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How to integrate primary care as a service line in CCRCs

October 20, 2014
by Pamela Tabar, Editor-in-Chief
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The next hot service line for continuing care retirement communities (CCRCs) could be one that has traditionally been outside the long-term care settings—primary care. Organizations that are working to integrate primary care delivery within their company models are encountering worthy successes and slippery pitfalls, noted presenters at this week's LeadingAge conference in Nashville, Tenn.
A CCRC's choice of primary care model depends on how much risk is economically tolerable, whether the primary care will be for profit and whether the clinicians will be partners or employees under the corporate operating umbrella, explained Jared Landis, practice manager of the post-acute care collaborative at The Advisory Board, a best practices research firm. Partnering with a physician practice can be fine for residential models, but collaboratively partnered or company-employed clinicians can be a better choice for long-term care (LTC) campuses that are more involved in risk-sharing and cost-saving models.
Although the staff ratios can vary, "to make this work financially, team-based care is a must," Landis said. A clinician team usually needs to see 14 to 17 patients per day just to break even, and teams often must travel from site to site.
Agape Senior, a multi-site, multi-service long-term care provider in South Carolina, is working with The Advisory Board on its primary care delivery model. At Agape's 10 assisted living communities, a clinician team typically visits each community two or three days a week, four hours a day. But at its skilled nursing sites, a primary care physician (PCP) is onsite five days a week, eight hours a day. It enables Agape to accept higher acuity referrals from hospitals and to do its own transfers from assisted living to skilled nursing without using a hospital visit in between.
"We decided we really wanted to employ our physicians. We wanted to have more control over the process, and wanted to be able to address wellness and prevention," said Theresa Younis, Agape's COO. "We want the clinician to see the patient and build that relationship. Providers can meet with families and discuss options for residents experiencing decline, so it isn't catastrophic to move to a higher setting of care."
Agape saw another benefit: It could urge physicians to save costs by sticking closer to the organization's formulary—and to assess residents for dangerous polypharmacy.
In proving the economic viability of providing primary care on LTC campuses, the hardest part may be aligning the goals of salary with clinicians. Most successful models involve incentives for productivity, of course. But some companies are applying creativity to increase engagement: Agape's productivity formula uses billing and collections rather than relative value units (RVUs), a reimbursement system used by most hospitals. 
At Bluestone Physician Services, headquartered in Stillwater, Minn., clinician teams travel among sites and use a strong delegation structure to increase efficiency. Support staff works to reduce no-shows and keep the physicians on schedule. Under the company's volume-based incentives, the entire team wins when productivity goes up.
Erickson Living, headquartered in Baltimore, has taken the primary care delivery concept several steps further by co-managing its own health plan with UnitedHealthcare, providing everything from primary care to podiatry and mental health services. Under Erickson's team-based clinician approach, each CCRC has its own team.
Most organizations experimenting with primary care services on the LTC campus have sought the perfect ratio for staff skills on a care team—top-notch and timely care, yet streamlined efficiency to help physicians see more patients per day. Agape has settled on one MD, three nurse practitioners and one medical assistant per team. 
Proper planning can make or break an organization's foray into primary care services, said Agape's Younis. "It took a lot of outreach and engagement, but we've seen an incredible return on investment." 
Plenty of choices lie ahead as the LTC market moves deeper into population management and risk-sharing. Accountable care organizations and health plan-based provider models are often in direct competition with each other, Landis explained. Yet those venturing into primary care models are betting that the benefits woven into better wellness management and chronic disease monitoring will pay off in the end.