A range of people involved in the skilled nursing profession on many different levels — from hospitalists to reimbursement experts — have over the years consistently preached a key of success for skilled nursing facilities: Identify the needs of hospitals, and try to meet those needs.
This is typically understood to mean taking on older patients in need of complex care, and that is certainly a critical component of meeting hospitals’ needs. Part of the reason for that lies in the fact that patients with more complicated medical conditions are hard to place — and hospitals need them to be placed in some kind of post-acute setting to free up beds.
The hard-to-place aspect of these patients can extend to more than just their clinical conditions, though. That’s the case for pediatric patients who need skilled nursing care in the state of Nevada, where this need is particularly acute.
Daniel Mathis, the CEO of the post-acute health care management company PureCare Living, came across this soon after a stint at the Nevada Health Care Association.
Four years later, his company is in the final stages of licensing for Silver State Pediatric, a 36-bed pediatric SNF in Las Vegas, with patient transfer agreements finalized as of March 24 — despite pandemic-induced construction delays and COVID-19 making it difficult to schedule surveys with the state.
Still, Silver State has its certificate of occupancy in hand, and the SNF is set to receive its license after logging a deficiency-free survey last week — but even in the pre-opening status, Mathis has already gotten multiple “serious referrals.”
“We’ve really focused on saying, ‘Not yet, not yet. Thank you for reaching out; sorry we can’t help you today, but we realize your admission has to move forward,'” he told Skilled Nursing News in late March. “We’re not asking anybody to hold anything. But just with word of mouth, easily 10 solid referrals, and they’re like: Please, if you don’t take this admission, we’re looking at possible out-of-state or adult SNF placement.”
When did PureCare Living first identify the need for a pediatric skilled nursing facility in Nevada? And what steps did you take after identifying that need?
It actually goes back quite a few years, I was the president of the Nevada Health Care Association, and through that association, one of our members had a pediatric skilled nursing facility that was more of a home- and community-based one.
The state of Nevada has contracts with skilled nursing providers outside of the state. It’s a small population, but there were sometimes as many as 50 kids being handled in SNFs outside of Nevada, and families had trouble commuting. That’s really when I became aware of it.
Then when I left the association, I met an individual who owned a building. And he had some history … where he thinks that children that need skilled nursing should have a place in Nevada, and he had a building. He reached out to me, and wanted to know if I could help him develop Silver State Pediatric. That meeting was probably four years ago, when we first started meeting on Silver State.
I’m curious about the demographics you were looking at, especially with so many kids getting sent out of state for this type of care. Obviously it’s not a huge population, but something that there’s still clearly a need for.
Nevada has about 55 SNFs in the entire state, so we don’t have a lot to start with. That’s something that people don’t realize.
And then, if you have a pediatric admission, you have to make sure they get to school, provide those services, exposure to education. It’s not something that the geriatric facilities wanted to do.
When I was an administrator in the state, you would get, occasionally, pediatric placement. But then on the compliance component of it, a lot of facilities had trouble with compliance. We had a couple of them that tried to mix pediatrics and adult and then it just got into a compliance headache, and they decided not to do it.
So demographically, we knew there were needs. There were some [pediatric patients] in the state that were in adult facilities, but there was a significant number that were transported out — and not only for just skilled nursing, but for some of those pediatric specialties. Say a family has a child that has to get cardiac heart surgery. The hospitals, because they don’t have a good discharge location, would hang on to those patients, because the families were refusing out-of-state placement when they needed probably eight to 10 weeks of post-surgery recovery.
Kind of the same issue for short-term and geriatrics. But if you’re a cardiologist, and you’ve just done surgery, and somebody says, “Hey, let me have your admission,” and they don’t do pediatrics at all, don’t have a pediatrician on site, the cardiologist is not going to cooperate.
So [the patients] end up staying in the hospital, or transported out. We’re going to apply, or we’re going to try to become that relief valve for those NICU [neonatal intensive care]/PICU [pediatric intensive care] units, so they can work on their length of stay and quality indicators.
