Leaders in the skilled nursing space have increasingly seen value in creating a primary care strategy, with some intending to become part of a risk-based model as part of that strategy — especially as acuity continues to be high among residents.
Operators looking to shift to such a strategy need a clear vision of how physicians will play a critical role in their organization, according to Stephen Taylor, principal and senior living and care segment leader at CliftonLarsonAllen (CLA). Reliable data to better understand their patient population is also a must.
Having a plan and knowing data can help make adopting a risk-based model look less risky. alternative is patients participate in these types of plans and SNFs simply aren’t involved.
“There may be risk in not taking risk,” said Taylor. “Ultimately, the patients and residents within the walls of a SNF are consumers of health care from someone, and if you’re not participating in it, that doesn’t mean it’s not happening, it’s just happening without you.”
Peter Longo, principal and managing partner at Cantex Continuing Care Network, said his team inadvertently got into their primary care strategy by way of implementing an Institutional Special Needs Plan (I-SNP) model, — a value-based care model that fits nicely with a SNF’s patient population.
Once the Cantex team got their I-SNP “sea legs,” they found the plan attracted high order clinicians, like a nurse practitioner (NP), to oversee patients and, in turn, forge relationships with the operator’s directors of nursing (DONs), patients and their families.
“[Cantex’s peers have] experienced something similar … It was a revelation,” said Longo. “Once you became a settled I-SNP with your own nurse practitioner practice, there clearly were new ways to leverage that primary care practice that would be of tremendous benefit to your patients.”
A need to outperform
The move toward a risk-based model and, in turn, primary care strategy safeguards nursing homes for a “financially viable” future, Taylor said, as the sector has to more than ever outperform other senior care options.
A PCP strategy also translates to enhanced revenue opportunities, he noted.
“By outperform, I mean an ability to accept increasingly complex admissions, consistently produce quality health care outcomes, and efficiently and effectively coordinate strategies to meet goals,” added Taylor. “The execution of this requires PCPs to be high-touch with the SNF population and be present in the collaboration with the team.”
As the sector continues to face a crippling staffing shortage, rising costs of care and inflationary pressures, the importance of outperforming other operators in local markets becomes even more heightened, he said.
“Hospitals and home health systems know you can take on these complex individuals. Also, peer to peer (physician to physician) communication strengthens referral relationships,” added Taylor.
Taylor recommends SNFs get involved in risk-based models and PCP strategies in some way, as risk-based care plans continue to mature. There’s an inextricable tie between the rise of higher acuity in SNF patients and greater primary care physician involvement, he said.
Greater involvement translates to having more of an everyday presence rather than what most SNFs do now which is having an outside vendor come in when needed for primary care. Taylor would like to see operators have PCPs as part of the core care model and ingrained in company culture.
“PCPs cannot be just a vendor relationship. They should be actively involved in your organization,” he added.
Population health opportunities
Given the high amount of medical complexity across long-term and short-stay nursing home patients, and a “high concentration of lives” in one place, having PCPs in-house leads to proactive decision making up the chain of command, Taylor said.
Certified nursing assistants (CNAs), dietary workers and everyone in-between can notice slight changes in health and behavioral baselines – they can then tell the PCP and potentially avoid rehospitalization or worsening symptoms.
“We believe SNFs have a real opportunity to manage a patient population, coordinate care, and deliver positive health outcomes — and primary care is paramount in the successful execution of this opportunity,” he said.
In-house physicians were much more in sync with patient outcomes, added Longo, monitoring progression toward individual clinical goals – and working collaboratively with other nursing home staff to achieve those goals.
If facilities think about risk-based models and primary care strategies within the context of the Patient-Driven Payment Model (PDPM), Longo added, implementation serves as a compliance measure.
PCPs and risk-based models move the needle on improving clinical outcomes, focus on patient-first initiatives and add value. Enough revenue is generated from the physician and nurse practitioner services to cover the cost of having advanced clinicians onsite, Longo said.
“The skilled nursing world always thought that physician services were above our pay grade, but I think many of us now, we’re saying, not necessarily,” noted Longo. “These are clinical services that we are able to organize and oversee to the benefit of our patient base.”
SNF operators that add a PCP strategy within a Medicare fee for service (FFS) model, on the other hand, are missing out on a “more significant opportunity,” Taylor added.
In-house PCPs working in an I-SNP or Accountable Care Organization (ACO) deliver more savings through preventative care, treating residents onsite and reducing hospital admissions, he said.
Notably, facilities with a PCP-led care model saw inpatient hospital utilization cut in half; such utilization was 300 per 1,000 residents compared to 600-plus per 1,000 residents, according to Taylor.
“Medicare Advantage and PCPs are focusing on the senior population because there is a significant need for solutions: care coordination and quality health care outcomes for the consumer and cost containment for the payor,” noted Taylor. “The advantage the SNF has is the concentration of lives, which makes the care delivery significantly more efficient and effective.”
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