Medical & Health Homes & Population Management Work Group
Dual Eligible Planning Grant
Nursing Home Supports Sub Group Notes
November 14, 2011
On the call: Denise Levis, Randy Best, Polly Welsh, Bob Wells
(rwells@ecpmd.com), Kim Sturkey, Chris Herman, Elise Bolda and Nidu
Menon
Left off at last meeting with homework asking everyone to send in components of
what must be in place as well as quality expectations for medical homes for nursing
home (NH) residents
Update re meeting with several NH providers,
 NC HCFA (Polly) will seek input from facilities – request has gone to 2
committees for information on
o Operations within their counties
o obstacles in their county
o experience with having an NP, PE, or contracting with Evercare or
Eldercare – with view to reducing ED & Hospital admissions and
increasing the quality of care
 Responses: Forrest at Duke provides high quality of care but that requires a
high level of funding. There is always the fear of regulatory sanctions;
liability is a major concern relative to head injury from fall & fracture
 Looking to hear what model will best serve facility residents and create a
‘Forrest of Duke’ level of care for Medicaid Consumers.
Suggestion regarding developing a ‘Continuum of Care’ delivery system that raises
the bar for all facilities serving duals, understanding that all Nursing Homes are
different and work in different communities with varied level of support services.
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Ultimate end of spectrum is a facility with
o good physician coverage,
o physician(s) and patients engaged in care,
o regular pharmacy review that is really being considered by physicians
with quick action
o 24-7 accessible support for after-hours needs
o good administrator
o Could get a PMPM (how money flows to be determined)- this would
be a way to fund a nurse practitioner within the facility
Along the continuum are facilities where we want to get stronger QI, stronger
physician involvement, incentives for more physicians to work with facilities
Need to recognize you are not going to get all facilities at the ultimate end
from the get go, some Nursing Homes may be need years to get there
This approach fits the triple aim of reducing avoidable emergency department
(ED)/hospital use, while improving care & improving access
Bob Wells (Extended Care Physicians) – drew up a list of quality indicators –
relevant to NH facility and to physicians/providers
o Having a call answering system 24-7 with certain standards – 80-85 % of
calls taken immediately, remainder within 10 minutes
o Practice & NH share and track data
o Clinical practice has systems in place to discuss advanced directives with
health care representatives (perhaps stipend for discussions)
o Clinician compliant with electronic health record (HER) requirements
o Physicians e-prescribing – PQI (?) and facility e-prescribing to reduce errors
o System to manage high risk activities – as defined by med mutual provider-ex: primary risk management anti-coagulants and toxic blood levels in policy
o Ongoing dialogues with hospitals on transitions of care
o Demonstrated onsite physician/provider time at facilities, ex: certain # of
facilities - if X patients need to be on site Y days per week
o Root cause analyses of all unplanned admissions to hospital, drug
interactions, allergies and contraindications
All these are absolutely consistent with previous thinking;
** These indicators will be further refined and emailed by Dr Wells to all the
workgroup members.
Considerations:
o NH are not included in any federal money for HER development and training
o ECP aware of pilot programs with Pharmarica & Golden Living building a
communications interface
o NC HCFA met with UNC systems intranet program to establish Nursing Home
ER in real time communications
o CMS considering it as potential non-compliance if use pharmacist who works
for supplier (Omni care stock dropped that morning )
o CCNC may have the appropriate resources for medication reconciliation
o E-prescribing is already a mandate for physicians
o Goal needs to include all 3 facets (hospital/physician, NH facility &
pharmacy) in electronic communications
o Admissions are the biggest zone for error & requires significant nursing time
to reconcile meds lists from 3 or 4 sources
o Many of these considerations may be able to be addressed through data
sharing through the Informatics Center Provider Portal
What does it take to create/ make sure an ED visit accomplishes what it needs to?
Best practice examples are Duke Forest/Croasdaile & Duke ED experience – where
geriatric fellow or a Nurse Practitioner can follow-up when patient is taken back;
patient may be able to get care in the acute care part of facility; Need a Medicaid
version of Hillcrest – Continuing Care Retirement Community (CCRC) scaled down
to a budget that works for a facility where 85% of the residents’ are dual eligible.
Medical homes are a start – incentivize quality and add on with experience.
What will help bring this to practice? NH peers-telling-peers works best - hearing
from others is difficult as industry feels horribly misunderstood.
o Trust level that breeds success –
o Improve electronic communications,
o Open key with physician supports
NH working with ECP-like groups and some other facilities are as different as night
and day.
o How do we get people interest in the middle of nowhere
o How do we manage in a progressive place like Asheville
Challenges:
Communications is essential– need to talk with someone at the facility who knows
what is going on with patient. Example – Nursing Facility told ED physician patient
had no living will, then patient’s’ power of attorney shows up with a copy
Case management may help fill this void
o who will employ them, potentially RN level
o need to assist facilities with training – communications, would that be helpful
Disconnect between NF & Hospital when NH get patients that have serious behavior
problems that are not disclosed at the time of referral
Discussion of the Informatics Center, CCNC – provider portal – means to improve
information sharing across settings. There are three video clips available on the
Dual Eligibles website which discusses some core capabilities and characteristics of
the system. http://www.communitycarenc.org/informatics-center/informaticscenter-explained/
Diagnostics are going to be an issue – with greater NH onsite physician/NP/PA
involvement will lead to more diagnostics being ordered
o Can NF access more than they do now in terms of X-ray & lab? few facilities
have onsite capacity,
o Concern is mobile x-ray & sending blood to lab rather than hospital
o Mobile x-ray notoriously bad for hip fractures. lit confirms – high false
negative & false positive; may be some procedures only – geographically
varied – where there is 24/7 coverage and time to response
o ED from NF facility – if send resident to hospital they are likely to lay there
for 20 hours  dehydration, skin breakdown, delirium
o Can get portable X-ray can get in middle of the night – 2 hour time frame –
informed families accept this as preferable to waiting in ED
o Overuse/unnecessary use of portable X-rays becoming a salve for family &
facilities
o NH Lab capacity limited, see some finger stick technology for anticoagulants
o I stats- point of care testing – comfort level of facility & CLIA certification &
standards require a lot of work
Next steps: In-person Raleigh meeting before Dec 8 – to further develop
continuum idea, Chris hopes to participate in this meeting. Polly Welsh will
send in the contact information for the Nurse practitioner from Wilkes County.