a common end-stage symptom of many dementias. This condition can lead to diminished appetite (and weight loss) as well as aspiration of food, drink or saliva, which can cause acute onset of fever, coughing and shortness of breath, and often results in the patient being transferred to the hospital.
CarePlus advanced practice clinicians are trained to anticipate complications such as aspiration pneumonia in this scenario and to build out a care plan with the patient, family, SNF staff and the attending physician. The care plan likely would include early advance care planning and interventions consistent with previously stated goals of care to focus on maintaining comfort in the SNF, which could include administering fluids, antibiotics, and extra visits from the nurse practitioner and the facility staff, ultimately leading to higher quality of care, enhanced coordination and a better outcome.
A successful case study
An East Coast health plan seeing an uptick in its Medicare spending partnered with Optum to conduct a detailed claims analysis and identify opportunities to improve care outcomes, improve satisfaction and reduce unnecessary medical expense. Optum pointed to the fragmented and inefficient care system and uncontrolled medical expense attributed to the plan’s institutional population. Through the CarePlus Institutional program, nurse practitioners took a holistic and patient-focused approach, working with patients’ families, caregivers and facilities. They made sure required tests were performed, wrote prescriptions as needed, reconciled medications and managed conditions effectively. They emphasized advance care planning and a patient-centered, goals-of-care approach. They encouraged nursing facility staff to function optimally, providing care and services in the right place at the right time.
The health plan began to see changes immediately, as demonstrated by:
- 74 percent reduction in hospital admissions over six consecutive months
- 90 percent reduction in skilled nursing days over six consecutive months
- Approximately $619,000 in savings between July 2015 and February 2016, with an ROI of 2.8:12
SNF staffers were extremely receptive to the presence of the Optum CarePlus advanced practice clinicians and the helpful coordination of member care they fostered in the facilities.
Learn more at CarePlus, where you can also download our case study “Better management of SNF population yields positive clinical and financial results.”
1. The Henry J. Kaiser Family Foundation. An overview of Medicare. kff.org/medicare/issue-brief/an-overview-of-medicare/. April 1, 2016.
2. Based on Optum’s experience.