Executive Outlook 2021: Redefining the Relationship Between Nursing Homes, Physicians

Nursing homes have long existed in a liminal space between acute care and senior living.

The short-term rehab side of nursing care has increasingly turned into something like a mini-hospital, as both Medicare and Medicare Advantage have looked to reduce overall spending by cutting down on hospital admissions and lengths of stay — and operators responded by developing high-end “medical resorts” geared toward younger, healthier residents.

The long-term, Medicaid-funded units often do not feature the same bells and whistles — both in terms of clinical acuity and creature comforts — but they still house extremely vulnerable people with multiple co-morbidities.


The COVID-19 pandemic exposed the danger in approaching nursing home care as simply long-term housing for the elderly. Research has shown that strong staffing coverage is a key indicator of a facility’s ability to keep COVID-19 outbreaks in check, and geriatricians have called for a larger role in shaping nursing home policy and operations.

For the second part of SNN’s annual executive outlook, we wanted to see how physicians and specialists can play a role in the continued evolution of nursing care, and how they believe the relationship between doctors and operators must change in the wake of COVID-19.

Dr. Jerry Wilborn, CEO, GAPS Health

Calendar year 2021 is here and skilled nursing facilities will continue to face many new challenges. This is a resilient industry, and I have no doubts that solving these challenges will create entirely new opportunities. Improving clinical care and enhancing census management will be at the forefront of SNF success and survival as we endure this pandemic and beyond.


We have seen the skilled census drop across the nation. This trend was accelerated by the pandemic. Numbers mid-year saw at least a 10% decline as a result of deaths, admission bans, and reduced elective surgical procedures related to COVID-19 outbreaks. It will recover, but I suspect not to pre-pandemic levels. Increased regulatory scrutiny, infection control logistics and cost, increased patient acuity/behavioral problems, and reimbursement cuts will only compound future operational challenges.

Public perception post-pandemic may provide headwinds as well. I doubt public perception will enhance census, but it may provide an opportunity or a narrative for payers to further define who is a skilled candidate versus who is not.

We have already seen patient-initiated, payer-activated changes like this — particularly for our post-op ortho patients and their discharge destinations. Managing and optimizing social media platforms and focusing on star ratings will continue to be important.

A new normal may be on the horizon.

For decades, physicians and SNFs have not been aligned to provide the best clinical outcomes for residents. SNFs have been considered an afterthought by many physicians, as it is often not their primary clinical focus. As a result of a paucity of effective physician presence across the industry, SNFs have developed their own clinical protocols without the input of physician guidance.

We need to redefine this relationship.

As a clinician who has dedicated his career to caring for patients in the post-acute ecosystem, I was troubled that there were nursing homes during the heights of this pandemic that closed their doors to in-person physician rounding. Granted, there were successful telemedicine pivots and workarounds; this was a missed opportunity, truly underscoring the misalignment between physicians and SNFs.

Physicians are essential and crucial members of the care team, especially given the increased clinical complexity the SNFs are now handling. And therein lies the opportunity.

Integrating active and dedicated physicians into the clinical and FINANCIAL operations of the SNF will lead to better clinical outcomes, census stability, and success in value-based initiatives.

Value-based initiatives will continue to play an ever-increasing role in defining which patient goes where, how long they stay, and what specifically needs to be done during that stay. Many value-based initiatives are based on clinical outcomes. The best way to achieve optimal clinical outcomes is to engage the physician with the signatory authority to impact patient care on all post-acute fronts.

Every SNF by mandate has a medical director. In my experience, this is where we begin. For example, there are facility-based savings that can closely tie into measurable outcomes by simply managing medications. This should be a medical director-driven initiative. The medical director has purview over all residents.

No resident in their seventh, eighth or ninth decade of life benefits from medication regimens including 10 to 20 or more medications. Unfortunately, this is often overlooked by all stakeholders.

Physicians, pharmacists, and interdisciplinary teams managing medications as a part of what we do daily, with unrelenting diligence, will positively influence outcomes: Return to acute rates drop, skilled med costs decrease, rehabilitation participation and outcomes are improved, falls decrease, wounds heal better, appetites improve, families are appreciative, and most importantly our residents feel better. This is one of many examples whereby effectively integrated medical directors can help achieve success within the SNF for all residents.

Our go forward opportunity is an empiric one. Better outcomes, financial stability and census management is at stake for us as an industry. I mentioned “US” as an industry — that includes physicians as a means to better end, and to no longer view them as vendors, but true partners.

We have to create the new normal by melding the regulatory knowledge of the administrator and director of nursing with the clinical experience and insight of committed medical directors/attendings. Nurse practitioners and physician assistants need supervisory and collaborative support in this space to really succeed.

