In the overall structure of the MCOs we studied, one of the benefits that is germane to the care of patients with hip fractures and strokes was that all the MCOs paid specific attention to evaluating the quality of care delivered in skilled nursing facilities. This is often overlooked as a beneficial aspect to the imposition of a formal, coordinating structure to the care of high-risk senior beneficiaries in the Medicare program, and is especially vital to the transitional care needs of patients with hip fractures and strokes. For both these conditions, there is a critical juncture following the evaluative and interventional phase of acute care, marked by a transition to a rehabilitative setting. In conventional Medicare, the transfer to rehabilitative settings can be poorly coordinated (Rosenberg and Popelka 2000), and the choice of facility is often left to the physician and family, although a caseworker may assist in the informed choice. In contrast, the case study MCOs established specific quality criteria for the skilled nursing homes in their network. This attention to quality was particularly important because the MCOs relied heavily on skilled nursing facilities as alternative, less expensive options for the postacute care of both patients with hip fractures and those with strokes.
The two group-model MCOs also tried to promote quality in their network by using a set of specialized physicians and nurse practitioners to coordinate care in the hospitals and skilled nursing facilities. The physicians who specialize in the delivery of hospital care, the “hospitalists,” have the potential to improve care by developing specialized medical expertise as well as valuable institutional knowledge of the hospital staff and facilities (Auerbach et al. 2001). Similarly, the use of a small core of physicians and advance practice nurses to manage all the MCO’s patients who require care in skilled nursing facilities offered several advantages. At both Aspen and Kaiser Colorado, the physicians assigned to work exclusively with the nursing homes provided a high level of patient contact and worked with facility staff to develop more effective and efficient procedures.
At the same time, the use of facility-based specialized staff had the potential to fragment care. Most hip fracture and stroke patients moved from the community to the hospital to a skilled nursing facility and then back to the community. At each stage of this process there was a corresponding hand-off from one physician to another. While the group model MCOs made an effort to ensure that a patient’s medical record was moved with them, the physicians and patients in our focus groups noted some instances where the patients arrived in a facility before the records. Furthermore, the facility-specific physicians may not have enough interaction with a patient to determine the best way to communicate with them or their abilities to follow through on alternative treatment regimens. Thus, the advantages of specialized staff such as hospitalists must be balance against any loss in the continuity of care.
Keystone East used a different method to promote quality of care in skilled nursing facilities. It provided incentives for primary care physicians to follow institutionalized beneficiaries. In addition to furnishing supplemental payment arrangements for this patient population, they also expedited the referral process:
[The MCO] has decided that if a patient is in a nursing home where I conduct rounds, I can issue referrals for any of the specialists I want, even though that patient is not capitated to me. That is a very positive view.”