BUSI 511 Week 6 Discussion Board Forum 6 Example

Discussion Board Forum 6: Managed Care, Integration and Long-Term Care

BUSI 511 Healthcare Administration, Discussion Board Forum 6

Thread by [Student Name]

The health system, the assisted living communities, the resident and the classmates are composites; the textbook, Scripture and the peer-reviewed sources cited are real.

At 2 a.m. last Thursday, an 84-year-old woman with moderate dementia arrived in our emergency department by ambulance after falling in her room at an assisted living community two miles from the hospital. It was her third fall in four months. Each time, the aide on duty found her on the floor, could not assess whether she was hurt and called 911, as the community's policy requires. Each time, we imaged her head and hip, found bruises but no fracture and sent her back with discharge instructions that no one at the community could find the next week. Her daughter told our case manager that no one had ever reviewed her mother's sedating sleep medication or the dim path from her bed to the bathroom. Our hospital spent thousands of dollars on three visits that a single nurse assessment might have prevented, and she risked a hip fracture each time.

Shi and Singh (2019) describe long-term care as a continuum that runs from informal family care and home and community-based services through assisted living to nursing homes and specialized units, with services matched to a person's functional needs. Assisted living occupies the middle of that continuum, offering a room, meals and hands-on help with bathing, dressing or medications to residents whose needs fall short of continuous nursing. The authors explain that assisted living is regulated by the states rather than by federal standards like those for nursing homes and is paid for mostly by residents and families, with Medicaid covering services in some states. Medicare pays for hospital and physician care but not for the custodial care assisted living provides. As a result, a resident like ours lives in a setting no health plan manages, staffed mainly by aides, connected to the hospital only through the ambulance. The managed care and integrated delivery models the textbook describes in its previous chapter were designed to coordinate medical care, and most of them stop at the door of the assisted living community.

Research shows how much depends on staffing and training. Hsu et al. (2026) reviewed assisted living regulations in all states and found that in 2023, 43 states required training for direct care workers, but only 28 specified training hours, with a median of just 10 hours, only 28 required dementia-specific content and only 5 required workers to pass an exam. Hua et al. (2024) linked Ohio assisted living data to Medicare claims for 12,144 residents with dementia in 455 communities and found that each added registered nurse hour per resident-day was associated with a lower risk of an injury-related emergency visit, with an incidence rate ratio of 0.59, while aide and licensed practical nurse hours showed no such association. Mao et al. (2024) followed 59,831 Medicare beneficiaries who entered assisted living in 2018 and found that residents spent 94% of the following year at home on average, with longer home time in states whose rules were more specific about direct care worker training and staffing. Registered nurse time and trained aides, in short, appear to be what keeps residents with dementia out of the emergency department.

I recommended that our hospital propose a partnership with the six assisted living communities that send us the most patients. A geriatric nurse practitioner from our hospital would visit each community weekly, review medications after every fall, train aides in dementia care and post-fall assessment and share a one-page care plan through a secure portal. We would track emergency visits, falls with injury and hospital days for residents in partner communities, and offer the model to the regional Medicare Advantage plans, which would share in the savings.

The law of Moses commanded Israel to rise before the gray head and honor the face of an old man, joining that honor to the fear of God (English Standard Version Bible, 2001/2016, Leviticus 19:32). Honoring an older woman with dementia means more than treating her kindly in the emergency department at 2 a.m. Honor for the aged is measured less by how we treat them on their worst night than by whether we organize care so that night does not come again.

Reply to Grace

Grace, your thread described the PACE program in your city as the most complete example of integrated care you had seen, and you suggested that every health system should start one. Shi and Singh (2019) describe PACE as a model that combines Medicare and Medicaid financing for frail older adults who qualify for nursing home care but live in the community, with an interdisciplinary team responsible for all of their medical and long-term care needs. That combination of pooled payment and full clinical responsibility is exactly what my thread found missing in assisted living, so I agree the model deserves attention from health systems.

Recent research supports your praise while identifying limits. Kyei and Mumba (2026) analyzed PACE using two policy frameworks and concluded that it shows strong efficacy and effectiveness, with fully integrated interdisciplinary teams and less institutionalization of enrolled older adults. They also found that the program falls short on equity because of its limited geographic reach, racial and ethnic differences in enrollment, its exclusion of people who have Medicare but not Medicaid and persistent nursing workforce shortages. Dual-eligible older adults make up a small share of Medicare beneficiaries but account for an outsized share of spending, which explains why the program focuses on them, but it also means many frail older adults with modest savings cannot join.

Training is one of the constraints a health system could address. Hodgson et al. (2026) randomized 11 PACE sites to train occupational therapists and registered nurses either in person or online to deliver an evidence-based program that helps family caregivers manage dementia behaviors, and found no significant difference in clinician knowledge, competence or caregiver outcomes between the two methods. If online training works as well as in-person training, a health system starting a PACE program could prepare its staff faster and at lower cost.