You’ve mentioned compliance and education as a big issue there. Can you go into that, the different compliance requirements for a pediatric SNF that are different from a geriatric one?
The law is if you’re a child under the age of 17, 16, whatever it is in the state, you’ve got to be enrolled in school, and they apply that. The surveyors come in, and if you’ve got a child — Clark County does have (and this is in Vegas, this is not indicative of the entire state) specific schools and support, where if you can load up that pulmonary-case kid, with his vent on his wheelchair, you can send him to school. If your facility’s not ready or prepared to get a ventilator pediatric kid in a wheelchair, and his vent onto the school bus and receive him back, you’re going to have compliance issues.
That’s what was happening. At first when you have the admission, if the child was not able to participate, that might do for a while. But once that child stabilizes and gets to the point where they can attend school, that’s a requirement, and we want that.
We’re going to have in-house tutoring, a Clark County compliance teacher, and then we’ll also be prepared for those kids that can be mainstream and utilize the resources of Clark County for these kids.
[Another] of the biggest challenges is the clinical component. There’s only seven pediatric pulmonologists in the entire state of Nevada, when we put it together. Two of them have California addresses, and to get one that will round in a skilled nursing setting, it’s just extremely difficult.
Then you’ve got to have pediatrician coverage for these kids, and it’s just not something that the state has enough resources. We were very lucky in aligning ourselves with University of Nevada, Las Vegas School of Medicine; we have access to all UNLV clinicians. Dr. Evelyn Montalvo Stanton is a pediatric pulmonologist, and she is the chair of UNLV School of Medicine’s pediatric department, and then Dr. David Parks is a pediatric pulmonologist also with UNLV School of Medicine.
And then they’re going to have nurse practitioners, pediatric nurse practitioners, or other resources — the pediatric dental school. Without them, it would be extremely difficult to have a program.
What has been the response of hospitals to the prospect of having a discharge destination for these patients? What about the community in general?
The community is really supportive … and then the hospitals are very excited, because we’re already getting referrals and we’re not even licensed yet. Our survey is Thursday, April 1, and Friday, April 2. [Editor’s note: The facility passed its survey with no deficiencies after the interview was recorded, according to a spokesperson.]
We’ve gotten through our life-safety component, and then we are cramming for our health compliance review on Thursday and Good Friday.
All the hospitals know who we are, we’re getting referrals. They’re very excited. The hospitals’ response has really been overwhelming.
We’ve had contact from several groups … and they’ve actually come and toured and asked some very hard questions about: “Can you, when will you be able to take our post-operative kids that need short rehab?”
My answer to them is that’s probably not going to be our first admission. Our first few admissions will be stable. All of our team, we meet the requirements on paper, but we need to work together as a team, and then probably start with a lower acuity and work our way up to a post-operative pediatric cardiac recovery.
The opportunity is ours. Luckily, with the School of Medicine, we’re going to have that depth of clinicians, where it’s not just one doctor; it’s a team of physicians. They’re going to be able to help us push our acuity level where our staff can take it.
Is there a sense of how many patients already people want to place with you?
Serious referrals? Probably 10, and I’m not really talking to a lot of people. When I was the state exec, there were at any one time, 10 people running around with plans under their arm, saying they’re planning some kind of pediatric SNF. That’s been going on for years.
There was a 10-year period in Nevada where not a single SNF was built, so the problem is that people have heard it before. I’m really not going to press hard until we get our license in hand and we can actually admit.
Those discharge planners, when you’ve got somebody ready to go in there from the hospital, you’re not waiting 30 days, six weeks; you’re not waiting until we get our license.
We’ve really focused on saying, “Not yet, not yet. Thank you for reaching out, sorry we can’t help you today, but we realize your admission has to move forward.”
We’re not asking anybody to hold anything. But just with word of mouth, easily 10 solid referrals, and they’re like: “Please, if you don’t take this admission, we’re looking at possible out-of-state or adult SNF placement.”