As physicians, op-cos, and owners, we all have to recalibrate our expectations and redefine our relationships. I think this opportunity, however it looks, will drive the new normal, and create new clinical and administrative pathways for better resident care.

Dr. Ari Kalechstein, President, Executive Mental Health

In retrospect, 2020 has been a brutal year, particularly for the skilled nursing community. Prior to the onset of the pandemic, reviews from various executives at investment groups offered mixed reviews regarding the viability of SNFs in the future; raised concerns regarding future reimbursement at the federal and state level; and offered caveats as to the effects of various investment funds on the manner in which SNF operators attempt to generate revenue.

Then, with the onslaught of the pandemic, SNFs struggled to adapt with the day-to-day costs associated with ensuring that facilities remained open — e.g., ensuring that facilities maintained adequate safety on behalf of residents and staff, sustaining the appropriate staffing levels, and reducing staff turnover/absenteeism.

Aside from the financial and/or operational concerns, SNFs faced additional issues, including how to maintain the continuum of care for residents when a subset of the care providers were not allowed to enter the facility. For example, during the first several months following the onset of the pandemic, a number of SNFs struggled to implement mental health services as a consequence of learning to manage and cope with COVID-19, both in terms of prevention and treatment of the disease.

While this was understandable, it did not lessen the need for residents to receive that mental health care, particularly given the prevalence of depressive, anxious, and trauma-based symptoms within that cohort. Eventually, and as a result of the good relationships that were fostered with our partner facilities, many facilities worked with EMH to integrate telemedicine media so that mental health services could be resumed/implemented on behalf of residents.

Given this context, the key challenges that emerged in 2020 also represent opportunities for the SNF community to recast itself in 2021 and beyond.

Communication is key: At the outset of the pandemic, one of the most vital communication tools was rendered moot — the face-to-face meeting. Hence, it was necessary to re-conceptualize the method and frequency of communication. In March, we quickly transitioned to internal Zoom calls and scheduled them in the morning and the afternoon, seven days per week, and make a concerted effort to establish new ways of connecting with our partners via media outreach, blogs, social media, surveys, and personal outreach. We see open communication as a vital component of success for SNFs in 2021.

  • Adapting to 21st century technology: At the time of the onset of the pandemic, it was our experience that most SNFs were averse to utilizing telemedicine technology. Even after the onset of the disease and the ensuing lockdowns, our experience at EMH was that a number of SNFs were slow to embrace the implementation of telemedicine. Our experience was that, for those SNFs that worked with us to create solutions that circumvented the issues posed by the pandemic, their residents ultimately received the mental health care that they desperately needed.
  • Creating new employment opportunities: As we worked with partner facilities to implement telemedicine, it became clear that one obstacle was that those SNFs oftentimes struggled to find the staff member to move the telemedicine hardware from room to room. To solve this problem, EMH created a new position, the device technician (DT), which was fully subsidized by EMH. Our experience has been that, once our partner facilities embraced this option to facilitate the needed mental health care on behalf of residents, our partner facilities appreciated that EMH “thought outside the box,” created a simple, straightforward solution, and absorbed the cost of the DT.
  • Attending to the needs of care providers at SNFs: It is well-documented in the peer review literature that, during the pandemic, health care providers are at an increased risk to experience depressive, anxious, and trauma-based symptoms. Anecdotally, this has been our experience, as well. Yet, and to the best of our knowledge, many health care providers do not seem to be accessing the mental health care that they need. The ramifications of this are manifold. For example, untreated mental health conditions are more likely to lead to absenteeism at work and job turnover. In addition, and for those individuals with mental health conditions that go to work, they are likely to demonstrate performance deficits. From our perspective, to the extent that SNF administrators can attend to the mental health needs of their staff, we perceive that there will be a number of benefits. A healthier staff will likely demonstrate better job performance, reduced absenteeism, and a lower likelihood of leaving their job. Additionally, to the extent that employees perceive that their employer is invested in their well-being, those employees are more likely to view their job in a favorable manner and feel committed to it.

Taken together, 2020 has been a year of extraordinary challenges, both personally and at work, that probably exceed those which most anyone has previously faced. I believe that 2021 will be similarly difficult.

My perspective as a CEO was to communicate effectively and frequently with the EMH team, be honest about what I knew and didn’t know, lean into the myriad challenges that we faced, maintain cautious optimism, and believe that my team and I would devise solutions that would carry EMH through the pandemic. Of course, there are no guarantees about the outcome for 2021; nonetheless, I believe that our approach to managing in the time of the pandemic was effective and may be useful for others.

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