Skilled nursing operator North Shore Healthcare recently announced an expansion of its work with a Dallas-based physician-led organization to its entire portfolio, with the goal of enhancing and standardizing the clinical care in North Shore’s 71 SNFs and assisted living facilities.
It’s work that North Shore CEO David Mills is particularly important because of the “missed opportunity” medical directors present to the skilled nursing world, he told Skilled Nursing News on September 21.
“I’ve been in this in the profession for over 30 years, and I have always felt the need to have a more coordinated approach to our physician practices,” he said. “Oftentimes, those physicians, medical directors are one of the most stable parts of our care delivery because of their relationships in communities. It’s been a real missed opportunity in my world and in our profession to not tap into that local medical professional as part of our global strategy for health care delivery.”
The overarching theme is to give North Shore’s attending physicians a voice, and to provide more consistency with care delivery — both priorities for SNF operators in any context, but priorities that have become all the more paramount in an era of global pandemic. COVID-19 has highlighted the importance of drawing on physician resources for care delivery, Mills said.
The professional services agreement signed by North Shore and GAPS Health builds from a pilot with six North Shore centers in the Shawano, Wisc., market, where GAPS took over some medical directorships and provided “governance and direction and support” for some others, GAPS CEO Jerry Wilborn told SNN on September 23.
GAPS Health — the acronym stands for “Geriatric Administrative Provider Services” — provides medical directorships to SNFs across the U.S., with a presence in 20 states and licensure in 42; the focus of the practice is on those medical directorships with the goal of thriving in a value-based world, Wilborn said.
“When [the company] started in January 2019, our goal – this was pre-pandemic, of course – was to help facilities … to articulate with the present physicians that they’re working with how to do a better job,” he said. “It’s physicians speaking to physicians about outcomes, not necessarily directors of nursing, or administrators, speaking to physicians about outcomes.”
In the case of the North Shore pilot, the result was improved outcomes on several key metrics, including return-to-hospital percentages; medication utilization and managing resident medications; utilization of ancillary services such as laboratory and X-rays; standardizing Quality Assurance & Performance Improvement programs, and physician communication, Mills told SNN.
Improving physician integration in the post-acute setting has been a focus for some time, with multiple experts touting the benefits. The “SNFist model,” with primary care doctors specializing in skilled nursing, could be one of the ways SNFs improve medical coverage and avoid hospital stays, according to one presenter at the Post Acute 360 Conference in 2018. Another approach, from The New Jewish Home in 2017, outsourced the physician team at its Manhattan SNF to the Mount Sinai Health System.
More recently, leaders such as Dr. Grace Terrell, the CEO of skilled nursing-focused physician group Eventus WholeHealth, and Justin DiRezze, CEO at Theoria Medical x 5-Star Telemed, have put their focus on the physician presence in the skilled setting.
All the initiatives are trying to address the same problem: The gap between the federal mandate that skilled nursing facilities have a medical director and the care under this model.
“Traditionally, the care in these facilities by — or the oversight by the medical directors — honestly has not been the best model in the world,” GAPS senior vice president of strategic partnerships and M&A Jeff Winter told SNN on September 22. “They literally may appear once a month; they may or may not be as aggressive. If you look at the oversight that’s really needed in these facilities, it’s pretty intense.”
One of the other effects of the traditional model is that with a medical director in each facility, even SNFs under the same operating umbrella might have very different ways of operating when it comes to care.
“I can tell you, with 71 locations and 60 skilled nursing homes, we have 60 medical directors, and other than traditional contracts that we all have, there are really 60 different ways in which services are being delivered,” Mills told SNN. “We saw that as a real chance to — not take the creativity out of what they do and how they support us — but foundationally [know] that we’ve got those medical professionals with a level of consistency.”
GAPS will “sit on top of” the individual medical directors to improve the model, Winter said. In practice, this will involve educating physicians on why they should take certain steps with regard to care, including a mandatory weekly clinical call where GAPS physicians provide case studies and share best practices on management and medication or infection control, depending on the issue being discussed.
Getting the partnership fully implemented will take some time, Mills noted, simply because of the size of North Shore’s footprint — and the need to be sensitive to and account for relationships with medical directors that are long-standing and tied into local communities.
“It is safe to say that it will be months, and not weeks,” he said. “With that, it will be with the idea of really making it a market-driven plan and case-by-case: meeting with a medical director, providing the education, working through the contracting, outlining our goals, and also listening to them on areas of opportunity.”
The pilot program with North Shore highlighted one such area, since it happened to start just before the COVID-19 pandemic swept the U.S. and shut down significant portions of the country. GAPS witnessed firsthand the loss of life that the coronavirus can bring in the skilled nursing setting, when a slew of patients in Connecticut began to sicken and die toward the end of February, Wilborn told SNN.
“It was a terrible time,” he said. “And we said, ‘My gosh, there’s only so much we know. Let’s just go by the ethos of virology. We know about transmissibility, but we don’t know a whole lot about this virus.’ All this information was coming out. So we said: ‘Let’s standardize a way to see COVID patients.'”
With no treatment, GAPS ended up developing what it calls STATt rounds — or “surveillance, tracking, assessment, teaching and treatment” — to address the needs of the COVID-19 population. Ultimately, GAPS now has data on more than 4,000 patient encounters with about 2,500 people who have been COVID-positive, Winter told SNN. Most of those encounters were conducted through telemedicine, and involve GAPS tracking the patients and categorizing them by whether they are positive, recovering, or negative for the virus.
“We’re tracking the patients, we’re doing assessment on it, we’re teaching staff and patients about infection control, and then we’re treating the patient,” Winter said.
These rounds were something GAPS was able to present to the Centers for Medicare & Medicaid Services (CMS), Wilborn said. And though they rose out of the immediate emergency of the pandemic, Winter added that this protocol could be used to help address challenges related to the flu season, or as an on-ramp to other kinds of specialty care, such as diabetes.
The COVID-19 situation also highlighted the ways the role of the physician should change in the SNF setting; many facilities ended up shutting physicians out of the buildings when CMS banned all “non-essential visits” to nursing homes, Wilborn noted. While it’s a move he found “kind of crazy” as a clinician — a pulmonary critical care doctor by training — he believes it has shed light on the need to bolster the presence of physicians in the post-acute setting, and could explain why so many facilities have had the outcomes they did.
“There has to be more of a medical model going forward. There has to be real infection control which is guided by physicians in conjunction with the admin and nursing staff,” Wilborn told SNN. “And there’s got to be more in the way of clinical direction. There has to be, going forward. You saw what just happened. Who knows what happens this fall, or what happens next?”