Forging partnerships isn’t just about trying to crack into preferred referral networks, according to one CEO. It’s about getting ahead of government changes and other market factors, and defining your company’s role in a specific region — instead of allowing regulators and partners to do it for you.

Most SNFs know they need to keep track of their readmissions, but Julianne Williams, co-founder and CEO of Dycora Transitional Health and Living, told Skilled Nursing News that SNFs have to go beyond their internal metrics. It’s not enough to be aware of what’s happening in house, she explained. SNF providers have to know what’s going on outside their own walls.

The Clovis, Calif.-based Dycora, which has 19 SNFs in the Golden State and eight in Wisconsin, has made this strategy a priority. Williams, who worked for 25 years at Plano, Texas-based Golden Living — eventually serving as president of the skilled nursing chain — caught up with Skilled Nursing News about changes in the industry and why providers should think about narrowing their own networks, even as hospitals do the same to them.

Can you talk about how you’ve seen SNFs change over the course of your career?

I’m in my 28th year, so I look back when I started in in my management of nursing homes, at a facility that is now in our portfolio: the Clovis facility, a 57-bed building. I was an administrator there, and we were full every day. We had a two-year waiting list for private-pay patients; we were really able to pick and choose what we wanted to focus on. Back in those days, that facility didn’t have anybody that was clinically complex.

Now that same facility has a very healthy Medicare population, short-stay patients. Obviously we do long-term care, but they have a good mix of short-stay.

When you look at the transformation in long-term care, we’ve gone, I think, from almost a space that was meant to provide care for the chronically ill over a long period of time and instead — while we do that — the types of residents that we have obviously have more co-morbidities, lots of medications, lots of other things going on. In addition to that now, some of us have units that look almost like a med-surg floor; we’ve got people on IVs and some people have sub-acutes with ventilators. It’s just very different than when the industry started.

At the National Investment Center for Senior Housing & Care (NIC) fall conference in Chicago, you talked about the importance of regional strength. How have you approached building this at Dycora?

The way we are laid out geographically, we’ve got three or four dense markets, meaning multiple facilities in a market. Especially where I am, here in Fresno, Calif., we have a lot of beds: 700 beds in the county. And that’s a lot. If you have density and you have a number of centers, you can really look and see: What are the needs? And because we have multiple sites, we’re able to tailor certain sites to certain needs. When you do that, you’re also able to attract staff that are passionate about certain kinds of care — maybe somebody’s really passionate about respiratory care, or ortho, or whatever it is. Then you can have them work in their passion.

The other thing is: We know in the medical field, the more you do something, the better it is, right? I think there’s a little bit of that as well, which is our staff has the opportunity to work with a lot of people with a condition, and it just continues to grow their competency and their expertise.

In our regional markets, what we’re really trying to do is be a provider of choice in many, many ways. We are not limited by one facility or one wing. That allows us to really evaluate what’s needed, and then develop the programs that are needed in the community.

It also gives you strength in talking to your referral sources because where we have a lot of beds, the partnership is going to be stronger. We see that as a real blessing and opportunity, because then we’re able to have the conversations that maybe we wouldn’t be able to have if we just have one facility out of 20. I just think you become a lot more relevant.

I think it’s a really exciting time to be where we are, especially for people who want to come work in the field. The last three to five years, we’ve really seen the recognition of the great things we do, and how they’re needed in the health care continuum.

What do you recommend for SNFs that are just starting the process of building up those partnerships?

Like everything else, a lot of it is based on relationships. It’s incumbent upon us to tell our story, because how else do you tell a hospital system or home health agency to refer to you? If you don’t start the conversation, then nobody else will.

So I would say the first and most important thing is to understand what’s going on within your community and your market. Then it’s up to you to come up with a solution. One thing in our profession that I said for a lot of years — and we are better, I think, now — is that we get new regulations, and we didn’t get involved, and then we’d complain: “How can they do this to us?” Now we have to go out there and be proactive. We can’t let people define what we do or how we fit in.

