Nursing Homes Vital to ACO Success? Depends on Whom You Ask
Jennifer Dennard, Social Marketing Director
July 8, 2011
The National Accountable Care Summit, held recently in Washington, D.C., provided a perfect
platform from which the American Health Care Association and the National Center for Assisted
Living (AHCA/NCAL) proclaimed their advocacy for accountable care organizations (ACOs).
AHCA/NCAL President and CEO Mark Parkinson, a strong supporter of including nursing homes in
ACOs, and a featured speaker at the summit, described skilled nursing facilities and ACOs as
"perfect partners," according to a recent McKnight's Long Term Care News report. His statement
seems to make sense. Nursing homes play a major role in their ability to keep their patients'
hospital readmissions down - most likely a key factor in the as-yet-undefined accountable care
regulations.
But does his statement resonate with those that work in the trenches, so to speak? Do
long-term care providers and vendors see the value nursing homes bring to ACOs in the same way that
Parkinson does? As with any hot topic in healthcare, it depends whom you ask.
Vendors' Varied Opinions
"In some ways, the two terms become inconsistent," explains John Landis, Senior Vice
President of Cerner, which recently acquired Resource Systems, developer of the CareTracker®
point-of-care electronic documentation system primarily used in skilled nursing and assisted living
facilities. "ACOs must place a focus on pre-acute care, as well as post-acute care," he says. "Many
of the care venues defined as 'post-acute' today will evolve to fit into a proactive model of
managing health."
Landis' comments somewhat reflect those of Scott Kuhlman, a veteran of the long-term care
industry who has a unique perspective on the issue. Kuhlman is COO of Geriatric Practice Management
Inc., provider of physician management services to long-term care practices primarily in the
Asheville, N.C. area, and Extended Care Physicians, a GPM-managed physician group that provides
care to patients in nursing homes, assisted living facilities and retirement communities. Through
GPM, Kuhlman offers his staff of physicians the Talking EMR system - an electronic medical record
built by Kuhlman's staff of developers specifically for long-term care settings. According to
Kuhlman, the long-term care-specific product has resulted in increased physician productivity of
30-45%.
Kuhlman feels that long-term care providers have important roles to play in pre- and
post-acute care settings, and therefore will have big parts to play in ACOs. "We feel that
long-term care physicians are going to be critical in the ACO model because they have the ability
to control costs with the Medicare patients they treat. In the nursing home, we provide care on a
regular basis and therefore can control hospital admissions tremendously because our model is to
treat in place whenever possible.
"We can play a major role in reducing readmissions as well," Kuhlman explains. "It's going
to be a marketing advantage for the nursing home if they can show the hospital that they can
control readmissions. They can't control readmissions without a physician component, so we work
hand in glove with them."
Though Kuhlman is optimistic about the value long-term care providers will bring to ACOs and
their hopefully improved clinical outcomes, he is a bit more hesitant when discussing the role
healthcare IT will play in this scenario.
"Accountable care is too cumbersome as it's written today," he says. "A lot of legislation,
like the HITECH Act, does not have long-term care in its sites at all. Long-term care is the
redheaded stepchild of the HITECH Act. It is very far behind everybody else when it comes to IT
adoption, so this is a conundrum that we're going to be in."
Kuhlman believes EMRs are the long-term care industry's gateway healthcare IT product. Once
EMRs have become effectively implemented, the industry will likely have a greater, more experienced
voice in developments like health information exchange and accountable care.
Provider's Perception
Caregivers who work on a daily basis in long-term care settings are optimistic when it comes
to the value they can provide their patients through an ACO, but like Kuhlman, realize that their
segment of the healthcare industry has some catching up to do when it comes to ACO-enabling
healthcare IT solutions.
"Unfortunately, the HITECH Act and the pay-for-performance benefits of early implementation
of electronic systems have not reached the skilled nursing level of care," says Melinda Pierce,
Director of Rehabilitation at not-for-profit, Evanston, Ill.-based Presbyterian Homes. "However, we
are excited about the prospects of better accuracy and efficiency that are possible through the use
of an electronic system. Our physicians who are on staff at local hospitals are able to access
their patients' hospital records through their systems, but do not anticipate being able to
interface our systems due to restrictions on the part of the hospitals.
Pierce has heard very little talk of ACOs, other than that they are the latest rendition of
an HMO, and has some concern about the perceived financial benefits.
"I personally feel that in general there is far too much 'passing off' of patients by
hospitals - patients discharged before they are stable in the interest of the hospitals'
reimbursement situation; hospitalists who are too quick to suggest hospice over rehabilitation for
patients who opt for DNR status; hospitals that keep patients with straight-forward pathology on
'observation' (which precludes them from skilled nursing Medicare benefits at the next level of
care) to keep their own admission numbers down.
"All of which does little to foster the collaborative atmosphere across person-centered
levels of care necessary for optimal patient outcomes," she says. "I don't feel confident that
hospitals in general would be good stewards of shared funds based on actions I have observed in
independent provision of service.
"I respect that there is a time and a place for different levels of care delivery, whether
it be acute care, in-patient rehabilitation, skilled nursing, home health or outpatient services.
My concern is that the criteria for determining care would be based upon the financial benefit of
the most powerful portion of the ACO, rather than upon the best interests and needs of the
patient."
The Verdict is Still Out
It is obvious that a dialogue between providers in hospitals and long-term care settings is
needed to truly assess the financial and technological viability of ACO participation. As events
like the National Accountable Care Summit become more popular, and vendors work to develop
solutions that will help bring long-term care up to speed, time, successful implementations and
clinical outcomes will truly tell the tale of the ACO.
Editor's Note: Please see part one in this series, "
Does
Long-Term Care Hold the Key to the ACO Puzzle?" to learn more about the challenges the
long-term care industry faces when it comes to operating within accountable care organizations.
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