The operator North Shore Healthcare has navigated rapid-fire growth since the company’s beginning. From two locations, it has grown rapidly.
Now the Glendale, Wisconsin-based North Shore has 71 locations, 60 of which are skilled nursing facilities, with its primary footprint in the Badger State. The company grew in spurts over that time period, but CEO David Mills emphasized during a fireside-chat style interview at Skilled Nursing News’ Rethink conference on September 30 that the goal is not to be the biggest operator.
“We see a real opportunity as a regional provider, so we’re concentrated primarily in Wisconsin,” he said. “We have five locations in Minnesota, and then one in North Dakota and one in Michigan. But having that regional presence is the thing, or the sweet spot that we believe is an opportunity for us, with the business really being local.”
The conversation, edited for length and clarity, is below.
How does having such a local focus help manage the complexity of the skilled nursing business and manage your growth?
The complexity of the of the state is so great that it is very difficult to be an expert in in many, many states. Business is local, so the relationships that we have with local public health, with local regulators, state reimbursement plans – we need to be incredibly proficient, because mistakes are certainly costly. So if we’re able to narrow the focus with our team, we believe there’s a significant opportunity to be that expert. And not be the best across the country, but as a regional provider, be able to be nimble, respond quickly, have efficiencies because of our size.
On that note, North Shore has grown in batches, so to speak, over the years. Can you go into that growth on a year-by-year basis?
We were founded in 2014. Actually, the two centers that we brought on board was [in] 2015. Then in 2017, there were a couple of different acquisitions. One was related to Golden Living properties, and then through a Fortis receivership, we brought on a number of properties. It was 22 in Wisconsin at that time, and then a year later – actually it was 2019, our 22 properties again in receivership related to another organization.
So I think a big challenge that we have, and a responsibility that I have, is how do you create a culture for North Shore when you have multiple different acquisitions over a short period of time? As a young organization, there’s a lot of foundational things that we’re putting in place, and systems and structure that will allow us to create efficiencies in kind of a standard approach, in that North Shore culture and brand.
What are some of the lessons you’ve learned along the way? I’m curious particularly about any surprises or curveballs in terms of assessing facilities or potential deals.
The due diligence process is incredibly important. Fifty percent of if we’re going to be successful or not actually happens before we start operating our centers. And that is making sure that we have the right terms; whether it’s a lease or purchase is critically important, obviously. Having the right partners, and those are key strategic partners, whether they’re pharmacy, therapy, DME [durable medical equipment] and the like.
We know if we have the right structure from a financial perspective, if we have the right partners with therapy and pharmacy, and then from a management support that isn’t top-heavy, but creates efficiency and allows that support that’s necessary, that that’s critical to any deal. While it’s not necessarily a lesson learned, it’s a recipe that we believe is critically important.
Then it comes down to the hard part: operating and providing care and staffing your centers and growing occupancy during COVID.
I think the only other point that I’d make on it is being realistic. With pro formas, don’t necessarily build in the optimal and what the growth plan looks like, but more history and what the the realistic results have been.
You’ve mentioned occupancy during the time of COVID-19, and that’s made headlines over the course of the pandemic. In everything you’ve spoken of, how has it changed during the pandemic? And what has the effect been on how you assess growth? What does that mean in the time of COVID-19?
I think the short answer is proceed with caution. We don’t know, ultimately, how funding is going to shake out. I know the previous [Rethink] panel talked about: at what point are the stimulus dollars – when will that go away? We certainly have staffing and census concerns.
With that, I think, are going to be great opportunities. From a skilled nursing purchase and a growth, I think it’s very much: Proceed with caution, until the dust settles. But I also think that it creates opportunities in other areas that are shaping out: home health care, telehealth, and some of those things are certainly emerging because of the need related to COVID, and also reimbursement changes. We believe there’s going to be opportunities there.
What might some of those opportunities look like, for North Shore specifically?
Even prior to COVID, it’s ancillary growth opportunities and in partnering to be more part of the health care continuum. And that includes partnering on therapy, a pharmacy partnership, looking at DME opportunities, certainly telehealth, home care.
A lot of the areas that are really outside of our core business are areas where we think partnering with those organizations at a much greater level are opportunities.
