Annals of Long Term Care

In an attempt to describe how a private group practice in geriatrics operates and the various ways in which it can be successful, Jeffrey E. Escher, MD, Acting Associate Program Director for Gerontology, and Associate Professor of Clinical Medicine, New York Medical College, used his own metropolitan New York-based practice as an example. The 20-year-old practice is located mainly in the southern part of Westchester County and the northern section of Bronx County and has contracts primarily with nursing homes, assisted living facilities, outpatient clinics, physician practice members, and nurse practitioners and physician  assistants. In reference to the nursing homes that have agreements with his practice, Dr. Escher said that, “in a way, what they’ve done is they’ve outsourced their medical care to a medical group, which is us.” The speaker explained that this type of practice is “fluid in its content and its relationships with respect to personnel and institutions” in that “we drop one, we pick up another.” In addition, physicians in this practice do not get paid a salary to go to the nursing homes—“we are only fee-for-services.” 

According to Dr. Escher, about 70% of the practice’s work involves long-term care, 15% is at the hospital level, approximately 9-10% of the practice comprises office work, and about 5% is in various forms of clinics. The speaker pointed out that his practice also conducts research, provides teaching, and is involved with home care and home visits. In terms of home visits the practice is very selective because “we find that if we are very liberal with home visits, we get abused by it,” the speaker said. “The home care basically involves the physicians’ decisions on their own as to whom they’re going to see, what their functional level is or the level of their dysfunction, and whether they think they simply cannot achieve care in a meaningful way other than with a home visit.”

Dr. Escher noted that most of his home care patients were his patients when they were ambulatory. “Primary care MD is the primary care person,” meaning that, “our practice retains primary care control, relationship, dedication to its patient,” the speaker said. “We keep the patients from various institutions in various sites in a continuum–long-term care, hospital, home visits, clinics; they stay our patients.”

There are currently five physician extenders and 25 physicians at the practice, with seven of the 25 physicians having done fellowships in geriatrics. The office staff is comprised of a nurse, two receptionists, an office manager and assistants, an accountant, someone who works on credentialing, and five billers for the practice’s in-house billing organization.

In long-term care, depending on how the practice is run and the qualities and skills of the caregiver, “we figured that anywhere from 80 to 160 residents can be handled by one person.” In addition, Dr. Escher pointed out that there is a variation in what kind of subacute care exists in each institution, so allotment is integrated into the nursing home’s overall population. A majority of acute care is performed by the primary care MD from the referring nursing home. “In terms of outpatient care, scheduled hours are integrated with respect to nursing home and acute care rounds,” said Dr. Escher. Most physicians “rarely have more than one or two half-days per week” to devote to outpatient services because “of our obligations to other practice sites and other facilities.”

“Time is money, and when we’re in this practice, we have to think about that,” stated Dr. Escher. A critique of this type of practice (which the speaker referred to as being hybrid, complex, and atypical) concerns time management that, as Dr.