Geriatric nurse practitioners in long-term care: demonstration of effectiveness in managed care.

OBJECTIVE: This study was undertaken to review the impact of utilizing geriatric nurse practitioner/physician (GNP/ MD) teams on cost and utilization for a cohort of Medicare HMO enrollees residing in long-term care facilities. The results would be used by the organization for further development of the GNP Program. DESIGN: A 1-year retrospective data analysis on revenues and cost for 1077 HMO enrollees residing in 45 long term-care facilities. SETTING: Proprietary and not-for-profit, licensed long term care facilities in the HMO's service area of central Massachusetts. Facilities in the study had both skilled (Medicare-certified) and custodial beds. MEASUREMENTS: Data were collected retrospectively on overall cost, revenues, emergency department (ED) transfers, hospital, and subacute days. RESULTS: Of 1077 residents, 414 were cared for by GNP/MD teams compared with 663 by physicians alone. Acute care and ED costs were significantly lower for the GNP/MD-covered patients. There was a gain of $72 per resident per month (PRPM) with the GNP/MD-covered patients compared with a loss of $197 PRPM for physicians alone. There were no significant differences in ancillary services or prescriptions. CONCLUSION: The use of GNPs in collaboration with physicians reduced ED and acute care utilization costs as well as overall costs for a cohort of HMO enrollees in long-term care. This encouraged the HMO to support the concept that all long-term care HMO residents should be covered by GNP/MD teams.

A reduced order extended Kalman filter for sequential images containing a moving object.

The extended Kalman filter (EKF) is applied to the reduction of noise in sequential images containing a moving object and to the estimation of the object's velocity. A computationally tractable approximation of the EKF, called the parallel extended Kalman filter (PEKF), is generated. The PEKF consists of a parallel bank of third-order EKFs, operating on the Fourier coefficients of the image, followed by a finite impulse response filter. The PEKF is shown to converge to the optimal (in the mean square sense) algorithm in the limit as the velocity estimation errors approach zero. The performance of the PEKF is demonstrated for very low signal-to-noise ratio (SNR) images. The PEKF also provides a natural setting for tracking slow changes in the object (real or apparent) and its velocity, since these variations are included in the model. The relation of the PEKF to another frequency domain algorithm for velocity estimation is discussed. The algorithm is illustrated by application to an example and its performance is demonstrated in the presence of velocity estimation errors.

Lessons learned in managed care.

Competition, reduction in health care premiums, rising health care costs, aging of the population, and technologic advances are several factors that create both challenges and opportunities for managed care organizations (MCOs). The demands to constantly improve quality of care and efficiency of operation while holding down costs are drivers meant to stimulate organizations to constantly strive to rethink their process of care provision. The most cost-effective program is one that maintains its health plan members who are active in the community and away from the institutional setting. This is optimally achieved through an accessible and comprehensive ambulatory practice. Innovation and paradigms of practice change in the acute, subacute, and long-term care arenas have allowed us to dramatically impact quality and utilization in these expensive areas, while at the same time freeing up additional time for MCO primary care practitioners to focus on their community-based patients. MCO primary care providers have not only supported but welcomed these changes in their organization, recognizing that these innovations represent a component of the continuum of health care needed to effectively serve their patients.

A geriatric nurse practitioner/physician team in a long-term care setting.

A large Massachusetts group practice and affiliated HMO studied the effects of a geriatric nurse practitioner/physician team on quality and cost of health care delivery in a long-term care setting. A geriatric nurse practitioner (GNP) was recruited to work with one physician in three nursing homes. The GNP/MD team made joint routine visits; the GNP provided primary care, including episodic visits as needed. After one year, a retrospective chart review was conducted comparing the periods before and after the implementation of the GNP/MD team. There was a 26% reduction in hospital admissions, and a decrease in the total number of hospital days after the GNP/MD team was implemented. Patients, nursing staff, and physicians all expressed satisfaction with the program. This study suggests that significant cost savings and increased quality of care can result from the implementation of a GNP/MD team in a long-term care facility.

Nonlinear correlation for estimating the motion of multiple objects in image sequences.

A nonlinear correlation algorithm is proposed for estimating the motion of objects from an image pair. This algorithm requires no a priori information on the number, size, or shape of the moving objects and does not require feature extraction or segmentation of either image. The algorithm directly yields information on the number of moving objects, the motion of the objects, and the size of the objects. Additional processing can be performed to yield the centroid of the objects in either frame. The utility of the resulting algorithm is demonstrated by application to a pair of example image sequences.

Tilt Estimation in Moderate-to-Strong Scintillation.

Adaptive optics systems are being applied in ever more challenging environments, for example, the projection of lasers over long horizontal paths through the atmosphere. These long atmospheric paths corrupt the signal received from the beacon and typically yield highly scintillated received wave fronts. Tilt estimation for controlling the fast steering mirror in these systems is complicated by the presence of branch points in the scintillated received wave fronts. In particular, correlation between the tilt and the projected beam's centroid error at the target has been observed in horizontal laser beam projection experiments. The presence of this correlation indicates that better tracking performance should be achievable. We compare the performance of four estimation schemes applied to tilt estimation in a horizontal laser projection system. It is demonstrated that all four schemes underestimate the tilt required to return the laser beam to a target in highly scintillated environments. A method of correcting this tilt is presented, and the expected performance improvement is quantified.

Demonstration of the cost-effectiveness of a nurse practitioner/physician team in long-term care facilities.

To an HMO with a Medicare risk contract, providing high-quality medical care to a nursing home resident may generate considerable costs. To address this issue, Fallon initially assigned each primary care physician to just one nursing home. The program was successful in that coverage of all Fallon patients admitted to nursing homes was assured. In a pilot project 5 years ago, a geriatric nurse practitioner (GNP) was hired to provide primary and episodic visits to nursing home residents in three area nursing homes. Research was conducted to determine the effectiveness of a GNP-MD team. Based on positive outcomes, additional GNPs were recruited. In the current follow-up study, a review of the 1992 fiscal and utilization data for nursing home patients revealed significantly lower rates of emergency room transfers, hospital lengths of stay and specialty visits for patients covered by GNP-MD teams, as compared to patients covered by physician only. Nursing home drug costs, skilled nursing days and primary care visits were higher for patients covered by the teams, but the differences were not statistically significant. Overall costs were 42% lower for the aggregate pool (skilled nursing plus intermediate care) and 26% lower for those with long-term stays.