The COVID-19 pandemic has highlighted the importance of medical care and infection control at skilled nursing facilities with an unrelenting spotlight, but one operator believes that its role as an insurance provider has given it a leg up in dealing with some of the challenges — and in thinking about the future.
The Norcross, Ga.-based PruittHealth, which has SNFs across the South, has found itself benefiting from its PruittHealth Premier institutional special needs plan (I-SNP) as it navigates the best provision of care in the crisis.
And Dr. Rayvelle Stallings, who was recently named senior vice president of PruittHealth Physician Services and corporate medical officer, has seen seen the benefits firsthand. She had previously served as the medical director of the health plan, and is taking the lessons from that role to the new position.
Skilled Nursing News caught up with Dr. Stallings on July 8 to discuss the role and her work on the “Rethink” podcast. The interview reflects the regulatory and COVID-19 situation at the time.
What was included in your previous roles at PruittHealth Premier and what’s going to change now in this new position?
I joined PruittHealth a little over 18 months ago, and when I was initially hired, it was to be the medical director of their Medicare Advantage plan, PruittHealth Premier. It is a special needs Medicare Advantage health plan, meaning it was offered as a Medicare insurance health plan in some of their facilities.
We offered the ability to provide a unique model of care that provided boots on the ground — nurse practitioners, physician assistants within their facilities to monitor acute changes, to address those, decrease hospitalization/rehospitalizations, and to really assess the acuity and the underlying kind of co-morbid conditions that we can see with individuals that reside in long-term health facilities.
My role really expanded organically, as COVID-19 became a global pandemic. I’ve had experience in physician-led organizations before, and Pruitt had initiated their own physician services, having medical directors and nurse practitioners being the attending model in a number of facilities in their Atlanta area.
And as we saw the pandemic really outbreak in those facilities — not only in Georgia, but also in other facilities and other states — it was imperative to have that communication with the attending medical directors at the facilities to make sure that we were aligned on clinical delivery, quality delivery, safety, and regulatory.
Understanding clinical practice oversight, understanding and getting alignment with required end results really led organically to the promotion. Now I work very closely with our chief clinical officer of PruittHealth, as well as medical directors that are not employees but are contracted providers at our facilities, and other organizations and ancillary care in the organization such as hospice, home health, pharmacy and such. It’s expanded what I was doing initially.
What’s been your experience having the institutional special needs plan model (I-SNP) during this time? In other words, what it is like to be an insurance provider and a skilled nursing provider during COVID-19?
I think it puts us in a unique place. When you think of institutional special needs plans, a number of organizations can decide in the commercial world to initiate that, but Pruitt is a little unique in the sense that we also provide the facility. There’s PruittHealth, all of its long-term care facilities.
There’s PruittHealth hospice, pharmacy, and so it is unique to work — even though we’re very separate in the sense of our special needs plan and what we have to provide from a regulatory sense — but to have the complete offerings of services that you really need to have in place to support [it], I think, successfully.
When I say successfully, I’m really talking about the clinical outcomes of the patients and enrollees in these plans. So it’s been unique. At the same time, I think we’ve had the advantage of having all the best that PruittHealth in general has to offer with our SNFs, because they are manned well — not only by medical directors, but also the nursing staff there. We have our own wound care services at PruittHealth, so our members didn’t really have any interruption in care by having to go out to wound care services. We also have our own physical therapy.
There were a number of advantages of having the PruittHealth Premier I-SNP within PruittHealth facilities, and all of these ancillary services that PruittHealth has to offer. I think just like any other plan, we definitely saw the increase in utilization of services, so we’ve had to definitely skill-in-place — monitoring for COVID, in particular fever, respiratory changes, increasing the type of nursing services to care for individuals that have become COVID-19 positive, but did not require hospitalization.
We definitely had to adjust the frequency in which we were seeing those patients. Sometimes it meant instituting telehealth. I tell people COVID-19 has been the great initiator of change in how we really provide health care, because we really looked at early on: How do we manage our patients that were COVID-negative and not introduce risk to them, but still providing care, and also needing to assess and be present and take care of our COVID-positive patients as well? Not only from a plan standpoint, but also from PruittHealth’s and our nursing care facilities’ standpoint.
It really was a unique time in establishing service and making sure that we had the correct assessment and care planned, and then implementing those changes.
What are some of the changes you’ve made around telehealth specifically?
We definitely found for routine, non-acute care that there was the opportunity to provide telehealth without a huge disruption in both expectation as well as the the outcome of the care received. Now, that being said, there are some limitations to telehealth, and we’ve found ourselves having to navigate through that.
