Confessions of a SNF Telehealth Executive: Providers Need to Step Up, Fight Staff Pushback on Tech

With increased pressure to improve skilled nursing outcomes and advances in technology, telehealth providers have emerged as a key target of attention from operators and investors alike.

But that investment won’t provide the intended returns if the workers at the building level don’t fully buy into an operator’s overall telemedicine strategy, according to a telehealth executive who spoke to Skilled Nursing News for the inaugural edition of our new Confessions series.

In this anonymous Q&A format, leaders in the skilled nursing space can freely provide their opinions on the state of the industry — and the biggest challenges they face while working to position post-acute and long-term care for the future.

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First up, an inside look at the roadblocks and opportunities a telehealth leader has seen when implementing the technology at skilled nursing facilities.

Know a skilled nursing industry leader who’s been itching to sound off? Drop editor Alex Spanko a line to submit your choice — or yourself — for an upcoming edition.

How ready are most skilled nursing providers to incorporate telehealth? SNFs have a reputation of being the least tech-savvy settings on the care continuum.

I think the question is a good question, but the thrust is wrong. The thrust to your question is about how ready are they for the technology. My issue is: How ready are they for the care? And that’s the bigger issue that we face.

Technology, I think, is relatively simple. Our technology is very simple to use once the nurses get around to using it. Sometimes we’ve even done calls over FaceTime with a nurse because a computer was down, the battery was dead or whatever — and the nurses are very adept at using this technology to see the patients. The bigger issue that we have is: Are these facilities ready to take care of really sick people?

When we’re dealing with telemedicine, we’re just projecting in a level of care that they never had before. We deal with this constantly in facilities — and especially in the rural facilities, where the path of least resistance is: “Send the patient to the hospital, send them out, I don’t want to deal with this.” So for us, the biggest challenge is getting them around this new model of care, of becoming a health care center — becoming a place where you can actually see patients multiple times a day.

On the one hand, the facility pushes back: “Oh, this is so much work!” But on the other hand, they’re [complaining] and moaning about census. Everything we’re talking about — value-based care, and all these great things — it’s all predicated on everybody moving a little bit up the food chain. Everybody’s going to move a little bit up. The nursing home of today is the community hospital of yesterday. But the biggest challenge for me is: Are facilities actually ready to provide the level of care that we can give them over telemedicine? I don’t think the technology is a big issue. I haven’t seen that to be an issue.

I take it that they’re frequently not ready?

Some of them are. That is a challenge that the industry faces, and especially when you get into the rural markets. There’s staffing challenges, from the ability to retain staff [and] the interest of wanting to pay for those levels of staff. Everything is all around that. Do they really want to step their game up, and if they want to step it up, can they step it up?

You may have some corporate parents that are willing to, and they talk that talk, but when it gets down to the facility level, it gets stymied over there, because the facilities themselves — [sometimes] they’re so overworked and understaffed. There’s a whole mix of it, but there are some times where you can have the most well-meaning corporate parent — depending on what level of control they exert over the end facilities. But many of these corporations, especially some of the mid-sized regional types, they give their buildings a lot more latitude than they should.

I came from the operations side, so I know exactly what it feels like to be told what to do by corporate. But unless there’s corporate dictating certain things, a lot of it doesn’t happen in the facilities. This type of initiative — bringing up the acuity level in the building — it’s very easy for a facility to push back and say, “Hey, I can’t. I don’t have the staff for it. The doctor doesn’t allow us to take this patient.” There’s always that sort of pushback on the ground level, and that’s I think the biggest headwind that we face, and it’s something that we’ve been working hard against.

How do you break down those walls? I feel like I’ve seen this happen covering the transition to PDPM: The executives are all in, but people on the ground still have tons of questions.

Take it a step further. You go out to the rural facilities … where they may have three or four Medicare patients in the building if they’re lucky. So they’re thinking to themselves: The whole world is coming to an end over PDPM, and it only affects four of our patients, really, and two of those patients are managed care, so it doesn’t even affect them.

Everybody’s got their own interest in mind, so from a corporate, macro-level, 30,000-foot view, everybody’s worried about it and busy with it, and rightfully so, and it’s a real thing, no doubt. But when you get down to the facilities, especially the smaller, rural facilities, where it doesn’t even apply to them so much, they’re just trying to keep their head above water.

What telehealth does, in my mind — it’s the great equalizer. It can bring resources to places that don’t have access to that sort of resource. My experiences in a large company that had a mix of urban and rural facilities — all of our urban facilities had on-site NPs every day, they had physicians every day. They had a whole medical model of care and it really worked. So you take what works in an urban market and you use technology to project it into a rural market, the thought was — and the thought is — that we can bring up the level of care in those rural markets and allow them to really come into the next century with a lot of their care.

