Annals of Long Term Care

On-call rotations are stressful for most clinicians. Taking on-calls for the nursing home (NH) population presents many challenges for covering clinicians, who may not be familiar with geriatrics practices and patient presentations. Information related to the patient condition may be communicated adequately from the nursing staff, but the clinician may not be familiar with NH capabilities of care and other mitigating circumstances. Liability and the ability to assess the best place of care based on patient changes in condition can make for difficult decision-making.

The Evercare Model
Evercare is one of the nation’s largest care coordination programs for people that have long-term or advanced illness and disability. The Evercare model using the nurse practitioner/physician assistant (NP/PA) as the center of an integrated team (includes the physician, patient and family, and NH) detects changes of condition earlier and provides more proactive care management. NH patients can be treated in place more readily, thereby avoiding costly and debilitating trips to the Emergency Department (ED).¹ Evercare is part of Ovations, which is a division of United Health Group. At the Evercare New England site, NP/PAs, physicians, and care managers serve residents in NHs and persons who live independently in their home.

Evercare is a model that Robert Kane looked at in a study published in the October 2003 issue of the Journal of the American Geriatrics Society, in which hospitalizations were reduced by 45% with no change in mortality. Kane also found reduced ED visits and decreased acute episodes in the NH setting. Kane reported that the Evercare model, which focuses on holistic care and early intervention, was directly responsible for the positive results.^2,3 Another source that did not participate in a study about Evercare estimated that 55% of ED visits are not medically necessary.4 It is reported that physicians who have patient panels at skilled nursing facilities receive an average of 49.5 calls per patient per year.⁵

Evercare New England, which includes Massachusetts (MA) and Rhode Island (RI), has an on-call system to complement the high-touch care provided by the collaborative primary care teams in the NH. The on-call program provides service to Evercare members in approximately 169 NHs in MA and RI from 5:00 PM to 8:00 AM, and 24 hours on weekends and holidays. Our on-call staff includes telecommuters and rotated NP/PAs who work collaboratively in teams with physicians as back-ups to provide the on-call service. Our average metrics are 37 calls made or received from 5:00 PM to 8:00 AM and 113 calls from 8:00 AM to 5:00 PM made or received on weekends and holidays. We estimate that we avoid unnecessary hospital transfers without loss of quality for two to four members per shift. The avoidance of unnecessary acute transfer has proven to be cost-effective. The savings from avoidance of unnecessary transfers is over 100% of the cost of the on-call program. Our goal is to provide continuity of care and to ensure that care is delivered in the appropriate setting.

In order to manage these calls effectively and efficiently, the system is structured to have teams of NP/PAs on call. The on-call staff consists of clinicians whose full-time job is to take calls along with NP/PAs who care for patients from 8:00 AM to 5 PM who volunteer for rotation into the on-call shifts. The full-time on-call staff works a combination of 5:00 PM to 8:00 AM and weekend shifts each week. The rotated staff works as the structure changes with review of metrics and can be adjusted to enable the on-call clinician to be successful in the delivery of high-touch telephonic care in the appropriate setting.

All on-call clinicians attend a seminar and have a mentoring period with a seasoned on-call clinician.