How Skilled Nursing Providers are Dealing with ‘Very Heavy Burden’ of Rising Patient Acuity

Operators in the nursing home space are dealing with a crippling workforce shortage and rising costs of care – all while seeing continued higher acuity among residents.

Providers and vendors in the space agree they’re seeing a larger proportion of patients with higher acuity, but the definition of acuity varies along with methods to measure the trend.

Still, the trend is clear and is leading to heavier burdens on existing staff, dragging down quality scores, and creating even more urgency around technology adoption across the sector.

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Defining acuity

Annette Salisbury, senior vice president of clinical services at PruittHealth, qualifies rising acuity based on comorbidities – PruittHealth clinicians are seeing residents that one would typically see in a hospital setting receiving IV therapy and other skilled therapy.

Joy Herring, vice president of clinical analytics for LTC Services, defined rising acuity within the context of Covid – managing Covid signs and symptoms and striving to alleviate the burden on acute care settings has transferred to the skilled nursing setting.

Others believe rising acuity can be measured based on the proportion of people that fall in certain brackets of frailty and need more monitoring and more help with daily activities.

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Software solution firm MatrixCare has even created an acuity score for its SNF clients. As patients move across the care continuum, their score changes.

While the ins and outs of MatrixCare’s acuity score is proprietary, about 180 clinical data elements factor into MatrixCare’s acuity score for clients, according to Amy Ostrem, vice president of strategy and portfolio management at the company.

Medication can play a huge role in shifting acuity scores, Ostrem said as an example. Doses may cause confusion, or increase the need to use the restroom and in turn increase fall risk.

Facilities are getting hospital discharges sooner during the pandemic, which lends to more medically complex residents, and more comorbidities on top of a slew of medications, according to Ostrem.

That also means more time needed with each patient depending on acuity. It’s an interesting factor to keep in mind considering the looming federal staffing mandate as part of the Biden administration’s reform initiatives.

“As a result of all that, there’s more monitoring required,” said Ostrem. “You want to take vital signs and monitor for any behaviors … one of the common things you see now through Covid [is]depression, and just being able to monitor for that even more closely with those residents that do have a higher acuity.”

People are generally living longer too, Ostrem said, and were deferring their care during the worst of the pandemic, which are other factors in SNF resident acuity.

Travis Palmquist, senior vice president and general manager for senior services at PointClickCare, has seen acuity rise gradually over a number of years in the industry — he served as a SNF administrator in the nineties.

“I don’t know that the high end of acuity has necessarily climbed dramatically. What I do believe has climbed is the resident mix,” said Palmquist. “Fast forward even beyond assisted living, you’re starting to see other at-home care options emerge, [such as] SNF-at-home, hospital-at-home.”

Acuity and the staffing crisis

As the proportion of high acuity residents continues to increase in nursing homes — and more high-functioning residents move to other care settings — there’s a “very heavy burden” placed on staff, Palmquist said.

“Are you going to find a one-person assist that doesn’t have other serious complexities in a SNF today? Probably not,” he said.

Palmquist remembers residents walking to the dining room and to activities. That’s not the norm anymore; it’s not hard to imagine how much more taxing today’s residents are on staff, he added.

Extensive services including isolation, trachs and vents increased nearly five times between 2019 and 2020, according to Net Health data analytics company PointRight. Depression increased more than two times over the same time period, while cognitive impairment among residents increased four times, restorative nursing by two times and swallowing disorders almost four times.

Meanwhile, the number of nurses and nurse aides anticipated to meet federal staffing mandates – which takes into account higher acuity among SNF residents – has jumped from 187,000 to 191,000, according to a report released by CliftonLarsonAllen (CLA). That’s an annual cost of $11.3 billion for staff wages.

Remote patient monitoring and generally driving efficiencies through data acts as a “staff multiplier,” noted Palmquist. With rising acuity coming up against the staffing shortage he said, tech advancements will “have to happen.”

“Rising acuity certainly fuels that need,” he said.

Making data available to an extended care network outside of the nursing home, for one, or establishing a baseline level of connectivity with crucial players in a resident’s care can help facilities facing higher acuity amid staff shortages.

