When it comes to the long-held traditional post-acute care model, significant change can be difficult to envision, let alone implement. Yet when Tim Fields set out to establish Ignite Medial Resorts, disrupting the tried-and-true is exactly what he did.
After a career in health care including skilled nursing, Fields and his partner have successfully developed a model with seven short-term rehab “resorts” across the Midwest — and two more in development, set to open this year — to turn the traditional post-acute care experience upside down.
Focused on hospitality and payment partnerships all driven by patient outcomes, Ignite is reshaping the perception of traditional skilled nursing with Fields at its helm. We sat down with him to talk about how he inspires change, the greatest industry change he has encountered so far, and where he sees change likely to transform post-acute care in the years to come.
Walk me through your experience in the space. How long have you worked in the industry?
I’ve been in the industry for about 14 years, but I’ve been in health care my entire career. I started off working in the cardiology industry, working for physician practices. And I’ve worked now for a couple of different long-term care operators in the Chicago area. I started Ignite Medical Resorts with my partner, Barry Carr, about two and a half years ago.
The impetus for starting Ignite was to do one thing and do it well, which was to be the short-term rehab provider of choice in the markets we serve. That’s through some new development, and being able to define something unique and different around the type of place that patients have a choice to go to when they need post-hospital nursing or rehabilitation services; as well as the care model and the hospitality model that we deliver that kind of changes the industry.
ACOs, bundled payments, and Medicare Advantage are all looking for people who can specialize in something so they can get high-acuity patients at the right cost in the right setting, and get them home with a quick length of stay, avoid rehospitalizations — but also have an environment that is unique and different, that has a hospitality flair to it. Because my grandmother’s nursing home is much different from my mother’s nursing home.
In my opinion, the old-school institutional, semi-private rooms, white hallways, white floors is not what the baby boomers are looking for. The hospitals have updated and changed that; most hospitals have private rooms and have amenities and Starbucks cafes and have food room service, because that’s what people are wanting. Our industry has to adapt very similarly. And I think when you are trying to do short-term care, with people who are coming here for a specific reason, and who are coming for a nursing reason, for IV medications or for wound care, for rehabilitation after a stroke or a bout of pneumonia, we should be treating them like they’re going to a fine resort or a boutique hotel to get better — almost like a med spa, to heal their mind, body and soul.
That includes physically — PT, OT, and speech; clinically with our nurses and our aides and our physicians. But also the things they like to do. So if they like to do Sudoku puzzles in the morning or they like to Skype their grandkids on Friday afternoons, or they like to have their favorite latte in the morning, we want to make sure that they feel like themselves as they’re recuperating to go back home.
In your time in the industry, what is the biggest change you have seen? And how would you say you played a role in that change?
I think the biggest industry change has been the increasing expectations of our industry due to accountable care organizations, bundled payment programs, and Medicare Advantage, penetration, where our industry is being forced to take higher-acuity [patients]. Or I should say, being asked to manage higher acuity, as a partner. So we’re sitting at the table with these hospitals or these conveners or managed care organizations saying: How do we do this together? And not just: I refer to you, you refer to me, we all serve the community.
We literally work together on clinical handoffs and communication and protocols set and physician alignment and training and education, so that we can do this together to get a better outcome clinically and financially for both the patient and the hospital, physician group or managed care organization. I think that has continued to evolve in the last 10 years.
And every market’s different. I operate in five different states now, and every market is different. Every hospital, every managed care company, every physician group that’s in a bundle, every hospital that’s in a bundle has different expectations, different processes, and different ways they want communication — whether that’s sitting in your [interdisciplinary team] meeting and aggressively managing your discharges, to how they want to be communicated with around hospitalizations, to what type of physicians they want in your building, and the coverage they’d like and the handoffs from the hospitalist group, or the primary care groups. You have to know and learn your market.
And you have to figure out how you become the best partner for them. What could work in Milwaukee is different from Kansas City, or Oklahoma City. We don’t have a brushstroke approach to how we do this. We learned the markets and figured out how to adapt and be the best downstream provider. Because without the hospitals, without the managed care companies, we’re nothing — we don’t get their patients. They’re top of the totem pole, and we need to be good partners to them.
[In terms of acuity], 10 years ago [there were a lot of] hips and knees and orthopedics [in post-acute care], and that’s what everybody specialized in. That’s all in home care now. We’re seeing more LTAC-level appropriate patients. I actually view the LTAC industry as Blockbuster Video; it’s going to go away. Chicago, the third-largest city in the country, has five LTACs that are all for sale, and all are half-empty. Yet there are other places in the country where that aggressive migration of acuity hasn’t hit yet, because they haven’t had very sophisticated ACOs, or very sophisticated bundles, or very sophisticated Medicare Advantage plans that have pushed that line of the spectrum.
