Practice Patterns among Nurse Practitioners in a Transitional Care Pilot for Medicare Advantage and Medicaid Managed Long-term Care Patients Patrick Luib, MS, ANP-BC, Manager of Geriatric Clinical Services 1 Claudia Beck, MS, ANP-BC, Director of Clinical Support Services 1 Peri Rosenfeld, PhD, Senior Evaluation Scientist 2 Daniel Kurowski, MPH, Research Analyst I 2 1 CHOICE 2 VNSNY Center for Home Care Policy & Research

Objectives Describe the components of the Nurse Practitioner (NP) led Transitional Care (TC) Program designed for Medicare Advantage and Dual Eligible Medicaid Managed Care Long Term Care Patients Discuss the Methods, Data collection and Findings of the Survey of NP Practice Patterns Outline components of the full evaluation plan for the NP-TC program

VNSNY CHOICE Guiding Principles VNSNY CHOICE Health Plans: Offer benefits that improve access to appropriate care, including assistance with navigating an increasingly complex health care system Shift the focus of care from the institution to the home and community Believe care management is the cornerstone of all managed care plan options and all members are assigned to a care manager; multi- disciplinary care management facilitates integration across all care settings Target and customize interventions

Medicaid Managed Long Term Care (MLTC) Medicare Advantage (Special Needs Plan and Part D) Managed Long Term Care Plus Benefits and Services Provided Alternative to long-term institutional care. 14 home and community–based services, including care management, nursing home, adult day care, home-delivered meals All services in Medicare Parts A, B and D; Hospitals, Doctors, Labs, Rxs Supplemental: Dental, Vision, Hearing, and Transportation benefits Combines services offered in Medicaid MLTC and Medicare Advantage Special Needs Plan. However, provides less supplemental benefits due to cost shifting Payment Source NYS Medicaid, partially capitated, rates risk- adjusted by population (2-year payment lag) Medicare Advantage (CMS), fully capitated, risk adjusted by individual Separate payments from NYS and CMS – (Lower combined premium) Providers 1,900 Network Providers 29 Nursing Homes 2,200+ Primary care phys, 5,800+ Specialists, 37 Hospitals, 32 Nursing Homes, Labs, Pharmacies Full networks for both VNSNY MLTC and Medicare Special Needs Plan VNSNY CHOICE Health Plans Managed Care Plans for High-Cost Chronically Ill Dual-Eligibles

VNSNY CHOICE: Transitional Care Protocol NP-led, interdisciplinary set of interventions aimed at reducing preventable re- hospitalizations by –Improving health care coordination and continuity across settings –Providing member-centric TC plan –Providing critical information to IDT –Following up on unmet needs with IDT

Why NP led? Distinguishing NP from RN role NPRN Communicates vital elements of mbr's pre-admission clinical, functional, and mental health history to hosp. staff Provides care management on home visits and telephonic encounters Provides medication reconciliation on every visit including first post-hospital MD appt Provides skilled nursing treatments such as medication administration and wound care

NP Practice Patterns This presentation is the first component of a larger evaluation study that examines the activities of NPs engaged in a TC program The full evaluation will analyze process measures (such as fidelity to the model) and outcomes measures (e.g. determination whether the NP program results in lower hospitalizations and ER visits) are in progress.

Methodology Designed and piloted data collection instrument for the 8 NPs to use daily Data collected on daily activities for 10 work days (two weeks in November 2011) Obtained 100 percent response rate but three surveys were eliminated from analysis due to inaccuracies Follow-up key informant interviews were conducted with 5 NPs

Number and Types of Patients Served by NPs

Average Distribution of Daily Care Activities

Direct Care: Types of Visits Home Visits comprise over half the time spent in Direct Care Almost one-quarter of the Direct Care takes place in the hospital, prior to discharge Other direct care activities include visits to rehab settings/nursing homes

Indirect Care: Measures of Time and Effort

Care Communication Activities

Themes from NP Interviews Program barriers include –Late notification of hospital discharges –High level of frailty of patient population Program facilitators: –Solid administrative support, including frequent meetings and check-ins –Existence of strong pool of clinical colleagues and contacts

Themes from NP Interviews (cont) NP Model characterized as “The Cadillac” –Special set of clinical management skills –Able to negotiate hospital and physician relationships –Benefit of Advanced Practice competencies, e.g. Ability to interpret lab work and prescriptive privileges (helpful with medication reconciliation) –Able to address overlooked or underlying social/behavioral/environmental issues

Next Steps Complete evaluation study (quasi- experimental design) to examine outcomes (hospitalization and ER rates) of patients in NP-TC program as compared to comparable home health care patients receiving usual care Results expected by end of year.