The challenge, again, it’s not a technology challenge. Obviously technology always has its challenges — we have issues with broadband in some buildings, but most of the nursing staffs these days, a lot of them are younger, they’re fairly tech-savvy. The technology’s pretty easy to use. The resistance is — I’m going to say — in a sense worse, because if it was just technology, you could fix for that. The bigger issue is the willingness to up and change those care models, and bring them into what the new care levels are going to demand.

And it will happen. We see it happening in our buildings. We’re in 40 buildings now, and some of them are dragged kicking and screaming into this; some of them are all over it right away. But even down to a shift level, you could have really great nurses on certain shifts or in certain parts of the building, and then you’ll have others in other parts of the building who’ll just send them to the hospital, and then call you after and tell you that they did it.

What’s the excuse? There was no technology issue. The excuse is that they simply don’t want to call us, because they know that if they call us, we may actually give them a bunch of orders that may result in them having to care for this patient right here. And they’re saying to themselves: “What the hell? I can just send them out, and I don’t have to deal with them.”

You’d think that would be part of the training.

Listen, they find us when they need us, like when you have a patient bouncing off the walls or whatever — all of a sudden, they remember. I think just overall, [there’s] this mindset change of being able to treat in place and the idea that a nursing home is now a health care facility, not just the Shady Acres Retirement Home.

We actually treat people that are sick here — and that’s what’s required by all the new models. All the PDPM, and the value-based care, and all the rehospitalization issues — everything coming our way requires these facilities to step up that level of acuity and to be able to take care of that. And we’re giving them a tool to do it.

The federal government just made it easier for Medicare Advantage cover telehealth services. Do you think most plans will take them up on that offer?

I think they’ll do it. We’re in talks with a few, and what’s also nice about that benefit — it’s not really dependent on where the patient is. It can be non-rural, it can be in the home, it can be pretty much anywhere the patient is. I think there’s a lot of cost savings to the system, especially with high-risk patients.

We take care of patients who are chronically ill, so we’re seeing patients many, many times a month in many cases. You talk about the Medicare Advantage plans, where they’re managing a pool of risk. For them to pay a telemedicine provider a few hundred dollars a month to see a patient, versus sending them to a hospital for $15,000 to $20,000 each time, the money is certainly there — and with all of this, you just have to follow the money. And the Medicare Advantage people are very smart. I would say even if it wasn’t good for the patient, they’d be good at doing this, because that’s what they do.

Even this push to sending patients home — they say that if you send patients home, their hospitalization rate is a little higher than if they go to a SNF. But the Medicare Advantage plans are still doing it, because overall, it saves them money. So even though the hospitalization rate is higher, they’re still doing it, because overall, it just saves them a lot of money. Everything points to Medicare Advantage plans embracing this in a big way, and we’re seeing it. We’ve had conversations, and there’s definitely an interest. There are plans that have already been covering it in other ways, outside of this scope. I just see that expanding, and then I see it expanding beyond that into traditional Medicare probably a year or two behind that.

What about Medicaid?

In many states, Medicaid already covers it. The thing with Medicaid is that most of the patients we see, something like 80% of the patients, have Medicare Part B. So Medicare Part B is going to be the first payer on this anyway, and then Medicaid is the secondary in most cases for us — although there are some patients that we encounter that don’t have Medicare, and then it goes straight to Medicaid.

In fact, the telehealth that’s incorporated under Medicaid, that’s usually much broader — I don’t know of any of them that have rural health designations or anything like that. They’re typically much broader than the Medicare rules as far as where you can see a patient. There’s Medicaid covering it, and then there’s the telehealth parity laws that many states now have, which require insurance companies to cover telehealth as if it was in person. So there’s a lot of push to that, but for the nursing home patient, the majority of them have Part B, so that’s who is impacted the most. Whether it’s a straight Part B or a managed care Part B, that’s usually the payer. So that’s really where the big impact is for those patients.

Anything we didn’t touch on that you think people need to know about telehealth?

I think one frustration that we have, as telehealth providers, is that the words telehealth, telemedicine, they’re just bandied about. They mean so many different things to so many different people, and so many of the operators are so busy with just trying to keep their head afloat. And then they look into telemedicine, but they don’t really understand that there’s a lot of different flavors of it. I don’t know that they always realize the potential that it has to actually do all the things we talked about.

There’s a lot of opportunity — like I said, the great equalizer. Equalizer doesn’t only mean rural versus urban. Equalizer means hospital versus nursing home. Equalizer is just bringing resources to a place that traditionally does not have the availability of those resources. If you’re a nursing home, and you want to bring the emergency room to your nursing home so you don’t have to send people out, you can do that via telemedicine a lot better and quicker and cheaper than trying to bring in a doctor. If you want to bring in multi-specialty practitioners into your facility — cardiologists, pulmonologists — you can do that over telemedicine, whereas if you wanted to bring them in traditionally, it would be very difficult.

Operators should think about using telemedicine more to really bring up that level of care, but also to compete. We’re all trying to move up that food chain, but how do you do it? On the one hand, you can take the more complex patients, but you need to be able to support them. You have the opportunity to do that with telemedicine.