I also think that in the past, we would come up with clinical programs that we thought could be really helpful, but we didn’t really involve people who would be able to refer the patients or see if that was a need that a patient might have after leaving their care. So it’s more about us seeing ourselves as a very strong piece of the continuum, so that we can go in and then figure out what’s needed.

That leads into my next question, actually — how have SNFs changed in relation to their hospitals and downstream providers?

Many years ago, we would go and talk to the hospitals and say … “We’re open for business, we can take patients — who needs care?” And we would receive patients.

That was before all the transparency. Now I look at how it’s changed. You can investigate almost anything you want to find out about any of our care centers online, and learn a lot about what their quality looks like, what their surveys look like. It’s really changed from just patients being placed because of preference — or location or whatever the reason may have been — to being placed because of outcomes. What you’re really looking for is patient-centric, high-quality care that leads to the right outcomes.

The other thing is we didn’t link together all the pieces of the continuum. I think what all these changes have done for us is really linking together: How does everything fit together to provide the best care and experience for every patient that needs health care?

Before, we would refer to home health. Now  we refer to home health and we want to know what they’re doing. We know it doesn’t only affect us; it also affects the hospitals. It really makes you look at: How does every piece of the health care continuum affect one another, and then how does that provide really the most patient-centered care coordination?

How have you implemented this at Dycora, especially in terms of how you look at your downstream providers?

There’s a lot of data out there in the public now, for home health agencies, everything. So it’s really about doing diligence. If we have somebody that we think we should have as one of our partners, what we need to do is look and see what are their outcomes and what do they do. So [for instance] hospice: Our partners are generally very good about presenting to us all the things we need to know, such as how is pain controlled? How quickly can they start care? Is someone with the resident when they are passing? These are the things we want to know. Those are the things that can make a difference.

We need to hear from them on a quarterly basis, so one thing that I expect my care center leaders to do is to meet with their home health and hospice [partners] and review all of the metrics that are kept publicly and then also learn about what their resident/patient and family satisfaction is. So we get a picture of what’s happening and see the results of maybe some of the surveys that they do, and so on.

Obviously for us, we want to make sure they’re not causing rehospitalizations in that 30 days because not only does it hurt us, but it hurts the acute care hospital.

How long have you been doing these checks?

Actually, it was an initiative that I started when I was the president of Golden Living that I felt was really important for all the reasons that I’ve just talked about. The great thing about it is we found it made a difference. We all get better when we hold each other accountable, and that’s what I really think it does.

It’s probably four years or so that we’ve been doing it, and it’s hard to get people to think about it outside us. We have to ask for it. But once it starts with the other provider, I think it goes well. And I think as skilled nursing providers, we know with ACOs (accountable care organizations) or other organizations, they have their set of metrics, and they rank us every day, right? So there’s no difference. It’s the same thing. We should know our metrics. We should know the people we work with, what their metrics are. And that is how you really develop the network that is quality.

How many SNFs would you say have a handle on this? 

You know, I don’t actually know the answer to that. I feel like a lot of people are aware of their metrics with ACOs and conveners and all that, and even with the hospitals, with their rehospitalizations. I think everybody is very well dialed into that, and everyone in the industry is taking it very seriously and cares about it a lot. I don’t know how many take it down to the next step of: How do I also manage and monitor who I’m working with? That’s a great question, and I wish we could have a set of people who say “I’m doing it” or “I’m not.” But I think it’s a minority, as opposed to a majority.

Is this something that SNFs can start working on right away?

I personally think we’re already held accountable to the metrics, right? We already know what we need to do, so for me, I wouldn’t delay. Even if you’re not dense in a market, you still have all the same metrics you have to meet. In the end, you can still set yourself apart with one center in a market if you have the very best care with the very best metrics.

This interview has been condensed and edited.

Written by Maggie Flynn