Tom Coble is president and CEO of Oklahoma-based Elmbrook Management Company. Elmbrook has 12 facilities, 11 SNFs and one assisted living facility. In addition to his leadership role, Coble has run his own Institutional Special Needs Plan (I-SNP) since 2005.
Through the Value-Based Care series, Coble shares his belief that nursing homes can become senior health centers by integrating long-term care with home- and community-based services, while reaping in the benefits of shared savings that come with value-based care. He also discusses the importance of helping the communities recognize the important role nursing homes play in the care continuum.
In one sentence, define what value-based care means to you.
Value-based care is providing appropriate care in the best setting.
What do you think value-based care requires in order to be successful?
Providers must be proactive, flexible and have a system that enables them to deliver care in the appropriate setting during the resident’s stay, but also as they move across the continuum of care.
What do you see as the biggest hurdles to achieving value-based care in today’s health care landscape?
It has been difficult because everybody is in a different place. I’ve been running an I-SNP here in Oklahoma since 2005, and they’re just beginning to catch on in the U.S. As the health care system changes, the flexibility needed to take care of residents is increasing, along with the need to measure outcomes.
If you don’t have a system to move residents through the continuum of care, it will be hard to achieve a better outcome. Technology is helping us a lot with that. Now you can do home care with a hybrid model using telehealth, and technology is continuing to push the possibilities.
Do you have any other thoughts on how technology is supporting that shift towards value-based care?
We’re getting to the point where we can monitor patients and perform wellness checks electronically. With respect to the value-based care system, our nursing homes and our I-SNP here in Oklahoma are adopting home care models, but we’re approaching it as home and community-based support.
We’ll have nurse practitioners visit residents and people living at home that we’re taking care of in the Medicaid system. We’re there to make sure they have food and good living conditions, then we can monitor their health and use the I-SNP system to provide further medical support as needed.
Do you see any downsides to value-based care?
Only if it is not being used to reduce rates. There’s a lot of pressure right now on reducing rates, but if a provider is willing to invest in the right systems, and hire the best people to help support residents at home, they should be allowed to participate fully in those savings.
Why do you think it’s been so hard for SNFs, in general, to get a seat at the table when it comes to value-based care?
The Medicare system is centered on hospitals, so it has always been hard for us to get a seat at the table. What we do best is take care of short-term residents medically, get them home and that’s what we’re doing in nursing homes as well.
If for some reason a resident can’t go home for a while, we provide room and board and nursing services to support them. Now, we’re able to take that same level of support into the community, and especially in rural areas that have traditionally been harder to serve. The way I see it is we’re opening up our nursing facilities in the rural areas to become senior health centers.
What role should skilled nursing facilities play in the value-based care landscape?
When it’s non-emergent SNFs have a role in providing preventive, proactive care. I think nursing homes are a much better place to do that when the systems are in place, because hospitals are there for emergent care. Nursing homes are there for short-stay care once the hospitalization is over with. Or they’re there to maintain and take care of someone until they can go home safely. We can provide that same support in the community, if everything is aligned right.
What do operators have to do in value-based care to get a fair financial reward?
We have to continue to talk about the importance of what we do in communities. We’re generally in rural communities and are probably the largest employer besides schools, in most cases. We’re very important to those communities. If we weren’t there, the people that live there would have to move somewhere else as they age, putting a lot of stress on families to move back and forth.The workforce in those communities would have to drive somewhere else to go to work.
We have to prove that we can provide quality care wherever that may be. At the same time, we have to help the communities recognize the important role we play.
Do you think the shift to value-based care is happening fast enough, and does the pace of policy change align with that transition?
I think it’s all over the board. It’s rushed in some places — just look what’s going on with PDPM and the proposed rate cut. The policies are supposed to be revenue-neutral, but as we change policy, we’re opening a new landscape that needs a patient response, just like what we’ve been through with the pandemic.
Everybody needs to be patient and work together with a system that’s simple enough to yield measurable outcomes. That way, you can see where you are and what you’re saving, because the number of people we take care of is increasing, and we have to reduce our growing cost.