I think acute rehab will continue to be very specialized, and it’ll be for trauma. It’ll be for [traumatic brain injury] or spinal cord patients, and it’ll be very specialized. I think a lot of the hospitals who have traditionally had 20, 30, 40-bed units with their hospitals will start to repurpose those for making more private rooms or for specializing. Because if a hospital is in an ACO or bundle, it doesn’t incentivize them at all to send their patients to their own acute rehab.
Ignite is very unique in that we run in-house therapy. So if a patient needs four hours of therapy, we can deliver it, where most companies who use contract therapy will never take a patient like that because it’s too expensive. We can go to the managed care companies and say: Stop sending your stroke patients to acute rehab, send them to us because they’re getting the exact same care in a better, more aesthetically pleasing environment with more hospitality, flair, and nurture to it in terms of understanding the family and patient needs. But the clinical outcome at the end of the day — which is I’m going home, functionally better — just cost you a third or a fourth of what it would cost you if you went to another setting.
That’s the biggest shift I have seen in this industry.
What do you think it’s going to take to get more people to adopt that mindset?
This industry in general provides long-term care. We are licensed as long-term care facilities. We are regulated by long-term care regulations. We have been an industry of long-term care. So as the industry has migrated a little bit, you’re going to see a bell curve, and on the far right of it, you’re going to see the guys that are bleeding-edge, innovative, sophisticated, who are trying to figure this out.
That doesn’t mean the entire industry. There’s still a need for traditional long-term care, traditional memory care facilities that take care of folks who cannot take care of themselves at home, who need help with ADL management. I think the problem we’ve had in this industry is everybody has tried to say: Oh, well, I want to go after the Medicare dollar. And I’m going to put up this little wing or this little unit inside of my building, to try to get extra revenue from those types of patients. But again, the reason we formed Ignite was to say: We want to be one thing and do it well, and not try to be everything to everybody.
I think that’s the difference in this specialization, but everybody’s not going to want to take a risk. In any industry, you’re going to have people who want to continue to innovate and push the agenda and do something different, and you also have people that just want to keep the status quo. And there’s a lot of people who have put a lot of money and have a lot of investment into 30-, 40-, 50-year-old buildings that have semi-private rooms, three bedrooms, four bedrooms, that do all Medicaid, and want to hold on to that model. They’re not going to change. And that doesn’t mean they even need to, right? There’s still a need for that. But there is a need, from the ACO’s perspective, the bundled payment perspective, from the hospital’s perspective, and from the Medicare Advantage perspective, to find providers in their market who can do this.
Obviously, you’ve seen our pretty aggressive growth strategy right now. This year, we’re just opening our seventh facility in Oak Creek, Wisc., south of Milwaukee, and we’ve got an acquisition for two facilities in Kansas City in July. We’re opening a new building in Kansas City in September, and we’re opening one outside of Chicago in October. We’re growing super rapidly. And I get calls every week about ways to do this, showing that, hey, there is somebody out there who can do this and who can be a good partner and, and can also make it work.
Unfortunately, I think some of the problems we’ve had in this industry have [resulted from] a lot of new development that was done, and a lot of operators didn’t make it work. But there is a way to do this right, and I think we spent a lot of time and energy around how to pick the right areas where new development works, and where the Ignite model works. Our model’s not going to work in rural areas [for example], and it’s not going to work in every market. So we have to be very careful where we go, where we develop, and where we acquire.
We’ve seen some upheaval in this space, such as the high end, resort-style model, but we’ve seen some hang-ups on implementing them in practice. Why do you think you’ve been able to grow when others in this niche have had problems with the implementation?
The answer to me is twofold. No. 1 is: This is very hard to do. When you run the bleeding edge, and you’re pushing the envelope and you’re innovating, it comes with a lot of cultural struggles. We also constantly say: We are not a nursing home, we are not a nursing home, we are not a nursing home. And with that comes: How do we innovate our culture around that? We have a phrase we use, that kind of embodies everything we do, which is: Vision without execution is hallucination. You can have a vision, you can have an idea, but if you don’t execute every day on that, you’re not successful.
