Reducing the likelihood of long-stay nursing facility placement through health plan-linked community services.

When I mention to people that I work full time in a nursing home, I often see reflected on their faces a measure of thedistaste that society has for nursing homes. I suspect tax collectors experience a similar phenomenon. As a geriatrician, I recognize that nursing homes are a necessity for some, but that nursing home placement implies a series of trade-offs of cost and institutional environment versus the provision of complicated and relatively intensive care. Generally this makes us consider the nursing home as a placement of last resort. Although much attention has been paid to factors triggering nursing home placement from the home or hospital, much less attention has been devoted to factors that prevent a short-term, putatively rehabilitative stay in a nursing home from converting to a permanent long-term placement. Social health maintenance organizations (S/HMO) were an experiment in the provision of extra services to a subset of members of a managed care cohort that were considered to be at highest risk for poor outcome. S/HMOs were intended to parlay a small premium in federal capitation payments to a health maintenance organization (HMO) by using screening instruments to identify a subset at high risk for expensive care and then provide targeted services including care coordination and some long-term care benefits in an attempt to avoid adverse and expensive outcomes. One mechanism used by the 4 S/HMOs that until recently remained active was to offer additional homeand community-based services to members of the S/HMO that were eligible for nursing home certification under their state’s criteria. Although the Medicare disability-based payment system that funded the remaining S/HMOs after the demonstration project ended in 2004 has been phased out, there are still lessons to be learned from this model. In this issue, Thomas et al compare the Medicare fee-for-service model that most of us are experienced with to an S/HMO.