The Evercare Model: Using Nurse Practitioners to Achieve Positive Outcomes Pat Kappas-Larson, MPH APRN-BC Professional Relations/Development April 24, 2008

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 2 A Care Model Becomes the Foundation for a Company  The Problem : For many people living in nursing homes, care is fragmented and uncoordinated. This results in transfers to physician offices, hospitals and emergency departments at great physical and emotional cost to them, their families, and increased financial cost to the health care system.  The Answer : In 1987, a company known as Evercare engages nurse practitioners as partners and places them at the center of an integrated team delivering personalized and responsive primary care. Evercare would ultimately become a successful Medicare demonstration project, helping to pave the way for the creation of Special Needs Plans in the Medicare Modernization Act.

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 3 The Evercare Premise:  Enhance primary care services to reduce avoidable acute care hospitalizations so as to improve quality of care for permanent nursing home residents.  Align financial and clinical incentives so that nursing facilities and physicians collaborate to achieve the highest level of health and well- being for the resident.  Comprehensive and continuous advanced care planning and family communication are essential in the care of this population. Evercare: Founded in 1987 by Nurse Practitioners

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 4 The Mission To optimize the health and well-being of people who have long-term or advanced illness, are older or have disabilities.

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 5 The Nurse Practitioner: The Clinical Model  Nurse Practitioners serve as collaborator, clinician, coordinator, coach, and counselor.  Nurse Practitioners are the center of a multi-disciplinary team that collaborates on the appropriate and proactive interventions, communicates the required changes in the plan of care to all parties, and rigorously monitors the responses.  Nurse Practitioners closely monitor changes in health and focus on early identification of any movement away from baseline functioning.  Nurse Practitioners constantly focus on reducing fragmentation of care, ensuring individualization of the care, and delivering care reflective of the values, wishes, and beliefs of the individual and their families.

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 6 Vital Engagements: The Clinical Model  Families: Who are engaged and involved in the care decisions and are available for more constant and consistent communication.  Nursing home staff: Who understand the goals of care for each resident and are intimately involved in the monitoring of the individual.  Other key professionals: Physical therapists, nutritionists and others who are available in the facility and are willing to function as part of the broader care team.

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 8  50% of people die in hospital outside of Hospice  Poor palliation services  May be functioning well, but sudden event is catastrophic  5+ chronic conditions= 2/3 of all Medicare costs  Greatest suffering = ineffective resource utilization  Single condition but very high impact, e.g. quadriplegia, advanced Alzheimer’s Disease Who We Serve In Our Products

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 9 Clinical Model Effectiveness: What is Attainable Today?  Enrollee satisfaction: 97%  Physician satisfaction: 90%  ER and hospital utilization for dual eligible community-based population: reduced 30%  Arizona: saved $111 million compared to FFS LTC Medicaid  Texas: saved $70 million in one county  Florida: reduced nursing home placement by 70% Unmatched clinical results…

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 10 Barriers Encountered Along the Way  A health care system focused on care in acute care settings, not on treating multiple chronic illnesses with an integrated care model responsible for the full spectrum of acute and long-term care services needed by the individual.  A dearth of staff and expertise in long-term condition management, geriatrics, and end-of-life palliation.  Lack of experience and understanding about coordination across providers and care settings.  System fragmentation and inadequate communication tools.  Resistance to working and engaging differently, accepting the need to change.

R: 106 G: 91 B: 151 R: 255 G: 227 B: 84 R: 163 G: 45 B: 132 R: 116 G: 141 B: 181 R: 235 G: 124 B: 0 R: 92 G: 102 B: 30 R: 177 G: 00 B: 33 R: 142 G: 130 B: 113 R: 170 G: 161 B: 148 R: 213 G: 208 B: 202 R: 227 G: 224 B: 219 R: 0 G: 0 B: 0 11 Policy Recommendations  Support initiatives that move toward innovative care models focused on coordinating high quality care across a variety of providers and settings.  Reauthorize and enhance Special Needs Plans, which focus on the needs of the chronically ill.  Transform the delivery of long-term care in all settings to support the key role of the nurse practitioner as the center of a multi-disciplinary team.  Ensure training and education for health professionals in geriatrics and chronic disease management, and support and expand existing academic programs focused on building a work force for the aging population.