Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Care for Custodial-Level Nursing Home Patients


For custodial-level nursing home patients who are health plan members, the plan is not liable for routine nursing home charges. Rather, these are typically paid by the patient or Medicaid. However, the health plan is responsible for the full range of Medicare benefits, including hospital care; physician services; durable medical equipment; and speech, physical, and occupational therapy. Also, the enrollee, not the health plan, selects the nursing home. As a result, the residents are distributed throughout the service area, which poses a challenge to the health plan in the delivery of services. For example, Kaiser Colorado has 500 enrollees spread over 35 nursing homes, and Aspen served 1,600 patients in 72 facilities.

Kaiser Colorado, Keystone East, and Aspen have made a special effort to provide primary care to long-term (custodial) nursing home patients. At Kaiser Colorado, the five physicians who serve patients at subacute or skilled nursing facility levels of care also have responsibility for the care of custodial-level nursing home patients. A physician or nurse practitioner routinely visits each patient roughly once every six weeks. This level of interaction is greater than typically provided under the Medicare fee-for-service rules which require a minimum of a physician visit every three months. Also, the physicians telephone family members of nursing facility patients, whether at skilled or custodial levels of care, to make themselves available. Typically, more time is spent with families of subacute/skilled patients than with custodial patients.

Keystone East has identified primary care physicians who have a special interest in monitoring and treating long-term nursing facility patients. The plan encourages its members who reside in nursing homes to enlist on the panel of one of these physicians. The physician receives a capitation payment of $40 a month, higher than the $24 paid on average for Medicare beneficiaries in the community (an amount that varies, based on enrollee age and sex). The $40 amount is intended to approximate the fee-for-service payment for a monthly visit, a level of frequency that Medicare carriers would often question in the standard Medicare program. These physicians are required to visit the patient at least monthly but may use nurse practitioners to perform some of the visits. A physician who manages the care of patients admitted to a hospital or skilled nursing facility receives an additional payment of $350 per admission.

Aspen uses the Evercare program to manage care for about 800 custodial-level patients. It receives a capitation payment for these seniors and is responsible for their medical care. Aspen’s program relies heavily on nurse practitioners who focus on treating facility-resident seniors. When they enter the program, patients receive a thorough assessment of their medical, functional, and mental status. The nurse practitioner also meets with the family to discuss what the family should expect as the patient ages. After the initial evaluation, the nurse practitioners see patients routinely, with the supervising physician accompanying the nurse practitioner on the visits once every four months. The nurse practitioners visit each nursing home at least weekly and are on call 24 hours a day. They also attend care conferences held by nursing home staff each quarter. Aspen administrators felt that this process produced a close relationship between the nurse practitioners and the nursing home staff and helped to promote the health of the participating seniors.

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