But I think acutely, when everyone was dealing with the initial surge of COVID-19, trying to understand what to do to mitigate risk to both the residents in our facility — patients, both long-term and short-term residents within our facilities and even the partners, employees of PruittHealth — how do we safely provide the services that are needed and and decrease that risk?
We found that there were a number of lines of services and specialty services that actually telehealth works well. Dermatology, for instance — being able to still see changes in skin or rash or nails or whatever was being evaluated through any type of kind of video or telecommunication allowed that to be done safely. Routine well visits, medication consultation, nutritional counseling, mental health counseling, were services that we saw could be provided with sometimes enhanced interaction with the patient and the provider. So there was not an negative impact to the outcome.
Where I think there are difficulties, particularly in long-term care, is when you have residents that have any cognitive impairment. I think COVID-19 overall has been difficult for this subset of patients and residents.
We’ve masked, literally, their interaction with people. They’re not able to read facial expressions. It’s very upsetting because they’re used to a routine and people that they know, and now we’ve made it very difficult for them to identify those individuals. There’s not always a very clear communication of what may be wrong, or if they’re having some type of acute discomfort or complaint that again, from a physical assessment, you may be able to understand better than a telecommunication. Sometimes even the technology can be offputting for that patient population.
So I think there’s still areas where we have to understand, augment and still provide the ability to provide face-to-face consultation. But I do think the gates have opened, and we will not go back to business as usual. I believe telehealth delivery is here. We realized that it can be effective, it can be safe, and I see it just only moving forward and growing.
In terms of quality and safety, what are some top priorities for you now? Is telehealth among them, and what are some of the others?
Telehealth is definitely an area that we are all looking at. But the first thing I want to say is that some of the initiatives are not new. A lot of it is just core practices that we refocus, realign, and really stress.
When you look at COVID-19 in long-term care facilities or nursing homes or assisted living facilities, it is really the alignment of continuing the training and infection control. It’s important that we have that top of mind, because we know that nursing home patients are at extremely high risk for this virus, and given their age and co-morbidity, the mortality when infected with COVID-19 is much higher.
So while that’s not a new initiative, it is important to continuously reinforce this, because I think all of us — it’s just normal to experience COVID fatigue. We’ve been over 100 days in this initiative of not business as usual, and really redefining our new norm. That is important, cross-communication. In every organization I’ve been a part of, communication has been key in success.
I think it is a continuation of: How do we make sure that everyone understands new initiatives that come out, that we partner and really support one another along all business lines, whether it is our consultant physicians, our employee physicians, group physician services, our Medicare Advantage I-SNP, PruittHealth Premier, as well as all facilities and all ancillary services connected with that — including home health and hospice. Having those type of initiatives and making sure that we have clinical leadership informed and communicating, as COVID-19 continues to be top of mind, is imperative.
Lastly, it is about standardization of care. I think the long-term-care line of business has been one that has been very dictated by regulatory initiatives. But COVID-19 has really highlighted the importance of clinical algorithms, standardization in care, making sure that we have the capabilities in all facilities that medical directors wish to initiate. I think it’s always happened, but maybe there hasn’t been as much of a focus in making sure that we’re all aligned, as much as COVID has brought that to the forefront.
From infection control to education to communication, I think all of those things really get the end result of quality and safety for our residents and partners.
What is infection control going to look like in the future? I suspect it’s not going to look the same as it was prior
No. Prior to COVID, we weren’t screening individuals and partners as they come to work every day for fever, or any questioning about symptoms or activities outside of work that could necessarily place them in a high-risk category. So the immediacy of risk evaluation and mitigation is right there every day.
And then how we do a day-to-day activity. Cohorting patients given COVID testing or symptoms, or secondary to them just being discharged from the hospital and really having this unknown of their COVID status, was something that didn’t exist over 100 days ago.
The necessary steps of infection prevention and control practices have really changed our day-to-day activity and how we do that. What hasn’t changed for us is that the type of work that we do in nursing homes and in long-term care facilities really puts everyone at risk. There’s close contact. You can’t social-distance when you’re helping someone brush their teeth, or helping someone get dressed or changing linen or changing them.
It means that we are very close, and I think navigating the activities to properly care for our residents and patients while still understanding that those activities actually in and of by themselves put us at a moderate risk, there are a number of precautionary [measures] — whether it is personal protective equipment (PPE) that we wear, whether it is screening, whether it is routine testing that is required now of staff to go through, all of those things are necessary, and a huge change over the last couple of months.