Quality of Care Provided in a Special Needs Plan Using a Nurse Care Manager Model

OBJECTIVES: To comprehensively evaluate the quality of care provided in special needs plans (SNPs; Medicare Advantage plans that aim to provide specialized care for complex older adults) and specifically the nurse care management model in the community setting. DESIGN: We adapted 107 process-of-care quality measures across 12 conditions from the Assessing Care of Vulnerable Elders set to obtain a clinically detailed evaluation of the quality of care received by complex older enrollees in a dual eligible Evercare SNP. We abstracted 13 months of primary care medical records to delineate quality of care provided by physicians and whether there was value added from the nurse care manager model. SETTING: Dual eligible Evercare SNP located in central Florida. PARTICIPANTS: Two-hundred thirty-one vulnerable older enrollees in the SNP who had complex disease. RESULTS: Based on physician medical records alone, the 231 high-risk participants (mean age 77, 67% women) received recommended care for 53% of 5,569 evaluated clinical circumstances, ranging from 12% for end-of-life care to 78% for diabetes mellitus. In fewer than 40% of these clinical circumstances was recommended care provided for dementia, falls, and urinary incontinence. In a second analysis accounting for care provided by both the Evercare nurse and the physician, recommended care was provided to patients in 69% of the 5,684 evaluated clinical circumstances. CONCLUSION: Comprehensive quality measurement applied to vulnerable older adults enrolled in one mature SNP showed that the Evercare nurse model addresses important deficits in physician care for geriatric conditions. Such measurement should be applied to other SNP models and to compare SNP care with that for complex, older, fee-for-service Medicare cohorts. J Am Geriatr Soc 59:1810-1822, 2011.