Community LTC, HCR ManorCare, and Mark Gloth

Abstract

This is the third in a series of columns that examines long-term care provider organizations that serve people in both facility-based settings and home- and community-based settings, as seen through the eyes of the chief medical officer (CMO). Previous articles have covered the Good Samaritan Society and Golden Living. This column spotlights HCR ManorCare and its chief medical officer, Mark J. Gloth, DO, MBA. With more than 55,000 employees, HCR ManorCare, headquartered in Toledo, OH, is a network of more than 500 skilled nursing and rehabilitation centers, assisted living facilities, outpatient rehabilitation clinics, and hospice and home health care agencies providing services in 34 states. A subsidiary corporation, Heartland Care Partners, is a professional medical practice that employs and manages medical directors, physicians, and nurse practitioners in 32 states. The organization’s current business strategies have been greatly affected by the focus on transitions of care, resulting in the geographical consolidation of posthospital providers and service lines. Since 2014, HCR ManorCare has been working with Optum on a Center for Medicare & Medicaid Innovation (CMMI) initiative, BPCI (Bundled Payments for Care Improvement) Model 3 in the Detroit, Chicago, and Philadelphia markets. This bundled payments initiative links the payments for multiple services that beneficiaries receive during an episode of care. In Model 3, the episode of care is triggered by an acute care hospital stay and begins at the initiation of post-acute care services with a participating skilled nursing facility, long-term care hospital, inpatient rehabilitation facility, or home health agency. Home and community-based services (HCBS) – through home health and hospice – are a part of HCR ManorCare’s business strategy. The company has also made a significant investment in developing a case management model that positions the registered nurse as a “transitions of care” coach. Dr. Gloth is also vice president for HCR ManorCare and has served in that capacity since 2005. His responsibilities include executive and operational oversight of medical services for the organization’s 500 sites of care, as well as for the company’s subsidiary corporation, Heartland Care Partners. Dr. Gloth is board certified with training in internal medicine, geriatrics, and physical medicine and rehabilitation. Dr. Gloth explained some of the joys and challenges of his role as CMO, particularly the move from direct clinical practice to the “virtual reality” of life in the corporate office and structure – the well-recognized shift from patient contact to interactions more broadly within the field, and the ability to influence quality of care and quality of life through education, systems design, and program development. The challenges are different, too, or at least they are on a different scale. Working systematically with 750 contracted physicians and 2,000 attending physicians across the organization, Dr. Gloth continually addresses issues related to consistency of medical care and the standard of care. Although it is universally acknowledged that the level of medical care is increasing dramatically, that consistency is getting better “as the paradigm of care changes,” Dr. Gloth told Caring for the Ages. The paradigm shift begins with another universally recognized trend: patients are leaving the hospital quicker and sicker. The PA/SNF settings of today look like the medical/surgery units of yesterday. What was formerly hospital-based care is shifting to the PA/SNF and HCBS settings. The pressures and requirements for the clinical systems of those respective systems are different and unique. To Dr. Gloth and HCR ManorCare, that paradigm shift and focus on transitions of care require systems that mitigate patients bouncing back and forth between settings of care. For example, Dr. Gloth pointed out “tool boxes of care” that target disease states (e.g., chronic obstructive pulmonary disease, congestive heart failure). In one of these tool boxes in the PA/LTC setting, the physician or nurse practitioner focuses on the first 72 hours, the 3 to 7 day window, and the 30-day window, targeting interventions to the particular disease state, in which “if you do nothing else, you must maintain the evidence-based standard of care,” Dr. Gloth said. In the home health or hospice setting, “tool boxes” become “disease management guidelines,” with an emphasis necessarily shifting to nursing: what to watch for, what information to report, and when. It’s important to have guidelines that are specific to the care environment. Given that there are differences in care delivery systems between facility-based and home-based care, are physicians who are effective in one naturally good in the other? “I used to think that ‘a good doc is a good doc,’ but there are variances,” Dr. Gloth said. “In both settings, you have to have an appreciation for and confidence in the clinical capabilities of the care setting. In both, you need effective relationships with the care team.” Important things that physicians practicing in home-based care settings need to know and embrace include an ability to work with less information or frequency of information; different resources than institutional PA/LTC settings; the need for time to ask questions – of patients and of staff; the areas of risk and liability and strategies to mitigate them; and the regulatory environment in which program managers operate. HCR ManorCare has a deliberate process for screening and developing its contracted physicians and medical directors across the continuum. Each is interviewed personally by the CMO. Each is educated on the clinical and operational tool box, and within the first 6 months, attends a medical director training seminar with essentially an SNF or Home Health and Hospice 101 curriculum. Monthly continuing education webinars are offered to physicians and medical directors, while contracted attending physicians and nurse practitioners receive training on topics covering electronic health records and legal, regulatory, and pharmacy issues. Both didactic and case study formats are used, but all focus on evidence-based medicine. After 2 years or more of service, attendance at a national conference – AMDA or American Geriatrics Society – is supported. Dr. Gloth looks for physicians who are familiar with PA, SNF, hospice, or home health care settings, and the continuum of care. They need not be geriatricians, but it is important for them to be board certified. “It’s not about ‘how many patients can you send me?’ but ‘why do you do this?’ ” Dr. Gloth said, adding that he stays personally connected to the physicians. He said he talks to a physician somewhere virtually every day. What does Dr. Gloth see on the horizon from his vantage point as CMO? Because of the higher acuity that is cascading down through the continuum, he pointed to several increasing trends: ▸More medical and clinical investment in SNF settings; decreasing investment in long-term acute care settings.▸Case mix/rehabilitation focus.▸More “money follows the patient” models, including coverage for assisted living.▸Home health on the cusp of another boom.▸More opportunities for growth in telehealth.▸Expanded role of nurse practitioners as part of care delivery.▸Increased use of hospice and focus on palliative care.▸Increased focus on chronic disease processes, advance care planning, decisions about life-sustaining treatment, and empowering people with health care decision making. Exciting and challenging times are ahead in health care, Dr. Gloth said. There is a distinct need for good physicians, particularly in the PA environment, and there are clinical practice opportunities for those who are able to recognize, adapt, and respond to them. Dr. Gloth is a passionate, articulate, and focused voice in this environment, and certainly one worth paying attention to.