January 2001

Grant Results

National Program

Changes in Health Care Financing and Organization

SUMMARY

Health Research in Albany, N.Y., conducted a three-year demonstration project that examined differences in cost and quality among four alternative staffing models allowed under Medicaid for delivering primary care services in nursing homes.

This project was part of the Robert Wood Johnson Foundation (RWJF) national program Changes in Health Care Financing and Organization (HCFO) (for more information see Grant Results).

Key Findings
The researchers found that:

  • The experimental closed staffing model showed both cost savings and improved quality of care when compared to the open staffing model control group.
  • Nursing home residents in the closed staffing model facilities experienced fewer total hospital admissions, shorter lengths of stay when hospitalized, and fewer visits to the emergency room.
  • The total cost savings to Medicaid and Medicare in these facilities was $1.7 million, or approximately $508 per patient per year.
  • The process of care was significantly better in the experimental group during the demonstration period.
  • A survey of residents showed that significantly more patients in the experimental group felt that they were examined more carefully, were able to express feelings, had better access to care, and felt the doctor cared and was friendly during the demonstration period.

The researchers concluded that having primary care providers on staff assures that nursing homes can provide care to residents as soon as it is needed.

Funding
RWJF provided a $438,525 grant from July 1992 to March 1996.

 See Grant Detail & Contact Information
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THE PROBLEM

More than 80 percent of the nursing homes in New York state use an open staffing model to provide medical services to residents. This model allows physicians to "follow" patients into a nursing home and provide medical care to them while they are in residence, while a closed staffing model uses the services of physicians and other providers who are employees of the home.

A significant concern with the open staffing model is that physicians typically have few patients in any given nursing home and therefore may not visit the facility often enough to provide necessary preventive and screening services.

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THE PROJECT

This three-year demonstration project examined differences in cost and quality among four alternative staffing models allowed under Medicaid for delivering primary care services in nursing homes. The closed staff models included: staff nurse practitioners with physician collaboration; staff physician assistants with physician supervision; and staff physicians only.

Twenty nursing homes were designated as experimental facilities using one of these three models. Sixteen additional nursing homes were designated as the control group, using the more typical open staffing model. In experimental facilities, investigators conducted a survey of residents before and after implementation of the staffing models to assess what they valued about their primary care provider. For both control and experimental nursing homes, data were collected on the process, outcomes, and cost of providing care.

The objective of the demonstration was to determine if placing medical practitioners on staff at nursing facilities has an impact on the cost and quality of or access to primary care.

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FINDINGS

The experimental closed staffing model showed both cost savings and improved quality of care when compared to the open staffing model control group. Nursing home residents in the closed staffing model facilities experienced fewer total hospital admissions, shorter lengths of stay when hospitalized and fewer visits to the emergency room. The total cost savings to Medicaid and Medicare in these facilities was $1.7 million, or approximately $508 per patient per year.

Although Medicaid incurred added costs for paying salaries of providers on staff at the nursing homes, overall, nursing home residents in the experimental model incurred lower Medicaid costs for home care, long-term care, and inpatient and outpatient care than residents in the control group. However, there was no difference in the average number of billed physician visits between the open and closed model groups in either the pre- or post-demonstration period.

The researchers did not find statistically significant differences in quality indicators. However, using a measurement tool that examined the process and frequency of care, as well as how providers managed certain diagnoses and complications, the investigators determined that the process of care was significantly better in the experimental group during the demonstration period. In addition, a survey of residents showed that significantly more patients in the experimental group felt that they were examined more carefully, were able to express feelings, had better access to care, and felt the doctor cared and was friendly during the demonstration period.

The researchers concluded that having primary care providers on staff assures that nursing homes can provide care to residents as soon as it is needed. In addition, nursing homes that have nurse practitioners and physician assistants on staff can institute more sub-acute services — such as intravenous therapy — and keep sicker patients in need of close monitoring out of the hospital.

Communications

The researchers made presentations at the Gerontological Society of America's scientific meetings and the Agency for Health Care Policy and Research annual meetings and published an article in Nursing Home Medicine (see the Bibliography).

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GRANT DETAILS & CONTACT INFORMATION

Project

Alternative Models to Ensure Primary Care Access in Nursing Homes

Grantee

Health Research, Inc. (Albany,  NY)

  • Amount: $ 438,525
    Dates: July 1992 to March 1996
    ID#:  020039

Contact

Project Director: Suzanne Moore, Ph.D., M.P.H., R.N.C.
(518) 478-1023
sxm10@health.state.ny.us

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Moore S, Koren MJ, Anderson E and Martelle MB. "Implementation of Alternative Models of Primary Care Delivery in Nursing Facilities." Nursing Home Medicine, 2(10): 199–205, 1994.

Presentations and Testimony

Moore S, Martelle MB and Koren MJ. "Primary Care in Nursing Facilities: A Correlation of Patient Values with Their Perception of Present Service," poster presentation at Agency for Health Care Policy and Research Annual Meeting, Washington, June 1993.

Koren MJ, Moore S and Martelle MB. "The Use of Concept Mapping in Defining Primary Care in Nursing Facilities," poster presentation at Agency for Health Care Policy and Research Annual Meeting, Washington, June 1993.

Koren MJ, Moore S and Martelle MB. "The Use of Concept Mapping in Defining Primary Care in Nursing Facilities," poster presentation at The Gerontological Society of America 46th Annual Scientific Meeting, November 1993.

Moore S. "Implementing and Evaluating Alternative Models of Primary Care in Nursing Facilities," paper presentation at Gerontological Society of America 46th Annual Scientific Meeting, New Orleans, November 1993.

Moore S, Koren MJ and Martelle MB. "The Use of Concept Mapping in Defining Primary Care in Nursing Facilities," poster presentation at the First Annual Public Health Symposium, Albany, NY, February 1994.

Moore S, Holmes D and Martelle MB. "Primary Care in Nursing Facilities: What is it, Who should do it, and at what cost?" symposium at Gerontological Society of America, 47th Annual Scientific Meeting, Atlanta, November 19, 1994.

Moore S and Martelle MB. "The Delivery of Primary Care in Nursing Facilities: A Pre-test, Post-test Comparison of Resident Satisfaction with Alternative Models," paper presentation at Gerontological Society of America, 47th Annual Scientific Meeting, Atlanta, November 21, 1994.

Moore S, Martelle MB and Koren MJ. "Nursing Facilities in NYS," paper presentation at the Gerontological Society of America, 48th Annual Scientific Meeting, Los Angeles, November 17, 1995.

Martelle MB, Moore S and Li S. "Changes in Quality of Patient Care as a Result of A Closed Model of Primary Care Delivery in Nursing Facilities in NYS," poster presentation at the Gerontological Society of America, 48th Annual Scientific Meeting, Los Angeles, November 18, 1995.

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Report prepared by: Karin Gillespie
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Nancy L. Barrand

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