At the heart of the Evercare Care Model are the Nurse Practitioners and Care Managers (registered nurses and social workers), who help develop and manage personalized care plans for members. They coordinate multiple services; help facilitate better communication between physicians, institutions, patients and their families; and help ensure effective integration of treatments. Evercare staffs approximately 1,800 NPs and Care Managers, with specialized geriatric training, across all of their programs.

In order to most efficiently and effectively manage the population it serves, Evercare has developed four levels of care, with each level involving different priorities and focus of care provided by the NP or CM. Nurse Practitioners and nurse or social worker Care Managers have information resulting form a health risk analysis for each individual that places them into one of four care levels:

• Level 1 individuals are primarily healthy and living independently. Level 1 individuals’ primary needs are service and education, which are met through phone-based services and mail. Care Managers in centralized call centers assist these individuals. Level 1 individuals also receive preventive health reminders via mail. Each Care Manager manages a panel of approximately 2,000 people.
• Level 2 individuals have at least two health care conditions and receive one-on-one time with a Care Manager telephonically. Care Managers facilitate care and coordinate community services as needed. Each Care Manager works with approximately 450 members, depending on members’ needs and geographic distribution.
• Level 3 individuals have numerous chronic conditions and/or significant functional disabilities. They may live at home or in a nursing home or long-term care facility (including assisted living). For community-based individuals, Care Managers coordinate care and community services. For individuals living in a facility, Nurse Practitioners coordinate and provide care. CMs and NPs meet frequently with families in order to discuss the patient’s care needs and progress and to address end-of-life issues and jointly prepare the treatment plans. Each NP or CM manages approximately 100 individuals depending on their geographic distribution.
• Level 4 is for members with advanced illnesses in the last year of life. Nurses provide hospice and palliative care services where the person resides—in her/his home, long-term care facility or nursing home. The focus of care is to adapt and respond to the needs of the individual and their families, minimize symptom burden, improve the quality of life, and honor and support the individual’s unique values and beliefs. If the individual resides in the community, the nurse-to-member ratio is approximately 1:60, and if they are in a long-term care setting, the ratio is approximately 1:100.

A 2001 analysis of how Evercare NPs working with nursing home-based members spend their time found that NPs spend approximately 35 percent of their time on direct patient care (about 42 minutes per patient on a given day). NPs spend an additional 26 percent of their time on indirect patient care (about 20 minutes per patient on a given day). Within indirect patient care, 46 percent of the time is spent with nursing home staff, 26 percent with patient families and 15 percent with physicians. The final 20 percent of NP’s time is devoted to administrative tasks.

Evercare also staffs RNs as Transition Coaches to help high-risk patients who are hospitalized make a successful transition home or to another care setting. The goal of the Coaches is to help reduce rehospitalizations and avoid adverse events during the periods of transition. Evercare is working with Dr. Eric Coleman’s The Care Transitions Program^SM in developing and deploying Transition Coaches.

Evercare’s NPs and Care Managers provide holistic care by helping individuals manage their identified conditions, avoid or prepare for the potential functional changes, and proactively manage their related psychosocial/behavioral conditions. The NPs and CMs try to predict for an individual when and how changes in their condition might occur and educate individuals and their responsible parties about how to recognize those changes and when to alert the NP or CM. This requires rigorous monitoring of those who are unstable or prone to changes in their condition and status, as well as the timely establishment of a care plan to limit the impact of a status change.

The NP or CM is responsible for coordinating a full range or services, including home health aides, medications, social work, and a network of all physician specialties and hospitals. The proactive, timely coordination is intended to improve members’ quality of life and reduce unnecessary costs. Proactive care includes activities such as vision testing, depression screening, and hearing testing, each of which can help prevent injuries from falls or other adverse events.

Evercare deploys a proprietary patient information system, Care One, through which the CMs and NPs have access to patient assessments, services rendered, and medications prescribed for each individual. This data repository allows immediate access to a full array of patient information that supports communication with the integrated care team and helps smooth patient transitions across care settings and levels of care. This computerized system houses clinical protocols and provides access to a wide array of clinical resources.