[This industry has had] a lot of vision and a lot of ideas, but nobody executed very well on it. Some of that was driven by long-term care operators trying to do something different, and they stepped out of their comfort zone, they didn’t adapt properly, and they failed. Part of it was, like I said earlier, new development of buildings that were not built in the right areas or in the right markets, or were built for not the right price, and they couldn’t financially make it work.
Vision without execution is hallucination, meaning: How do we execute every day? For us, it all starts with culture. We’ve built Ignite with a culture to do something different. We look at our culture and engagement in terms of things that we do to recruit and retain the best employees, and how we get the different kinds of nurses in our environment. For us that’s recruiting nurses from the hospital, from acute rehab settings, and from LTAC settings. It’s also retention and how we make a very fun work culture that has a lot of “work hard, play hard” mentality to it. That way we can make sure we’re hiring the right staff that can deliver the model.
I can set the vision and the course for the organization, but I need the right staff to be able to deliver and execute the vision. We spend a lot of time and energy and a lot of effort on how we hire, recruit and retain the right staff. That’s a big piece of our secret sauce.
In-house therapy — if you’re going to run this model, you can’t outsource your therapy, your core competency. Having in-house therapists is very, very key, in my opinion, to this model. Because of that, and most people don’t do that, we’ve been able to recruit the most top-notch therapists in the area.
I’ll give you an example. I’m sitting in Oak Creek, Wisc.; we’re opening a building here. I did a job fair before we opened, and we had over 300 people show up. Why are people coming to that? Because they see how we’re advertising the model we’re running and how we advertise for our staffing for in-house therapy. We have the pick of the litter of the best therapists in the area because people want to come work for a place that’s going to specialize and do this model.
And we’re hiring the best PTs, the best OTs, the best speech therapists we possibly can find, because of that. But instead of a pool of 20 I’m picking from, I’m picking from a pool of 150. With nurses, I’m able to pick from a different pool because people are saying, “Oh my god, this is not a nursing home. This is not an acute rehab. This is something different and unique, and I want to go check it out.” And then they hear about our huge cultural engagement program; a “superheroes in scrubs” program that allows our staff, through showing up to work on time and being dedicated high-quality staff, to earn raises and PTO payout and extra vacation days, and Ignite swag. That’s the fun culture of appreciating and rewarding our employees, so they stay with us. If I can recruit the best employees, and I can retain the best employees, that’s how our model works.
Secondarily, as I mentioned, is this model can only work in certain areas. So when we look at either a new development opportunity, or an acquisition opportunity, we’re studying the market. We’re studying the hospitals, in terms of how many patients they have, what types of patients they have, how much they discharge to skilled nursing, what type of environment is it between accountable care organizations, bundled payment.
There’s a lot of analysis to figure out: Is the market viable enough to run the model? Because without running the buildings pretty full, and having a pretty good census, this is a high-cost operation. I have a higher nurse-to-patient ratio, I have a higher aide-to-patient ratio, and I have a higher rent or a higher mortgage on these facilities because they are more high-end and posh. To be able to run that, I need to have a sense of revenue to pay for that. So we have to make sure the markets are deep enough. We study the competition, the demographics, and our ability to recruit and retain staff.
That’s why you find us in major metro areas like Milwaukee, Chicago, Kansas City, and Oklahoma City — major metro areas that have the labor pool to support it and the patient pool to support it.
Do you think there’s an opportunity for change in the Medicaid-focused model? Is there a way that you can innovate to make it more palatable to investment and new development? Whenever we hear about a new development, it’s always a beautiful building like one of yours. It’s never just a functional, long-term care, Medicaid-heavy plan, because that just doesn’t pencil out anymore.
I do think there’s probably a spot for that. I don’t think that our culture and our model would necessarily be the right operators for it. But I think you could build a building that is more functionally set up for that. I think there are operators in the country that are doing something similar to this.
One that comes to mind for me, right off the top of the bat, is Trilogy; I think Trilogy is doing some things in Michigan and Ohio and Indiana in some rural areas and some other places where they’re building buildings at a very economical price. They’re building both private and semi-private rooms, and they’re doing assisted living that’s on top of it. They’re trying to carve something new as a niche out of that.
Whether it’s retrofitting another building or or building a new facility, the question is: if I really, truly want to still be a long-term care operator, how do I still try to do that? That’s the challenge for some of the current operators that are out there, or some of the new people getting into this space: How do they continue to innovate that side?
You mentioned technology, and the skilled nursing space always seems 20 years behind everybody else in terms of technology. Do you think that’s going to change over the next couple of decades, as more and more seniors familiar with technology age into needing post-acute and long-term care? Do you think that’s an area of opportunity?
