The Evercare Model:

1. The Evercare Model: Using Nurse Practitioners to Achieve Positive Outcomes Pat Kappas-Larson, MPH APRN-BC Professional Relations/Development April 24, 2008

2. A Care Model Becomes the Foundation for a Company • The Problem: • For many people living in nursing homes, care is fragmented and uncoordinated. • This results in transfers to physician offices, hospitals and emergency departments at great physical and emotional cost to them, their families, and increased financial cost to the health care system. • The Answer: • In 1987, acompany known as Evercare engages nurse practitioners as partners and places them at the center of an integrated team delivering personalized and responsive primary care. • Evercare would ultimately become a successful Medicare demonstration project, helping to pave the way for the creation of Special Needs Plans in the Medicare Modernization Act. 2

3. Evercare: Founded in 1987 by Nurse Practitioners The Evercare Premise: • Enhance primary care services to reduce avoidable acute care hospitalizations so as to improve quality of care for permanent nursing home residents. • Align financial and clinical incentives so that nursing facilities and physicians collaborate to achieve the highest level of health and well-being for the resident. • Comprehensive and continuous advanced care planning and family communication are essential in the care of this population. 3

4. The Mission To optimize the health and well-being of people who have long-term or advanced illness, are older or have disabilities. 4

5. The Nurse Practitioner: The Clinical Model • Nurse Practitioners serve as collaborator, clinician, coordinator, coach, and counselor. • Nurse Practitioners are the center of a multi-disciplinary team that collaborates on the appropriate and proactive interventions, communicates the required changes in the plan of care to all parties, and rigorously monitors the responses. • Nurse Practitioners closely monitor changes in health and focus on early identification of any movement away from baseline functioning. • Nurse Practitioners constantly focus on reducing fragmentation of care, ensuring individualization of the care, and delivering care reflective of the values, wishes, and beliefs of the individual and their families. 5

6. Vital Engagements: The Clinical Model • Families: Who are engaged and involved in the care decisions and are available for more constant and consistent communication. • Nursing home staff: Who understand the goals of care for each resident and are intimately involved in the monitoring of the individual. • Other key professionals: Physical therapists, nutritionists and others who are available in the facility and are willing to function as part of the broader care team. 6

8. 5+ chronic conditions= 2/3 of all Medicare costs • Greatest suffering = ineffective resource utilization • 50% of people die in hospital outside of Hospice • Poor palliation services • Single condition but very high impact, e.g. quadriplegia, advanced Alzheimer’s Disease • May be functioning well, but sudden event is catastrophic Who We Serve In Our Products 8

9. Clinical Model Effectiveness: What is Attainable Today? • Enrollee satisfaction: 97% • Physician satisfaction: 90% • ER and hospital utilization for dual eligible community-based population: reduced 30% • Arizona: saved $111 million compared to FFS LTC Medicaid • Texas: saved $70 million in one county • Florida: reduced nursing home placement by 70% Unmatched clinical results… 9

10. Barriers Encountered Along the Way • A health care system focused on care in acute care settings, not on treating multiple chronic illnesses with an integrated care model responsible for the full spectrum of acute and long-term care services needed by the individual. • A dearth of staff and expertise in long-term condition management, geriatrics, and end-of-life palliation. • Lack of experience and understanding about coordination across providers and care settings. • System fragmentation and inadequate communication tools. • Resistance to working and engaging differently, accepting the need to change. 10

11. Policy Recommendations • Support initiatives that move toward innovative care models focused on coordinating high quality care across a variety of providers and settings. • Reauthorize and enhance Special Needs Plans, which focus on the needs of the chronically ill. • Transform the delivery of long-term care in all settings to support the key role of the nurse practitioner as the center of a multi-disciplinary team. • Ensure training and education for health professionals in geriatrics and chronic disease management, and support and expand existing academic programs focused on building a work force for the aging population. 11