Tthe other thing that’s going to be critically important is how we operate moving forward. We know that if we operate the next five to 10 years, like we did the last five to 10, we won’t be successful. We have to be very aggressive in reshaping our delivery model. Not only on infection control areas, [but also] private room conversions, how we communicate with families. The expectations, certainly related to COVID and our aging population are going to continue to change. And we need to change with that.
It’s not only looking at ancillary growth opportunities and things that kind of support that skilled nursing hub. It’s how do we redefine our core – which is still skilled nursing.
Going back to COVID again, how do you think about those areas during the pandemic? Is there still room to be opportunistic in this time, or is that completely off the table?
COVID is all-consuming, there’s no question about it. It is at the center of most, if not all, of our conversations. At the same time, our business has to continue. We don’t know what the new normal is going to look like. But the reality is we still have occupancy pressures, we still need to collect our money, we still have a service delivery model that we need to continue, whether it’s pre-, during or post-COVID.
So the challenge that we have is: Until we know what the new normal is, what do we do as an organization to keep COVID front and center and take it as seriously as obviously is needed, but still continue to focus on our other core business metrics?
What we need to do as a young organization is make sure we’re very strategically aligned with our senior team and that we have that clear direction, and we’re able to communicate that to our organization. So part of it is certainly COVID. But there’s other components of the business, a lot of components that we need to continue to drive and focus on as well.
On that note of components, how has the pandemic changed your view of technology in the SNF space, and are there particular technologies you’re interested in learning more about as you think ahead?
Technology is going to be critically important, and we’re investing a significant amount of money in that area for upgrading wireless systems, iPad technology, laptops and those types of things. I think there is a balance, because there’s a lot of technology solutions out there. We’ve got to decide which course we want to take, and then move forward with that.
I don’t think technology is the only thing. It’s very important for efficiency, and there’s automation opportunities. But at the end of the day, we’re people taking care of people, and we can’t forget that piece. We talked about telehealth. And I think that’s certainly a very, very big deal for us moving forward, converting for all EMR [electronic medical records] and physician’s orders and those kind of things,
Automation related to analytics is is critically important. So we have partners that are helping us with that. It’s the balance of how can we utilize technology to be more efficient and effective, without losing that that personal touch side that we have.
When it comes to maintaining that, how you are thinking about those fundamentals and bolstering those?
Myself and a few of my senior team members, conducted roundtables a few weeks ago with our administrators and directors of nursing (DONs), and there were about eight to 10 in each roundtable. It was really designed to listen, to support them, to understand their challenges and concerns.
I think a key thing for our listeners today, certainly for my organization, that is critically important, that we can’t lose sight of is: What are we doing to recruit and retain and support our local center leadership? They’re tired, they’re stressed, they’re committed. They’re working incredibly hard in a time that no one has has ever seen.
For our provider community to be successful, it really starts with retaining that ED [executive director] and DON, because when we have superior and stable leadership at the center level, that center can do incredible things. Where we have that instability is where we create some real challenges around many of our other metrics, including, certainly, patient care and quality, but [also] accounts receivable and census and so forth.
When it comes to recruitment and retention, how that has been in your markets, and how do you track that in terms of hires and retention?
It’s incredibly difficult. In complete transparency, at our 60 skilled centers, we had two DON openings two months ago, and we have 11 openings today. And when we do exit interviews, they’re tired. We need to really focus – and we’re doing a number of things. Number one is orientation and onboarding, mentoring programs, roundtables to listen, setting up mentor programs so that they can network with each other.
So we’ve got a committee that is focusing on it, but at the end of the day, when you’re in a pandemic situation, you have work-life challenges, pressures at home. There’s a lot of competing challenges for EDs and DONs, where I want to be as proactive as we can, and get in front of them as best we can. We identify our EDS and our DONs that are at risk, and they’re on a kind of an ongoing calling cycle, to touch base and see how they’re doing.
I wish there was a magic wand on it, but it’s certainly something we’ve recognized. We’re in the middle of growing department heads that are degreed and are interested in becoming administrators in our local communities. And we think we’ll have some success there, with certainly their commitment to our organization and commitment to their local communities.
We’ve got a lot of ideas and we’re implementing many of them, but the core of our organization’s success is really cracking that code of retention of great local leadership. So it’s a significant challenge today.