Trilogy Health Services last week announced the appointment of the company’s first-ever chief medical officer, naming Dr. Andrew McNamara to the post.
Appointing a CMO is just the latest step in Trilogy’s concerted, multi-year effort to elevate clinical care. The push can be traced to 2019, when Leigh Ann Barney became CEO.
“People asked, what’s going to be your vision now, for the future?” she told Skilled Nursing News during a recent interview at the American Seniors Housing Association (ASHA) conference in Scottsdale, Arizona. “We had always thought of ourselves as a very customer service-focused and very employee-centric organization. And so I said, the third leg of that stool will be a focus on clinical excellence.”
Barney aimed to provide more clinically complex services in skilled nursing while also enhancing the health and wellness offerings in Trilogy’s independent living and assisted living communities.
Trilogy was just embarking on initiatives to meet these objectives when Covid-19 struck, forcing the company to hit pause on some of those efforts. But the pandemic only made Barney more determined, as she witnessed how Trilogy and other organizations were forced to provide more robust clinical care than ever, in part because sending people to the hospital became impossible.
“What I shared with our team is, [the pandemic] is really a springboard for us to say, our industry can do these things, because we had to do these things,” she said. “All the things we learned and did very quickly — we changed policies, we kept people from going to the hospital and kept them in their home — why don’t we think of that now as everyday [practice], and get to a point where it would be offensive to us to send someone to a hospital … unless it’s just an absolute, dire emergency.”
The focus on preventing hospitalizations and enhancing clinical outcomes also is rewarded by value-based care frameworks that revolve around lowering costs while improving population health. Barney anticipates that she and her leadership team will make decisions this year about how to move forward with value-based payment models. And incoming CMO McNamara brings insurance experience, having most recently been chief medical officer for Aetna Better Health of Kentucky.
The clinical strategy also is helping Trilogy weather the current staffing crisis besetting the skilled nursing sector, with programs that help drive retention while enabling clinicians to learn and practice more advanced skills, Barney said.
Inside the clinical strategy
Trilogy’s focus on elevating clinical capabilities is enabled and informed by industry trends, as well as past business moves that the company executed.
For instance, Medicare’s Patient-Driven Payment Model (PDPM) for skilled nursing was designed to improve how resources are allocated for medically complex residents; several leaders within the sector have noted that caring for higher-acuity patients has become a smarter strategy from a financial perspective under PDPM.
“If you’re doing some of these more complex clinical programs, then yes, the reimbursement is higher to pay for that,” Barney noted.
Meanwhile, resident acuity has been rising in skilled nursing centers and across the care continuum. This trend pre-dated Covid-19, but the pandemic added momentum. For example, the three-day stay waiver allowed nursing homes to receive hospital discharges sooner, driving up average acuity.
Another large-scale health care trend has been the shift toward value-based payment, in which providers are incentivized to offer more integrated care that reduces high-cost interventions such as hospital stays, while also hitting quality goals.
Given that Trilogy’s standard model consists of independent living, assisted living and skilled care campuses, the company already has the ability to manage services for older adults as their needs change — a capability that is key for success in value-based models. Further strengthening the company’s managed care capabilities, Trilogy launched the Synchrony subsidiary last year.
Under the leadership of former Trilogy CEO Randall Bufford, Synchrony offers a range of services, including pharmacy, rehab and lab.
“If we can coordinate with one organization to provide some of that innovation and technology and support with programs, then that’s better than trying to deal with a lot of other organizations,” Barney said, of the Synchrony relationship. “The more that we can add to those services to create this whole managed service organization, that helps support what we’re doing on the clinical care side in our campuses … again, we can keep people where they live longer.”
With all these pieces in place, Trilogy is close to determining its next move in value-based care.
“We have a value-based care internal committee, and we’ve done at least one education summit to evaluate what’s the best approach for us,” Barney said.
The company already has been participating in some accountable care organizations (ACOs), but with limited financial risk and reward, she said. A potential next step would be to either join or launch a Medicare Advantage Institutional Special Needs Plan (I-SNP), and Barney anticipates “making a decision” this year.
“It’s just, what’s the right fit for us — do we want to control everything or do we want to take less risk and partner with someone else?” she said.
One consideration is that traditional, fee-for-service Medicare still is the dominant payer in Trilogy’s markets, even as Medicare Advantage has gained some ground, Barney added.
She sees promise in the Institutional Equivalent Special Needs Plan (IE-SNP), which would focus on Medicare Advantage benefits tailored to Trilogy’s assisted living population.
“I would love to see us be able to design or be a part of a project where we can focus on those assisted living residents to keep them in their home longer and allow them to take advantage of Medicare resources that they already have, versus having to leave and go to the skilled setting, even if it’s just right next door to use them,” she said.
Staffing advantages
The ability to offer more complex clinical services depends on having staff members with the relevant skills, so Trilogy has focused on education and training efforts. These are creating a “two-fold advantage,” according to Barney.
“We get to take better care of our residents, but it’s also a recruitment tool,” she said. “If we’re doing specialty units of stroke rehab and we offer specialized training, it may be a niche that a particular nurse or caregiver wants to work in, and they get the training, and they get extra pay for doing it.”
Trilogy plans to take this approach to training for onsite dialysis as well. These types of educational offerings build on Trilogy’s long-standing apprenticeship programs, which tie certifications to increases in pay. There are various apprenticeship tracks, allowing clinical workers to achieve certification in areas such as wound care but also enabling dining workers to earn culinary certifications, or housekeepers to earn customer service certifications.
Rather than offering sign-on bonuses, Trilogy touts the ability to earn pay increases while also learning new skills that “no one can take away from you,” Barney said. So, the educational offerings are a recruitment tool while also bolstering retention.
“Our retention is extremely higher in someone who has completed all of those courses,” Barney said.
Trilogy funds such educational offerings in part through workforce development dollars accessed through government channels. A policy not to use agency workers also frees up money that can be invested into programs.
“I don’t think it’s hard to put the infrastructure together,” Barney said of workforce education. “It’s just making that commitment that we’re going to grow our talent our own way and not take what might be seen as an easy way out, to call an agency to fix a problem.”
She is concerned about the effects of a potential federal minimum staffing mandate, which the Centers for Medicare & Medicaid Services (CMS) will float later this year. Given current staffing shortages, such a mandate could force providers to tap agency staff or else care for fewer people.
The roles of non-clinical workers, universal workers and residents’ family also should be considered, Barney argued, noting that family members were considered essential workers during Covid-19.
Perhaps unsurprisingly, given Trilogy’s push to enable clinicians to practice at the top of their licenses and skill sets, Barney also pointed out the issue of different regulations across states that limit the type of care that certain staff members can deliver.
She drew from her own life as an example, saying that for her own father — who lives on his own — she can administer medication or take his insulin, despite not being a clinician.
“Yet, in our settings, there’s so much restriction on what can be done, and it’s not consistent,” she said. “I think the issue should be solved, so that the staff that we have can do things that right now, sometimes only nurses can do.”
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