Integrating Nursing Home Care in Managed Care

By Penna, Richard D. Della | Generations, Summer 1999 | Go to article overview
Save to active project

Integrating Nursing Home Care in Managed Care

Penna, Richard D. Della, Generations

Twenty years ago, the level of care delivered in nursing homes was easily distinguished from that provided in acute-care hospitals. Nursing homes assisted and supported elderly "custodial" residents with activities of daily living and provided maintenance care for chronic stable medical conditions. They did not generally care for their residents when they developed acute illnesses and required more intensive medical treatment and nursing services. Residents who became ill were sent to the hospital for that care. Financial incentives for physicians and hospitals encouraged this process and reinforced the status quo. There was little motivation for nursing homes to develop the capacity to care for acutely ill residents or for physicians to manage their illness in the nursing home setting. Hospitals, reimbursed on a per-diem basis, were willing providers of acute care for nursing home residents, and physicians received higher reimbursement when caring for their patients in the hospital. Hospitals provided required medical treatment to nursing home residents until therapy was completed. Of course, some geriatricians called for a different model (e.g., Ouslander, 1988; Olsen et al., 1993).

In the first half of the 1980s, two modifications in the financing of healthcare acted as catalysts for the process that changed the ability of nursing homes to provide higher acuity care. These changes were Medicare's prospective payment system to reimburse hospitals for treatment for beneficiaries and the introduction of capitated payments to health maintenance organizations for Medicare patients (also referred to as Medicare "risk contracting" or "risk plans"). As a result of these changes, today many nursing homes provide "subacute" or "super-skilled" care that previously could only be provided by hospitals. In the past, for example, nursing home residents typically received treatment for pneumonia and urinary tract sepsis only in the hospital. Now residents regularly receive treatment for these conditions in the nursing home.

These changes also have affected the. way community-dwelling elders may receive care for acute problems. An increasing number of them receive all or most of care for acute illness in a nursing home rather the hospital. Treatments for some serious illnesses may begin in the hospital but often are completed in the nursing home. Some community-dwelling elders with problems such as dehydration or compression fracture are commonly evaluated in an emergency department and then sent to a nursing home for treatment, with no hospitalization.

This care path, however, is premised, first, on nursing homes having developed the capability to safely manage these admissions and, second, on physician willingness and time to direct care in the nursing home.

Policy makers and health plans envisioned medicare managed care as an opportunity for better integration of care for the elderly. Capitation would remove barriers and allow health plans and providers to become more efficient in providing seamless care for elders. Efficiency not only meant eliminating fragmentation and waste but actually improving care and continuity. However, these outcomes are yet to be demonstrated (Wagner, I996). Medicare risk plans vary greatly in the way they organize the components of their delivery systems. At one end of the spectrum are health plans that contract for all care and services with multiple providers and vendors. At the other end are staff and group practice organizations in which all care is provided within a single system of care.

An overview of Medicare managed care today finds that some positive changes have occurred. These include improved benefits such as medication and dental coverage coordinated programs for influenza immunization, disease management coordination, and programs specifically for frail elders. However, Medicare managed care has not by and large met the fundamental challenge of minimizing or eliminating the fragmentary nature of care delivery.

The rest of this article is only available to active members of Questia

Sign up now for a free, 1-day trial and receive full access to:

  • Questia's entire collection
  • Automatic bibliography creation
  • More helpful research tools like notes, citations, and highlights
  • Ad-free environment

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Project items

Items saved from this article

This article has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this article

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Cite this article

Cited article

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)


1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

Cited article

Integrating Nursing Home Care in Managed Care


Text size Smaller Larger
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

While we understand printed pages are helpful to our users, this limitation is necessary to help protect our publishers' copyrighted material and prevent its unlawful distribution. We are sorry for any inconvenience.
Full screen

matching results for page

Cited passage

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.