Managed care may be solution for nursing home residents with advanced dementia: study

Medicare managed care programs may provide a solution to the healthcare system as it looks for ways that nursing homes can offer high-quality care that also is cost-effective for elderly residents with advanced dementia, especially at the end of residents’ lives, according to new research published online by JAMA Internal Medicine.

Keith S. Goldfeld, DrPH, of the New York University School of Medicine, and colleagues at several institutions in Boston monitored about 300 residents at 22 Boston-area nursing homes for 18 months. Residents enrolled in Medicare managed care programs, they found, were more likely than those in traditional Medicare fee-for-service programs to have do-not-hospitalize orders. Also, the managed care patients were less likely to be transferred to a hospital for acute illness, had more primary care visits per 90 days and had more nurse practitioner visits. Both groups had similar rates of survival, comfort and treatment outcomes, investigators found.

“This study provides novel data suggesting that the model of healthcare delivery in a nursing home has important effects on the type of care received by individual residents,” the authors say. “Intensive primary care services may be a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome and affordable care, especially at the end of life.”

Traditionally, the scientists note, nursing homes have not received higher reimbursement to manage acutely ill long-term care residents; therefore, they have had a financial incentive to transfer residents to hospitals. For this reason, any systematic change from fee-for-service to managed care may require altering the existing underlying financial structure.

It’s going to take more than financial adjustments to address what ails the healthcare system when it comes to nursing home care for residents with significant cognitive impairment, says a geriatrician not involved with the study.

“Design of a long-term system that will provide our patients with advanced dementia the right care at the right time will require more than patches and fixes to the payments systems,” writes William J. Hall, MD, of the University of Rochester, in an invited commentary in the journal. Hall notes that, in the study, nursing homes that had more onsite nurse practitioners saw better outcomes in residents regardless of the type of insurance that residents had.

The study was supported in part by the National Institute on Aging.

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Lois Bowers

Lois A. Bowers was senior editor of I Advance Senior Care / Long-Term Living from 2013-2015.