Executive Outlook 2023: A New Playbook for Skilled Nursing

Over the last two years, skilled nursing providers have faced a pandemic and a labor crisis. As 2023 dawns, leaders across the industry are taking stock of their changed organizations and a reshaped business environment, and are preparing to execute strategies formulated in the COVID crucible.

As Signature HealthCARE CEO Joe Steier puts it: “Every quality health care operator needs to write a new playbook for skilled nursing.”

In our two-part Executive Outlook series, you will hear from leaders throughout the sector, learning more about their playbooks and what challenges and opportunities they anticipate the next year will bring.

While their outlooks and strategies differ in some regards, all are focused on addressing the massive workforce issues facing providers, as well as pursuing clinical innovation to work more fruitfully with hospitals and payers while delivering the best possible outcomes for patients and residents.

Joseph Steier, president and CEO, Signature HealthCARE:

As we have lived through the biggest “black swan” event in post-acute care history, every quality health care operator needs to write a new playbook for skilled nursing.

At Signature HealthCARE we remind ourselves that, in every generation, history has a groundbreaking event that redefines society as they once knew it. How we at Signature respond and grow stronger in this latest historical shift is the big question that I think we are ready to answer!

Like many in the skilled nursing and long-term care sector, we’ve had to shift and divest in this post-pandemic environment. But we knew that emotional deconstruction process could lead us into a new restructure process, allowing us to continue our vision to “lead radical change across the health care landscape to transform lives.”

To start our rebuilding, we realized becoming more compact as a company could actually be advantageous, allowing us to better maneuver upcoming challenges, and revamp our strategic plan and new Signature HealthCARE 3.0 platform for 2023. But to prepare for that future, we have to focus on some key projections.

Hospitals are going to re-enter the post-acute space. While skilled nursing units (SNUs) on hospital campuses are not new, with the current health care climate, the increased need for SNUs will grow exponentially. Unfortunately, closures of free-standing nursing homes will continue to increase over the next few years due to the ever-changing regulatory processes, staffing shortages, pending investigations and financial duress. And staffing challenges are not going away anytime soon. COVID PTSD, burnout, villainizing of nursing homes, and societal shifts have all impacted our health care heroes.

With these projections in mind, Signature HealthCARE is making aggressive changes like revitalizing our successful partnership history with acute care hospitals. This includes collaborating with the creation of SNUs in hospitals and creating direct risk sharing arrangements that have proven to be highly successful and are now in demand.

We are also focusing on accelerating our use of technology to reduce nursing staff fatigue. With programs centered around increasing bedside care times with A.I., augmented software, and controlled data sharing platforms, we can better embrace the rising acuity of new potential customers and families with “point of entry” collaboration between physicians, facility leadership, and payers, so advanced care planning can be more synergetic.

In all of this, leadership is key to the resurgence of our industry. It’s thrilling to see more of our inspired leaders at Signature come from the clinical side versus the business sector, which is exciting from the perspective of care management and risk-based gain sharing. This allows us to reshape our training and experience-based learning to harness their expertise and inspiration.

In closing, Signature HealthCARE has always stood on its foundational pillars of Innovation, Learning and Spirituality. In our outlook for 2023, it’s evident that even our pillars are expanding. Things we projected with one point of view a decade ago have now gone through a metamorphosis.

So, with innovation, learning, and the strength of our spirituality within, and as the post-acute industry world seems to darken around us, we are seeing our light.

Mark Parkinson, President and CEO, American Health Care Association/National Center for Assisted Living (AHCA/NCAL):

I am optimistic that 2023 will be a promising year.

The pandemic’s clinical nightmare has greatly improved thanks to the lifesaving vaccines, therapeutic treatments, an evolving virus, and our sector’s commitment to infection control. Our census is slowly but surely recovering. At the current pace, we will be back to pre-pandemic census rates by the end of 2023.

On the operations side, it is still extremely difficult for our providers to fully recover. The challenges that we continue to face every day with the workforce crisis and inflation are unprecedented. We have estimated that if nursing homes continue to gain jobs at the current, modest pace (on average 4,600 jobs per month), a potential recovery to pre-pandemic staffing levels could take at least four years. Our caregivers, who are working themselves tirelessly, and our growing elderly population can’t afford to wait another four years. The long-term care workforce needs a boost now, which is why we continue to fight on Capitol Hill and urge federal and state policymakers to put their support behind policies that attract and retain caregivers for our nation’s seniors. Nursing homes cannot solve this crisis on their own, and I believe things will improve in the years to come.

With that said, the Administration has made it clear that it intends to impose a minimum staffing requirement for nursing homes next year, and we have a multi-level strategy to address this. We continue to have conversations with the Administration, emphasizing that an enforcement approach will not solve this long-term care labor crisis. Ultimately, setting minimum staffing ratios without corresponding resources will further limit access

to care for seniors.

So, we are going to need the support of our providers to help communicate this to policymakers. We’re going to keep at it over and over and over until we get through this. And we will get through it. I’m sure of that because we have amazing providers, caregivers, and leaders who didn’t quit when we were at the lowest point, and I know we won’t quit now.

AHCA/NCAL will continue to work hard to advocate for our sector in Washington and provide our nation’s long-term care residents and staff with the support they need. In 2023, we are hopeful lawmakers will prioritize our population and take meaningful action. It won’t be easy, but we’ve come a long way, and we won’t stop now.

