‘Resurrection of Nursing’: Cantex, Touchstone, Brickyard Execs Talk PDPM, Portfolio Diversification, Staffing

Nursing home operators that were able to diversify their businesses and adjust to the patient-driven payment model (PDPM) while battling through Covid-19 now find themselves in a position of strength.

This was one message that top operator executives delivered last week at Skilled Nursing News’ CLINICAL conference in Washington, D.C. They discussed how Covid-era practices and policies pushed them to diversify their portfolios, increase technology use and deepen connections with staff.

“We had bifurcated paths, and I like to say, we were repurposing the plane while it was in flight,” Leslie Campbell, COO of Touchstone Communities, said of the myriad challenges faced during the pandemic. “So we’re responding to Covid. And then meanwhile, we’re launching a home health company. We’re launching a hospice company. We had our pharmacy, and now we are just realizing, coming out of the pandemic, that if we were the same company, we would not survive.”

The moment also drove Touchstone to apply cost-saving strategies, responding to the imperatives of value-based care.

“[We were] building that continuum of care but also working on our best in class outcomes, inculcating the mindset of, ‘We must do our part to take costs out of the system,’” Campbell said.

Now, Touchstone operates about 30 SNFs across Texas and also provides memory care and rehabilitation services, and recently added an I-SNP.

Peter Longo, principal and managing partner at Cantex Continuing Care Network, said that while the plan to diversify beyond SNFs began in the 1990s for his organization, the changes set Cantex up better to handle the fallout from the pandemic.

“So it’s [been] a journey, a long journey for us,” said Longo, of the transformation from a multi-facility SNF operator to a continuing care network. Among the first ancillaries for Cantex was a pharmacy, and over the years its services expanded to include home health, hospice, therapy, and then ultimately an I-SNP, and then more recently, a primary care practice attached to the I-SNP.

Today, Cantex provides post-acute services through a growing portfolio of about 40 skilled nursing facilities, as well as home health agencies and hospices. Longo said that it’s the ancillary services that keep the SNFs running smoothly in the current environment.

Diversification: I-SNP path to profitability 

Cantex’s primary care practice with the I-SNP was launched in the first quarter of 2020 with a “bumpy” financial first year, Longo said. But its inclusion has since helped the organization by drawing profits and efficiencies, including by reducing rehospitalization rates.

“It is absolutely astounding to me the way our NPs that are hovering over our patients in our plan, when we look at that cohort compared to everybody else in our system, their hospitalization rates are maybe 30% of what the rest is,” Longo said.

Cantex made over $1 million in profit last year on the I-SNP along with “excellent” clinical outcomes, Longo said, adding, “I’m not sure if we’ll do that every year in terms of earnings, but that was sort of an unexpected counterbalance to the challenges that we’re facing on the pure SNF business.”

It’s the ancillaries that are now rescuing the SNFs, he said.

“All of our ancillaries right now – pharmacy, home health, hospice, I-SNP, primary care – they are literally carrying the 40 SNFs because the inflation that’s taken place in the [operational expense] per patient day has just gone through the roof,” Longo said.

Indeed, expenses have risen so much that costs can’t be fully covered even though SNF census has mostly recovered to pre-pandemic levels, while home health and hospice census has surpassed those levels, he noted.

Other operators also cited diversification as a means to mitigate losses from SNFs.

According to Lisa Chubb, chief clinical officer at Brickyard Healthcare, diversification of services extends to areas not traditionally considered by SNFs providers.

“We’re looking at things like inpatient behavioral care, and how do we diversify in that area. How do we serve this ever growing opioid crisis with pain management and inpatient facilities … the I-SNP and ACO partnerships,” Chubb said.

Brickyard has 23 locations across the state of Indiana that offer a diverse range of skilled nursing and ancillary services for short- and long-term residents.

Mertz Photography for AMN

‘The resurrection of nursing’

The introduction of PDPM in 2018 contributed to changes in the business landscape for nursing homes, and also the way nurses do their work.

“[W]ith the shift of reimbursement away from therapy – our nurses like to say it’s the resurrection of nursing,” said Campbell. “It has really caused us to take a look at building nurse competencies in specialty areas.”

As a result, Touchstone was pushed into increasing clinical capabilities and “building market niches in places where we had density to allow us to care for the highest acuity patients in every single market that we have a presence,” Campbell said.

As for Longo, adapting to PDPM went smoothly and is largely in place, but now another problem looms: the rise of Medicare Part C plans, otherwise known as Medicare Advantage, will require some major adjustments.

“On the other side of the pandemic, we’re looking at PDPM and say it’s just minor tweaking, it’s not that much different in terms of what we’re doing with the patient,” said Longo. “The real 800-pound gorilla in the room is that now more than 50% of our patients are Part C, and it’s not about PDPM. It’s about having good relationships with your managed care entities and getting the best rates and knowing how to manage length of stay. And PDPM seems like a cakewalk compared to that.”

Meanwhile, at Brickyard, Chubb said, “[W]e definitely try to take care of as many patients as possible. And so with that being said, PDPM didn’t completely change what we were doing clinically and our strategies and our care mechanisms.”

What did change was how the new policies were incorporated using technology, resulting in efficiency and meaningfulness for clinical staff, Chubb said.

“[I]f you build your electronic health record around the regulatory requirements, and all of the data that you need to capture to actually show and capture the burden of care in the most efficient way possible, that’s how you can be successful around the PDPM world,” she said. “And really, that’s what it boils down to, and it also allows the nurse to be closer to the bedside and less in front of the device.”

Staffing outlook: shifting the mindset back to ‘noble’ work

Staffing presented particular challenges during the pandemic and became a source of much frustration. But that also forced providers to appeal to the nobility of the profession to drive satisfaction among workers.

“[Staffing] is top of mind every single day,” Campbell said. And while paying workers has been a way to improve retention, she pointed to other practices as being effective as well.

“No mistake about it, money matters. So compensation evaluation is definitely part of it, but life is too short,” she said. “ … For all of us, [it’s] in driving purpose and meaning and connection. And that’s been one of our primary focuses.”

For Longo, the pandemic drove home the point that the workplace can and should be a place of “safe harbor.” He said worker retention increased at Cantex facilities during the pandemic because his organization was able to provide safety and security to the employees.

“[A] great lesson learned for the future is to take care of your staff during hard times and they’ll stick with you and that will help when labor challenges come,” he said.

And Chubb concurs that making sure staff members are valued by acknowledging their concerns is important.

“[Staffing is] the highest priority that we all have. It leads to all of our outcomes. And let’s face it, learning and understanding [Payroll-Based Journal] is a full time job for all of us right now,” she said, referring to quarterly reports from nursing home operators that provide CMS with direct care payroll and staffing data.

All strategies aside, one thing never fails, according to Campbell: “Bringing joy into the workplace. It’s a dreary world out there now, and so just really focusing on bringing joy into the workplace. And how do we do that? Well, we give people hope for the future …. ignite the passion that is involved in doing this noble work.”