Unfortunately, our space is not known for being innovative, sophisticated, and tech-savvy. I think Ignite is on the bleeding edge of it. We’re clamoring for more.
If we’re going to run a more innovative and unique model and we’re going to focus on taking higher-acuity patients and having more hospitality and then delivering a different outcome than the traditional skilled nursing facility delivers, we’re going to need a different way of doing things. Some of that comes with technology. We’ve found in-house pharmacy solutions, in-house lab solutions, hospitality tablets that allow patients — almost like in a boutique hotel — to order room service and new towels and their Starbucks latte in the morning. We’ve also found clinical technology such as vital monitoring technology, technology that integrates with our PointClickCare records, where you can predict change in condition, other types of systems that can help us, help our staff better care for patients. I think there will be more people and providers who come into the space with better technology. And I think that we have to continue to push that agenda.
We’ve tried to figure out two things, right. One, does it improve the patient care or patient experience? Number two, is: is it functional and usable?
I’ll use telehealth, for example. Years ago, telehealth was these big bulky carts that you had to figure out how to get them connected to the Wi-Fi, and you had to figure out how to turn them on, and figure out how to use them, and when to call the doctor that was on call and wheel it in the room. To me, it never really took off. And when I did trials or test pilots, it’d never get any traction, because it was too un-user friendly, in my opinion. For a busy nurse who’s trying to take care of multiple patients and pass meds and call the doctors and get orders and this and that, it was a burden to them.
So we have chosen a telehealth vendor now that we feel is much easier. It’s a simple solution. It’s not a big cart, and it allows our staff to be able to utilize the technology to help them instead of burden them. And I think that’s the real key for the providers and the vendors out there to figure out: Do they really understand our space and they understand how busy our nurses are, how busy our therapists are, how busy our aides are? How do they make their lives easier? That’s when technology really takes hold inside of our industry, [when] it makes the lives of our caretakers easier.
Looking forward, what do you think the biggest change is going to be over the next 10 years?
If the experts are correct, there’s going to be some form of a silver tsunami. We’re going to have more people who are 80 years and older, or 75 years and older, coming into the space. I think they’re going to choose more Medicare Advantage plans. You’ll never see Medicare advertising on late at night TV; you see Humana, BlueCross BlueShield, Aetna, and others advertising the ability to switch over Medicare benefits. And I think hospitals and physician groups are going to continue to take more risk.
What I would love to see this industry do, and I think we’re very well-positioned for this, is to continue to take risk. That might mean risk-based sharing contracts with Medicare Advantage plans.
Again, this isn’t appropriate for all the country. Certain areas like California, Arizona, Texas, and others are a little more advanced with this, but I would say at least where I operate, which is mostly the Midwest, if you’re a five-star building or a one-star building, or you keep patients 30 days or 10 days, you get the same boilerplate contract for Medicare Advantage. I think that the future is going to be really honed in on specialized creative contracting, or specific partnerships. We’re partners with them; we have the same goals in mind. So we’re really pushing the agenda to get more specialized risk-based, risk-sharing contracts with them.
It’s the same thing with payment bundles. The closer we’re aligned on risk, the closer we’re aligned on the financial side of that, and the better we all coordinate and work together to get the right outcome.
Money is always going to follow quality. So everything we’re talking about, while it’s a financial arrangement, it’s all about quality. How do we get the right outcome, and get patients home in the right setting at the right time? If the money is always going to follow that quality, it’s just like anything else: A Ferrari costs more than a Ford. A Picasso costs more than me painting a picture. Money should always follow quality and I think in our space, that hasn’t necessarily happened. And I think that’s the biggest thing that I think is going to come over the next couple of years.
How will COVID-19 permanently change the industry in the long term?
None of us were prepared for this global pandemic, and it hit certain areas of the country harder than others.
I think there were a lot of unfair and misleading media articles about how COVID has affected our country’s most vulnerable and frail population. The front-line superhero staff deserve a lot of praise for rising up and adapting to our new normal — and they deserve accolades for all the great work and healing that is going on.
Going through anything like this has to give you learning lessons. I think our new normal involves stricter, more focused infection control and prevention programs, more infectious disease physicians in our space, social distancing in the facility, masks on at all times, a more rigorous stockpiling and auditing of medical supplies and PPE, and a stricter focus on the way visitors and ancillary providers come in and out of the facility.
I also think private rooms is going to be a huge topic over the next few months. Almost all hospitals have moved away from semi-private rooms, and I think our industry needs to follow — whether you are a short-term or long-term patient.