The document discusses UnitedHealthcare's Evercare clinical model and telemedicine initiatives. The Evercare model provides individualized care plans and addresses systems of care through increased assessments, treatment of changes in condition, and enhanced communication. A proposed telemedicine pilot would use existing equipment with Evercare nurse practitioners to improve communication, enhance treatment in place, and reduce transfers from nursing homes to hospitals. The document also discusses UnitedHealthcare's broader telehealth activities aimed at expanding access to care in rural areas.

1. UnitedHealthcare Nursing Home Plan
Evercare Clinical Model
Telemedicine Initiatives
Cathy Lipton, MD
Senior Medical Director
03/15/2012

2. The Evercare Model offers individualized solutions
Currently:
• Complex problems require individual solutions; not just disease –specific
programs
• Typical Disease Management programs have not demonstrated desired
outcomes
• Poor communication between providers of care and the delivery system;
doctors and nurses don’t get to do what they do best
With Evercare:
• Evercare programs offer individualized and comprehensive care plans
• Evercare program results address the systems of care with better quality
outcomes and improved satisfaction
Evercare Nurse Practitioners / Clinical Support accomplish 3 main
objectives:
• Increased assessments and proactive medicine to prevent ailments from
becoming acute
• Facilitate treatment of changes in condition immediately in place
• Enhance communication for entire care-plan, disease trajectory, ACP 2
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3. UnitedHealthcare Nursing Home Plan Clinical Features & Benefits
Nurse Practitioners as a central part of providing more intensive primary
care working in collaboration with nursing home staff and primary
care physicians.
Physicians who are encouraged to increase their involvement with
families and nursing home residents.
PCP continued participation rating of 91%
Decreased hospital admissions by 50%
Year over year family/responsible party satisfaction ratings of greater
than 95%.
Clinical staff provides both formal and informal education for nursing
home staff.
Early identification and change in condition programs and tools to
promote early clinical intervention and improve outcomes.
Annual Clinical Indicator Studies that drive clinical practice guideline
development that promotes quality of care.
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4. UnitedHealthcare Nursing Home Plan
Waiver of 3-day Qualifying Stay
– Stable Census
– Reduced Bed-Hold Days
– Immediate Part A Reimbursement
– Skilled Days Outside of Medicare
On-site clinician (NP/PA) at no additional cost
Focus on ongoing Advance Care Planning with families and staff
Enhanced Medical Records (EMR, documentation)
Additional Covered Items
– Therapy Screenings
– Dental and Eyewear Benefits
– Blood Glucose Monitoring
– Skilled Days Outside of 3-day Qualifying Stay
Afterhours support
Enhance overall clinical quality
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5. Evercare works in partnership with nursing home staff to execute
these components:
Intensive Delivery of Primary Care – by our clinical team, which includes nurse
practitioners collaborating with physicians
Onsite Nurse Practitioner – at no cost to the facility or resident, results in:
• Increased visits for residents
• Emphasis on proactive care
• Early identification of change of condition
• Increased communication with residents, families, staff, and physicians
• Formal and informal education to nursing staff
Treat in Place Model
• Frequent visits by Nurse Practitioner
• Intensive Collaboration with primary care physician
• Ability to initiate skilled benefit without 3-day hospitalization
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6. UnitedHealthcare Nursing Home Plan Population Profile
Custodial, permanent stay, frail elderly, no active discharge plan
Average age 81+ years old
80% female
85% Moderate To Severe Dementia
75% require assistance with 4+ ADLs
Must be long-term resident of SNF, have Medicare A & B, and not
enrolled in ESRD program
Primary diagnosis
• Dementia
• Hypertension
• Anxiety and Depression
• Vision Impairment
• Arthritis
< .5% discharged to home
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7. The Evercare Clinical Model: How does it work?
Apply an individualized, whole-person approach to care of frail,
institutionalized elders
• Focus on promoting maximum function, comfort, and quality of life
Preventive Care and Early Recognition of Change in Condition
• Evidence-based medical care
• Frequent monitoring and communication with nursing staff
• Rapid response to changes – rapid initiation of treatment
Provide care in a safe but least invasive manner, in the least invasive
setting
• Provide as much care as possible in the nursing home setting
• “Treat in place” philosophy – avoiding complications and trauma of unnecessary
hospitalizations
Provide care through a primary care team – partnership of nursing home
staff, primary care physician, and nurse practitioner
• Clinical support for facility
• Access to skilled benefits without hospitalization
• Enhanced reimbursement for physician services
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8. Why do patients transfer out of Skilled Facilities?
Fundamental system issues related to transitions in care
Physician/NP/PA presence in SNFs and coverage issues
SNF technical capabilities
ACP/Family dynamics
Staffing
Education/training in SNFs
Regulatory environment
Patient mix
Fragmentation in system/information systems
Over 50% of admitting diagnoses for avoidable hospitalizations:
• Cardiovascular (CHF and chest pain)
• Respiratory (pneumonia and bronchitis)
• Mental Status Change/Neurological
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9. Focused Expert Reviews of Transfers out of Nursing Centers
show….
Key facility factors identified when defining “avoidable” hospitalizations:
The same benefits could have been achieved at a lower level of care
The SNF should have been able to provide the care
Availability of on-site physician/NP/PA evaluation
Better quality of care in assessing the resident’s change in status
Better advance care planning
The resident’s overall condition limited his ability to benefit from the
hospitalization
Key facility resources helpful in preventing hospitalizations:
Examination by a physician, NP or PA within 24 hours
Physician or physician extender present in the SNF at least 3 days per week
Care by a registered nurse (vs LPN/CNA)
Availability of lab tests within 3 hours
Ability of the SNF to initiate and maintain intravenous therapy
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10. What can happen as a result of hospitalization?