Martha Schram, President and CEO, and Dawn Greaves, Chief Clinical and Innovation Officer, Aegis Therapies:

One of our industry’s most significant opportunities exists in successfully optimizing functional care management within skilled nursing facilities.

First, this requires understanding and agreement on what exactly that means and focusing on the right combination of services to create long-term success for an individual.

Managing the patient journey is imperative in an environment where providers are increasingly accountable for more efficient care and driving better outcomes. Now more than ever, success is measured by more than just the time spent in skilled nursing. Optimized functional care is about being ahead of a sentinel event – a move away from focusing on averting the crisis of the day or completing a specific intervention.

Creating sustained, effective and efficient outcomes is not a new concept, but accomplishing this in an integrated way can be a culture shift for everyone involved. It is about training every person in contact with a patient in their role in optimizing the care and identifying the signs of subtle change. You need to create a global understanding of the integrated care model and an awareness of the patient-specific goals and needs.

This is achieved through embracing collaborative and simultaneous treatment and activities that become a part of the plan of care. It is a move away from linear treatment where often only one intervention is used at a time – for example, where therapy completes their care plan and then “hands-off” to wellness, restorative or maintenance, or vice-versa. This is about collaborating and creating as many points of interaction as possible to ensure effective practice, carry-over, and a sustained result prior to, during and after skilled treatment intervention.

It’s not just about therapy, but about all the other patient-specific functional activities and interventions that can be delivered and reinforced across the entire team to the benefit of the individual’s success and quality of life.

While this concept has always been present, and many would argue it is implemented throughout the industry, we have seen that true integration — focused on an evidence-based plan of care that overarches skilled, restorative, wellness and activities — is lacking. While there has always been a relationship, the next step is to elevate that collaboration where there is a predictable and simultaneous focus, process, structure and engagement.

At Aegis Therapies locations where we have implemented this model, we have seen significant impacts on sustainability, creating value and positioning our partners to participate in managed care and value-based purchasing models successfully.

As we evolve, we continue to expand this concept and consider what else can be utilized to enhance and sustain outcomes. Consider the impact this level of collaboration can have not just on our patients but on our employees. This model supports engagement at every level, and we know engagement promotes job and patient satisfaction and builds stronger communities.

Cynthia Morton, Executive Vice President, Advion (formerly NASL):

As we end 2022 and begin 2023, the issue front and center for those operating in the long-term care space is staff.

We can’t find enough nurses, therapists, certified nurse aides and other caregivers, and once we find them, it’s hard to retain them. Technology has come a long way to help with retention and enable our staff to work smarter, but we still need people.

Unfortunately, policymakers in Congress and at CMS have done little to help this situation. Much of health care faces the same challenge, and we have not seen broad efforts by Congress to attract more clinicians to the health care sector. Our sector won’t be able to solve the staffing shortage overnight and we can’t do it alone. Efforts need to begin now to encourage young people to choose long-term care as a viable career. We also need more tools to better enable us to maintain our current workforce, which has done so much during COVID. Reimbursement reductions hinder our efforts to reward those who have stuck with long-term care despite a very difficult couple of years.

Despite the shortage, nursing home operators are resilient and will find ways to continue providing high-quality care, but it’s not a situation that can be sustained.

Tim Fields, CEO of Ignite Medical Resorts:

2022 was a great year for Ignite. We were able to grow in Texas and Illinois and now have 17 facilities in 6 different states. We strengthened and grew our core vision to ensure we run high census, have excellent quality and customer service and have an amazing culture and employee appreciation. We are excited about 2023 to continue to focus on and improve our vision.

2023 will pose a lot of new challenges and have a lot of new opportunities. We will continue to pour a lot of time, money and resources into our number one priority, our employees. We will continue to have a relentless focus on our culture. The only way to run a unique model and to thrive in a tough labor market is through culture.

Labor is the toughest challenge we all face and will get our No. 1 focus in 2023, as it did in 2022. We are excited in 2023 to explore new employee benefits, and we’ve just updated our reward and recognition programs for our front line superheroes. As we continue to grow as a company it is also important that we grow our staff. We are excited to launch some growth programs: an administrator in training program we call Lion in Training; a Chief Nursing Officer in Training Program (CNOIT); and a CNA Training School called Ignite University.

We are looking forward to more technology to help our nurses, aides and therapists provide better care and service. We are launching new robotics technology so our therapists have the latest and greatest technology to ensure we have the most amazing rehab stay for our guests.

Clinically, we are rolling out remote patient monitoring so our nurses can manage higher acuity patients and catch change of condition quicker, to prevent returns to acute care. In 2023, we will launch new in-house dialysis programs and more specialty clinical programming aligned with our key hospitals and physicians, including new advanced palliative care partnerships.

We will continue to fine tune our use of data, both with predictive analytics and digital dashboards, to put data in the hands of our decision makers every day so we can react better to trends and to measure and quantify our success.

While the recession and interest rates have been an issue as of late, we see 2023 as a year to get back to being bullish on new construction. We have plans for multiple new development projects and are thrilled to bring LuxeRehab to some new cities. We are also still looking for acquisitions, but the right acquisitions, ones that fit our model. We want smart growth and believe there will be a lot of opportunities in 2023.

Lastly, as we turn to 2023, we want to empower our local leaders to do what’s best for their community, their facility, their guests, families, and employees. We are so thankful to have a group of amazing leaders who are creative every day to thread the incredibly difficult needle on how to run a fast-paced, aggressive model while getting clinical, cultural and financial results. Vision without execution is hallucination.