How UnitedHealthcare, Optum have teamed up to boost outcomes for nursing home patients 

A new study examines UnitedHealthcare and Optum's program to manage skilled nursing facility patients' care. (GagliardiPhotography/Shutterstock)

The joint efforts of UnitedHealthcare and Optum to manage care for seniors in nursing homes has paid off in substantially fewer hospitalizations and emergency department visits, a new study shows. 

Researchers at Harvard Medical School tracked clinical service use among members of UnitedHealthcare’s Medicare Advantage Institutional Special Needs Plans (ISNPs), which, in conjunction with Optum’s provider services, place an additional advanced practice clinician on-site to assist with care management for members. 

These clinicians help fill in gaps for nursing home staffers that may be stretched thin and design and manage care plans for patients that involve other clinicians in the facility, primary care physicians and any other providers. 

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The study, based on data from 2014 to 2015, found that seniors enrolled in the plan saw 38% fewer hospitalizations, 51% fewer emergency department visits and 45% fewer readmissions compared to seniors in fee-for-service Medicare. 

RELATED: The downside of Medicare Advantage—Members more likely to end up in low-quality nursing homes 

Ronald Shumacher, M.D., chief medical officer at Optum Care Services, told FierceHealthcare that the added on-site clinician allows for far more acute concerns to be treated without the need for a trip to the hospital or ED. 

“We're able to manage a lot of those conditions right there in the nursing facility without the need to move somebody out to the hospital,” he said. 

Shumacher said the program’s roots date back to the mid-1990s, as UnitedHealthcare wanted to address the challenges that are endemic to this population. 

For example, in addition to the enhanced care management, UnitedHealthcare waives the so-called “three-day rule,” which requires a patient spend at least three days in the hospital before he or she is eligible for skilled nursing care. 

As a result, the researchers found 112% higher use of skilled nursing facility stays among the patients enrolled in the program. 

RELATED: The biggest discharge planning hazards faced by hospitals 

Plus, patients in a nursing facility often have complex chronic conditions in addition to an acute illness, and management of those conditions may not be as effective in the hospital setting, Shumacher said. 

These patients may return to the nursing facility in worse health than before the hospitalization, Shumacher said, so having a care team that can manage acute concerns on-site is a key strategy to reduce unnecessary hospitalizations and boost outcomes. 

“They’re able to avoid those kinds of outcomes by taking care of people in the facility,” he said. 

The model could also drive significant cost savings, the study found. If Medicare fee-for-service beneficiaries saw similar reductions in unnecessary hospital care, it could lead to savings of $1.6 billion per year. 

Shumacher said the Harvard team’s results track with internal results monitored by the UnitedHealthcare team. The program was last studied in a peer-reviewed journal more than a decade ago, he said. 

“It’s been a while, and this is really validating to see the results held,” Shumacher said. 

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