New physical or Conflicting
Outpatient (clinic)
chemical information
visits get scheduled
Altered functional restraint given to family
Increased when not necessary
status/weakness or appropriate
confusion-‘out of
sorts’
Pressure Sores
Psychiatric Lost teeth,
Over sedation/lethargy exacerbation hearing aids
Eccymosis from IV/lab and glasses
sticks
Decline in
Relocation Physically unkempt
ADL’s
Trauma
Incontinence
UTI’s secondary to catheter
MRSA and or VRE
Relocation Fecal Impaction
Weight loss/ Loss of Broken bones from
Trauma
appetite falls in hospital
Initial problem not fully
investigated/resolved
Advance Directives NOT followed
 Increased anxiety/agitation
Lost equipment:  Confusion from the
Decreased
(splints/braces)
Activity Phlebitis hospitalization that can take a
long time to clear
 Bad memories/waiting in ER
for up to 18 hours
Resident not a
Lack of discharge summary and
priority to acute 10
info related to hospitalization Heel ulcers
care staff Death or poor quality death
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11. Reduction In Unnecessary Hospitalizations
The University of Minnesota School of Public Health found that the incidence of hospitalizations among nursing home
populations was twice as high in control residents as in Evercare residents. Members in the control group were also twice
as likely to go to the Emergency Room than Evercare members. Evercare had ½ the hospitalizations compared to fee-for-
service Medicare (Control 1 & 2).
Effect of Evercare on Hospital Use
80
70
60
Admits per 50
1000
Enrollees 40
30
20
10
0
Evercare Control 1 Control 2 Evercare Control 1 Control 2
Hospital Emergency Room
Admissions Visits
Source: Dr. Robert Kane et al, University of Minnesota, 2003 11
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12. It’s not just good geriatric care…
One in 4 Medicare patients admitted to skilled nursing facilities from
hospitals is readmitted to the hospital within 30 days
Up to 2/3 of hospital transfers are rated as potentially avoidable by
expert long-term care health professionals
Health Care Reform requirement: “Hospital Readmissions Reduction
Program” becomes fully effective October 1, 2012
Medicare is putting in place financial incentives to reduce potentially
avoidable hospital transfers through pay-for-performance, bundled
payments, and other strategies
First phase: Heart Attack, Heart Failure, Pneumonia
Second phase: COPD, CABG, PTCA, Other vascular conditions
The OIG considers unnecessary hospitalizations during a nursing home
stay a compliance priority in its 2011 and 2012 work plans
Budget plans for similar reductions in skilled nursing facility
reimbursement as of 2015 for high rates of preventable hospital
admissions
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13. Proposed Telemedicine Pilot
Work in Ethica Health centers in conjunction with Georgia Partnership for
Telehealth
Target buildings that have the Evercare model in place and still have
continued high rates of transfers
Use existing telemedicine equipment with the Evercare NPs and PAs as
“end users”
Overlay Evercare’s existing 24-7 on call system
One year pilot proposed
Goals:
• Improve “face-to-face” communication with staff and families
• Enhance treatment in place
• Reduce transfer rates
Replicate across our shared nursing centers and expand beyond to
underserved and geographically remote centers
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14. UnitedHealthcare Telemedicine/Telehealth Activities
Goal to enhance use of telehealth in rural areas:
1. Expand broadband connectivity to enable growth of telemedicine adoption.
2. Improve and align reimbursement approaches across payers to encourage
greater
use of telemedicine across rural settings.
3. Encourage physicians to incorporate telemedicine into their practice.
4. Use telemedicine to build primary care capacity in rural areas.
5. Increase access choices for rural beneficiaries.
6. Raise patient comfort levels with telemedicine technology and encourage
its use
in rural care models.
7. Update regulations associated with technologies and professionals.
8. Improve care coordination and patient safety in rural areas.
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15. Bringing Primary Care and Specialty Services to the Navajo Nation
UnitedHealthcare serves 24,000 special needs children in the
Arizona Medicaid program. Obtaining pediatric specialty services in
rural parts of the state is a significant challenge for many children.
In 2010, UnitedHealthcare generated a Title V grant for the
expansion of telemedicine into Tuba City on the Navajo Nation in
Northeastern Arizona. Access to specialty medical care on the Navajo
Nation is extremely limited. Children and their families typically must
travel 200 miles to Phoenix, the closest urban center, to see a
specialist.
The Navajo telemedicine program utilizes high-definition
technology through an established T1 network that provides hub site
services (at regional clinics) to patients presenting from remote
locations on the Navajo Nation.
Financial support for travel and individual service plans are
helping underserved tribal members gain access to needed primary
care and specialty services in the most remote areas of Northeastern
Arizona.
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16. OptumHealth’s Connected Care Delivery of Telehealth Technology
and Services
Connected Care delivers telehealth services in low-access rural
and urban areas using a combination of advanced
telecommunications technologies, health care delivery expertise and
scalable operations.
Through the provision of telemedicine equipment and
operational assistance, Connected Care enables communication
among existing medical communities, providing the technology and
professional support necessary to implement telemedicine. This
includes everything from equipment, software and support services,
to coordinating scheduling systems, training, facility design and
reimbursement analysis. All equipment — video gear, stethoscopes,
etc. — is telemetry-enabled.
Connected Care improves access to care by reducing travel time
to see specialty providers and making it easier to provide follow-up
care in a local setting. It serves rural populations in collaboration with
local providers and remote specialists, including Critical Access
Hospitals, Rural Health Clinics and larger hospital systems.
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17. Thank You!
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