Several key metrics improved for 53 long-term nursing home residents in a six-month pilot study initiated by Menorah Park, and an annual savings of $750 million in drug costs and rehospitalization expenses could be realized if the model were expanded nationally.
Designed and led by Richard Schwalberg, the COO at Menorah Park in Beachwood, the study aimed to improve the quality of life and care of Medicaid patients as well as reduce drug costs.
Schwalberg initiated the pilot study after he noticed the duplication of services – and the siloed approach to care – starting about two years ago, when nurses from both hospitals and managed care began routinely paying visits to patients at Menorah Park.
“The current systems are very fragmented and duplicative,” he said. “There is no standardized care paths for a nursing home patient. We set up a model, a pilot, where it’s a centralized, provider-driven model through the nursing home.”
Schwalberg believed that coordinating care, with the nursing home taking the lead, might improve care and reduce costs.
The Medicaid Care Coordination Program pilot study was designed to track five metrics – falls, rehospitalizations, pressure sores, emergency room visits and drug costs – over a six-month period, which ended in February. A six-month control period prior to the intervention was used to establish a baseline for the study.
Rehospitalization is defined as returning to a hospital within 30 days of a hospitalization, regardless of diagnosis. Hospitals with high rates of rehospitalization are fined by the Centers for Medicare and Medicaid Services, Schwalberg said.
The study entailed two simple interventions: a 30-minute weekly meeting led by a nursing home pavilion manager who tracked each metric in each patient that was attended by hospital nurses, managed care nurses and nursing home nurses, and a monthly 30-minute conference call among nursing home CEOs or the designees to brainstorm ways to improve the metrics.
The study involved Menorah Park and two more nursing homes in Ohio: Montefiore in Beachwood and Jennings Center for Older Adults in Garfield Heights. It also included the Jewish Association on Aging in Pittsburgh, the New Jewish Home in Manhattan and the Los Angeles Jewish Home in Reseda, Calif. Schwalberg enlisted other Jewish nursing home leaders through his work as a board member on the Association of Jewish Aging Services.
Improvements were noticeable:
• Rehospitalizations decreased from 10% to 5% among the 53 Medicaid patients at the nursing homes in the study. The national average for rehospitalizations among nursing home patients is 19.4%.
• Falls were reduced from 21% to 16% among patients in the study. The national average is 45.9%.
• Pressure sores went down from 7.4% to 4.3% among patients in the study. The national average is 6.1%.
• Emergency room visits averaged 3% by the end of the study, Schwalberg said. The national average is 9%.
• Drug costs, which are not tracked on a national basis, were reduced by 9% during the study, Schwalberg said.
Schwalberg said he believes drug costs and rehospitalization expenses could be reduced by $750 million on an annual basis if the model were applied across the country.
“At the present time, there (are) really no best practices that are followed in nursing homes,” said Dr. Beejadi Mukunda, associate medical director at Menorah Park, who is also chief of medical staff at Hillcrest Hospital in Mayfield Heights and is medical director at CareSource, a Dayton-based company that is one of the nation’s largest Medicaid managed care plans.
“In the nursing facility settings, there are some protocols for intake of the patient, but (for) actual day-to-day care of the patient, there are no standard protocols. So, if you go to one facility, you may be cared for in one way; if you go to another facility, you may be cared for in other way. Every facility tries to come up with their own way of doing things, but obviously, there has to be a best practice in any given clinical scenario because there are multiple ways of doing things. One of the them works better than most others. I think this study will help to develop best practices.”
Schwalberg is attempting to raise $2.5 million to conduct a 500-patient, one-year study involving 50 nursing homes across the country.
While Menorah Park has 355 patients, Schwalberg said the average number of patients at the 15,600 nursing homes across the country is 120.
“Over 12 months, you do the whole population,” he said. “I believe it is sort of a slam dunk.”
Schwalberg has made a video urging nursing homes to use leadership to apply the model – in advance of the national study.
Once the larger study takes place, provided the results are replicated, Schwalberg said he will press for a law to use the model at nursing homes nationwide.
Schwalberg and other nursing home leaders in the study have already spoken before the U.S. Senate Committee on Finance.
“I’ve seen some of the initial data and reports from the MCCP pilot, and I think it's a promising start," Sen. Rob Portman stated in a July 11 email. "I’m hopeful that Ohio-driven innovation can be a national model for improving outcomes and reducing costs for seniors.”
Menorah Park had 11 patients in the study who improved on all metrics, said Schwalberg.
Seth Vilensky, president and CEO of Montefiore, said eight of his facility’s residents were part of the study, which he acknowledged was a very small sample.
“We found with this care coordination intervention, we did see some reductions in hospitalizations, so residents having to go to the hospital, that was really one of the main outcomes we were interested in,” he said. “We wanted to keep people in our facility without having to use any higher levels of care, like the hospitals or emergency room.”
Vilensky said there were some reductions in drug costs among the eight patients.
“What we would hope to do in the future would be to grow the number of participants in the pilot,” he said, adding that he would hope to participate in a larger study, “so we can really have some good data on the true outcomes.”
Vilensky said Montefiore already held “huddles” around patient care.
“I think this closer monitoring of people who are high risk (is something) we will continue to do in our clinical practice in our facility,” he said. “It’s exciting to put more of the resources at the provider level at facilities like ours, where we really know the patients better than, say, the managed care companies or other agencies.”
Rachele Rosa, executive director for the Garfield Heights campus of Jennings Center for Older Adults, spoke of the study’s importance in terms of putting nursing homes at the forefront of their patients’ care.
“Everybody generally operates very siloed, so this was just a beautiful way to bring it all together,” she said, adding that the study allowed those in the pilot group to consider the following question: “How can we as a group work together a little bit more collaboratively … to really talk and talk about best practices and set standards that hopefully set standards for the nation in providing better care for the seniors that have pretty much allowed us to be where we are today?”
Mary Anne Foley, COO at the Jewish Association on Aging in Pittsburgh, said the six patients tracked at her facility improved on every metric, including reducing medications and lowering drug costs.
“Every nursing facility that takes medical-assistance patients loses money every day on the care that we provide,” she said. “We’re not paid the same for a medical-assistance person as we are for a Medicare (patient or a patient) under another third-party insurance. So, when you talk about doing things like improving care coordination, you’re doing that with the staff that you have that are taking care of all of your residents.
“So, although this wasn’t burdensome to do a handful of our residents, without the ability to get some funding to do a larger scale pilot, I don’t know that any of the organizations that participated would be able to do it on a larger scale. We all believe that there’s a benefit here, and we believe that this could save money. However, what it means in saving that money, you need to be able to fund the project with the additional resources.”