Adding Hospice Services Could Bring PDPM Upsides for Skilled Nursing Facilities

Under the new Patient-Driven Payment Model taking effect October 1, skilled nursing facilities across the country will have to demonstrate their value to patients under a brand-new set of incentives.

With therapy minutes no longer driving reimbursement, providers have to be able to offer the best care to a sicker population in order to thrive under the new Medicare system.

One way they can do that is by embracing hospice care, according to Terry Holecek, the vice president of operations for VITAS Healthcare for the Atlanta and northern Florida regions.


Holecek, a licensed nursing home administrator, has extensive experience in the long-term care field, including stints at Diversicare Healthcare Services, Sun Healthcare Group, and Greystone Healthcare Management. He was recently appointed to his current role at hospice giant VITAS, where he specializes in implementing and developing strategic partnerships with nursing homes.

Skilled Nursing News caught up with Holecek to learn more about the opportunity to expand hospice in the SNF setting, and why it could be a boon in the age of PDPM.

This interview has been condensed and edited.


How many SNFs does VITAS have strategic partnerships with, at the present time?

We are nationwide, in 14 states and then in the District of Columbia. We serve approximately 3,500 patients that reside in a skilled nursing home on any given day. We serve about 1,500 in state of Florida [alone] — maybe a little bit more.

When it comes to forming those partnerships, what’s the profile of a SNF that’s a good potential partner? Would facilities focused on transitional care be a less likely fit, for instance?

We view all SNFs as great potential partners. When we look at SNFs, we not only look at the star ratings of a particular facility and how they fare within the community from a survey outcome perspective, but we also look at facilities that may be challenged from a five-star rating or survey perspective — where we can go in and enhance that service and provide that extra level of care and support within the facility to help them improve in those ratings.

On the flip side, we look at other facilities as we’re aligning with our referral sources from an acute perspective, and really try to align with those facilities with the higher star ratings, demonstrated outcomes in terms of performance measures and quality metrics.

But I think it’s important that we meet the needs of all hospice-eligible patients that qualify for that benefit entitlement, and we don’t exclude any nursing homes. One partner may look more attractive than another, just dependent on what those initiatives in those individual communities are. But I believe we can be a help and a great resource and partner for all skilled facilities.

I think it’s even more important now, as we’re embarking on a major payment system change with the PDPM. I’m very encouraged and hopeful that the long-term care profession will embrace hospice and the value that hospice can bring at the end of life, especially from a value, a patient-satisfaction standpoint — and our ability to impact the quality measures for those facilities that have some opportunity to improve.

Just identifying those residents at end of life is very imperative. I think those benefits go well beyond the obvious, from a quality-of-care standpoint, but it also extends into the regulatory survey, five-star ratings and also quality measures.

I do want to dig a bit more into the type of SNF that makes a good potential partner. Given how many SNFs have decided to move into transitional care, it seems like there are some where hospice wouldn’t be a focus. What do you look for in terms of patient mix and population — do you need a certain portion of patients to be long-stay?

You hit on it: Long-stay patients are more than likely to be the more appropriate patients for our mix. However, even the short-stay patients as well, as they transition through therapy or maybe they’re trying to get a little bit stronger for a life event, a wedding or some special marker in life. Then they transition to end of life care as well, where we’re able to provide them with some of those hospice services that provide that comfort, medication management.

We’re there to provide that end-of-life care, but also elevate the skills and knowledge of the staff to really deal and address those advanced illness needs within the facility. And as we look at the payment changes and the shift and the type of patients that may or may not be coming to the skilled environment after October, what other opportunities are out there for the SNF and VITAS to really focus on partnering as it relates to the end of life care?

When you’re in a SNF, what are the mechanics of the partnership? I’m thinking about staff here primarily, but how does the partnership look once you’re in a SNF?

Well, the mechanics are going to be based on end-of-life illness; we provide that support from a nursing, a nurse aide, interdisciplinary team focus. I think by partnering with VITAS, we’re enhancing the services being offered to the resident at the end of life, and also providing the staff with the skills and knowledge through training and development.

But I think the important thing that we provide is we improve the care coordination and collaborate with the nursing home staff to ensure that quality outcomes are absolutely achieved for our patients that we serve.

When the partnerships are in the works, do you approach SNFs, or do they come to you?

It’s a two-way street. We already have existing partnerships that are formed; we definitely reach out to skilled facilities. We have what we call VITAS reps in the community that are well-versed in services we offer, that reach out to our potential partners in the community, whether it be a SNF or assisted living partner.

We also have existing partnerships that we continue to develop and nourish as we move along. So it’s definitely a two-way avenue, and it’s about education and understanding of what the hospice benefit is and the services that we provide.

Can you talk about what’s necessary for long-term care to really embrace hospice, as you put it?

We have different partnership systems that we have in place. We have what’s called a partnership of care meeting that we establish with all our partner nursing homes, and in that partnership of care, we go over the details of what exact care we are providing — from care coordination to medication use, to education of staff needs, such as dealing with their own grief when they lose a resident or even a staff member in some situations. And we provide that bereavement support to the facility.

It’s an opportunity to educate not only on the disease states that most oftentimes are associated with end of life, but also the education of how to access hospice, what the benefit entails … also educating them on the quality measures and what’s risk-adjusted in terms of pain, depression, and symptoms, to also partnering with them on collaborative opportunities within the community

Would you say there’s room for hospice to expand in the SNF setting? How broadly is it used in that setting now?

I can’t comment other than my experience as a nursing home operator, and also my experience with VITAS Healthcare; it’s definitely underutilized, from an entitlement perspective and a patient-need perspective. I don’t think it’s intentionally; I think it’s just awareness.

I think it’s important, as we transition into the value-based payer models, to understand how we’re going to create that value as a unified post-acute provider, and attracting ourselves to potential referral sources. So I think the opportunity to expand hospice, given the demographics, given the patient population — we’re serving a much sicker patient than we did 15 years ago. I believe the opportunity is there.

I think there’s tremendous opportunity within the skilled environment and also assisted living — especially as the demographics are shifting. The type of patient, and the makeup of the patient, is completely changing, and it’s being driven by the current reimbursement environment, the current regulatory environment, and I think there’s opportunity to educate.

We’re looking at a sicker, more acute patient coming into the nursing home, and do SNFs have the resources and the partnerships out there to meet that demand and that change? That’s where VITAS will play a critical role in creating that value-added partnership: by establishing that care coordination and also that value-added support, especially at the end of life, where patients tend to utilize the emergency departments.

You’ve mentioned the changes in reimbursement, and PDPM is a particularly different set of incentives; it’s interesting that hospice could be a driver in adding value.

I think PDPM is going to carve out a unique opportunity and perspective that people have oftentimes overlooked in the past. And that’s really looking at the quality that we can add to the end of life. Hospice isn’t about dying; it’s providing quality of what life is left. Tapping into that resource of our interdisciplinary team, our volunteers, our chaplains, social workers and really providing that value-rich experience for the nursing home patients within the center — we can bring that into the center.

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