“There’s this whole care network that really wasn’t around 20 to 25 years ago, because, again, that acuity wasn’t as high and the reimbursement systems were different,” said Palmquist, referring to value-based care and Medicare Advantage.

Acuity and therapy

Infinity Rehab VP of Quality and Compliance Patty Scheets says she has been noticing a change in her patients — anecdotally across the sector, providers say skilled nursing residents are “different” now prior to the pandemic.

Infinity’s data, which breaks down patients into five groups based on ability to do activities of daily living, or ADLs, shows a dramatic shift in proportions across groups, according to Scheets.

The second to last group of Infinity patients — those in need of rehabilitation but don’t improve that much — has increased from 20% pre-pandemic to 34% currently.

This group is “hanging on by a thread” in terms of needing a higher level of care.

“Most are making it home … but they’re still vulnerable for hospital admission, vulnerable for risk of other adverse events,” said Scheets.

At the other end is what she calls the high functioning group that doesn’t need that much assistance in day-to-day living — that group has dropped from 25% pre-pandemic to 8% currently.

These patients are being funneled into home health care and community-based services, along with senior living and assisted living.

When thinking about how these groups will affect overall quality metrics, Scheets said she had a big “a-ha moment.”

“It’s a law of averages. When you look at quality metrics, you’re rolling up the outcomes of all of your patients,” noted Scheets. “We’re losing that group who really pulled those metrics up, because they really flew over [averages] in some of those thresholds. We’re having more of those patients who are responding but not to a huge degree.”

Scheets thinks about acuity in three ways — seeing patients who are more medically unstable, having patents with more activity limitation, and those with less responsiveness to care.

“Probably each of us, as a provider, has a way to think about rising acuity,” said Scheets. “I focused in on more medical instability, more need for physical assistance, and less responsiveness to care, because that’s the world that I experienced.”

On the nursing side, Scheets said acuity is more defined by the numbers of procedures, medication complexity, and patients in need of wound care.

Ancillary impact as acuity rises

Exercise specialists, direct care staff with a focus on increasing generalized activity and mobility in the nursing home, may be key to handling this change in patient mix as clinical staff continues to be hard to come by.

The idea is that those who can walk should walk more, and those who can’t walk should make more changes in position, such as moving from the bed to a chair. The idea is to support “more generalized activity and mobility,” Scheets said.

She believes there’s a “real opportunity” on the ancillary side to build in more structured programs directed by a therapy team, with nurses acting as support.

Pharmacy specialists and other clinicians dedicated to medication reduction will play a bigger role too, according to Ostrem.

It’s another tie to federal reform initiatives, with a concerted effort to reduce psychotropic drugs among SNF residents.

Salisbury said preparing rooms could involve specialty equipment, a BIPAP/CPAP machine, or having oxygen ready at the bedside.

“Communication is key between the admitting source and the facility to ensure that smooth transition and to ensure you have everything you need from the start,” added Salisbury.

Awaiting data

Providers and ancillary businesses in the space will continue to monitor data as patient mix continues to change.

Scheets said she will be looking at Infinity’s data closely to see if those group percentages will shift again in another year-and-a-half.

“I don’t know for sure if we’ll get some recovery,” added Scheets. “My guess is that the loss of those highest functioning individuals that we used to see in skilled nursing … I would say they’re probably not coming back.”

Ostrem believes the proportion of higher acuity patients will continue to rise, especially given the aging baby boomer generation — but remote patient monitoring may head this challenge off at the pass.

“I feel like technology and the health care system are really striving to do better at care coordination,” added Ostrem.

Already, Herring said MatrixCare software identifies high-risk residents with severe comorbidities. That leaves providers with the option to develop care plans for these residents with an interdisciplinary team.

Predictive analytics will tell the story of rising acuity much better for providers, she said, as facilities try to get more proactive with care services and avoid staff burnout.

“When you have a system that connects those dots and puts those graphs and the bar charts and the trend lines together for you, it’s much easier to predict, and be proactive,” she said.

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