As Post-Acute Care Shifts Home, I-SNPs See Case for Expansion to Meet Growing Long-Term Share

The COVID-19 pandemic brought an unrelenting spotlight to clinical care in skilled nursing facilities — one that will shine in the form of government audits and investigations before the immediate crisis ends and long after it passes.

But several operators had trained their sights on clinical care within their facilities before the start of the pandemic, and for many, this took the form of launching Institutional Special Needs Plans (I-SNPs) — a special type of Medicare Advantage plan for individuals who are expected to need SNF services or a similar level of care for 90 days or more, according to the Centers for Medicare & Medicaid Services (CMS).

In fact, during the pandemic, having an I-SNP paid off both literally and in the clinical sense. Operators who had a guaranteed, per-member-per-month payment had a “golden ticket to survive through COVID-19, and the pandemic, and the shutdown and significant downturn in utilization,” Avalere Health managing director Fred Bentley said during Skilled Nursing News’ virtual Rethink conference in September 2020.


I-SNPs have also proven valuable during the pandemic by their structures that allow operators to care for patients in place, rather than sending them to the hospital — a setting with the possibility of infection and the certainty of isolation for a patient when they return to the SNF.

For those reasons, Longevity Health Plan — which operates I-SNPs in Florida, Illinois, New Jersey, New York, and Oklahoma and announced its expansion into North Carolina earlier this month — is optimistic about the future of I-SNPs, even amid the challenges of COVID-19.

“One of the issues that we will see — and this has been an ongoing trend, the pandemic maybe accelerated it a bit — is the intensity of illness, the severity of illness of nursing home patients has gone up every year,” Rene Lerer, the CEO of Longevity Health Plan, told Skilled Nursing News on January 19. “And I think that trend will continue … so I think that the level of intensity of care will go up.”


That makes an I-SNP particularly valuable, since the management of those patients becomes more intense, and having nurse practitioners (NPs) in the building to oversee the care of enrollees provides significant value.

“Secondly, the homes also know — particularly once COVID hopefully is passed — that Medicare has made it clear to them that they want nursing homes to move to value-based contracting,” Lerer said. “Much of the world has already gone there; physician groups, medical groups, hospitals have gone to value-based. Nursing homes are one of the last bastions of fee-for-service, and they understand that under a value-based arrangement, what they’re being incented to do is the overall health care of the patient.”

That means that contributing to member health by treating patients in place, evaluating them early, and avoiding unnecessary care allows SNFs to share in the value.

It also provides considerable benefit to the patients, who are age 85 on average, Lerer noted; sending them to the hospital is both costly to the nursing home and a bad experience for the patients.

“Value-based says: If we can manage the quality and cost of patients, we will share that with you,” Lerer said.

He also sees it as a way for nursing homes to prepare for the demographic changes in nursing homes spurred on by the COVID-19 pandemic. Occupancy in SNFs has taken a beating across the country, and admissions to the SNF setting were showing no signs of recovery as of fall of 2020.

At the same time, post-acute referral patterns have shown a persistent preference to send patients to the home setting whenever possible, with referrals to the setting reaching 109% of 2019 totals by October 2020, while SNFs had just 83% of their historic intake.

It’s a pattern Lerer has noticed as well.

“Most health plans in the country are doing everything they can, whether it’s hospital-at-home, or better in-home care, to keep people out of nursing homes,” Lerer said. “As a result, we think the number of long-term patients ultimately goes up — not right away. But over time, the beds will be filled more by long-term [patients] than short-term, which changes the nature of the clinical needs of the building.”

The clinical capacities that an I-SNP adds are a considerable benefit for both nursing homes and their residents, especially during the pandemic. In New York, for instance, during the spring of 2020, many of Longevity’s nurse practitioners were unable to go into SNFs due to various restrictions around COVID-19, and sometimes because they had contracted the virus themselves.

What the company found was that many of the SNFs were asking when the NPs would be returning; when Longevity’s NPs returned, many of them were providing staff support of all kinds during that time because of the workforce shortage.

“We’ve truly become adjunct staff,” Lerer said.

As Longevity launched in North Carolina in nine buildings, it hired nine NPs, along with “roving” staff who can serve as backup of sorts, as well as management staff and a director of clinical quality. The goal for Longevity is to have adequate staffing to ensure it can care for patients in place.

Though the ideal NP-to-patient ratio can vary depending on the situation, “we tend to not want [NPs] to be going to more than two buildings, based on geography,” Lerer said. The ratio does typically start low, with about 20 patients to every one NP, but he believes on average, it will end up being 60 patients, roughly, per NP.

That said, the level of illness and geography will be factors in what the ratio ends up being.

“In a 60-building environment, my expectation is we’d have somewhere between 30 and 40 or more NPs to manage the population across the state,” Lerer told SNN. “It depends on ratio and distance, but we want to make sure the NPs have adequate time to take care of people. It’s not about taking care of someone when they get sick. It’s about longitudinal care. It’s about taking care of people, both clinically, but also socially and psychologically.”

Longevity does expect enrollment levels in North Carolina to be somewhat slower for the first four to five months of the year, but it believes the second half of the year will offset this as vaccinations roll out more widely in the nursing home setting.

Vaccine clinics have taken place in almost all of Longevity’s buildings, with the second vaccination completed before the end of February — and that’s with Longevity expecting to be in more than 150 buildings in seven states by the end of this year, Lerer noted.

He also sees nursing homes making improvements in treating COVID-19 when it surfaces, and having a better handle on how to isolate patients and maintain infection control. In addition, the studies on the COVID-19 vaccines being administered suggest high immunity levels, and uptake is increasing overall.

“We believe that come March, April will be in a different place in nursing homes. We’re pretty confident about that,” Lerer said.

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