Starting PACE is a large undertaking, since an organization must build a day center, assemble a full team and assume financial risk for every enrollee's care. A health system that cannot do that immediately might borrow PACE's central features, such as the interdisciplinary team, the single care plan and the transportation to a day center, for a smaller group of high-need patients. There is also a financial question your thread could take further. PACE organizations receive a fixed monthly payment for each enrollee and must cover all care from that amount, including hospital and nursing home stays, which gives them a strong reason to prevent falls, catch infections early and keep people at home. A health system that partners with or operates a PACE program takes on that risk, so it needs reliable data on how often frail older adults in its region are hospitalized and how much those stays cost before it signs on. That analysis would also show whether a smaller version of the model could pay for itself. Would your city's PACE program be open to accepting referrals directly from hospital case managers when patients are discharged?

Reply to Victor

Victor, your thread argued that Medicare Advantage plans at your hospital slow discharges to skilled nursing facilities because each placement requires prior authorization, and you described patients waiting days in medically unnecessary hospital beds. Shi and Singh (2019) explain that managed care controls costs partly through utilization review and authorization, and that those controls shape where and when patients receive post-acute care. National evidence suggests your hospital's experience is widespread. McGarry et al. (2025) analyzed 89.3 million hospital admissions from 2017 to 2023 and found that the average stay for Medicare Advantage patients grew from 6.0 to 7.1 days, compared with 5.8 to 6.3 days in traditional Medicare. Among patients discharged to skilled nursing facilities, the adjusted probability of a Medicare Advantage stay lasting 14 or more days rose by 3.1 percentage points relative to traditional Medicare, and the authors calculated that the excess days among plan members in 2022 added up to roughly the bed capacity of 288,000 ordinary admissions.

The picture is not entirely one-sided, which strengthens your argument by making it more precise. Cao and Luo (2023) compared 271,188 patients in inpatient rehabilitation facilities and found that before the pandemic, Medicare Advantage patients had slightly longer rehabilitation stays but lower payments per episode, were more likely to go home with home health services and less likely to go to a skilled nursing facility than traditional Medicare patients, and that these differences narrowed during the pandemic. Plans may be steering some patients toward home rather than toward facilities, which can be good care. The problem your thread identified seems to arise when that steering happens through delay rather than through a quick decision.

For your hospital, I would suggest tracking avoidable hospital days by payer and by reason, separating days spent waiting for authorization from days spent waiting for an open bed, since each has a different fix. Those data would strengthen the hospital's hand when it renegotiates contracts, for example by requiring a decision within 24 hours or by allowing transfer while authorization is pending. Patients bear part of the cost as well. A frail older adult who spends extra days in a hospital bed loses strength, risks delirium and infection and may end up needing more care than when she was admitted, so delays that look like an administrative nuisance can change where a person lives for the rest of her life. Hospitals also lose money on those days, because most payments are fixed per admission, which means the hospital and the patient both have reason to press for faster decisions. A shared dashboard that the hospital and each plan review monthly could turn complaints into a joint improvement project. Has your case management department already broken down discharge delays that way?

References

Cao, Y. J., & Luo, D. (2023). Post-acute care in inpatient rehabilitation facilities between traditional Medicare and Medicare Advantage plans before and during the COVID-19 pandemic. Journal of the American Medical Directors Association, 24(6), 868-875. https://doi.org/10.1016/j.jamda.2023.03.030

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Hodgson, N. A., Hirschman, K. B., Huang, L., Summerhayes, E., Piersol, C. V., Pokrandt, P., McElroy, C., & Gitlin, L. N. (2026). Noninferiority of online versus in-person training for health professionals delivering the COPE dementia care program in PACE settings. The American Journal of Geriatric Psychiatry: Open Science, Education, and Practice, 10, 43-57. https://doi.org/10.1016/j.osep.2026.03.004

Hsu, E. C., Carder, P., Smith, L., Zhou, Z. E., Yakusheva, O., Beeber, A., Jutkowitz, E., & Thomas, K. S. (2026). A profile of assisted living direct care workforce training requirements across the United States. Journal of the American Medical Directors Association, 27(10), 106445. https://doi.org/10.1016/j.jamda.2026.106445

Hua, C. L., Nelson, I., Cornell, P. Y., White, E. M., & Thomas, K. S. (2024). Changes in nursing staff levels and injury-related emergency department visits among assisted living residents with Alzheimer's disease and related dementias. Journal of the American Medical Directors Association, 25(8), 105087. https://doi.org/10.1016/j.jamda.2024.105087

Kyei, E. F., & Mumba, M. (2026). Integrating care for aging populations: Dual-framework policy analysis of the United States Program of All-Inclusive Care for the Elderly (PACE). Journal of Advanced Nursing. Advance online publication. https://doi.org/10.1111/jan.70595

Mao, Y., Li, Y., McGarry, B., Wang, J., & Temkin-Greener, H. (2024). Home time and state regulations among Medicare beneficiaries in assisted living communities. Journal of the American Geriatrics Society, 72(3), 742-752. https://doi.org/10.1111/jgs.18709

McGarry, B. E., Wilcock, A. D., Gandhi, A. D., Grabowski, D. C., & Barnett, M. L. (2025). Extended hospital stays in Medicare Advantage and traditional Medicare. JAMA Internal Medicine, 185(11), 1362-1369. https://doi.org/10.1001/jamainternmed.2025.4411

Shi, L., & Singh, D. A. (2019). Essentials of the U.S. health care system (5th ed.). Jones & Bartlett Learning.