As the Skilled Nursing News’ CLINICAL event in Washington D.C. came to a close last month, industry experts left with staffing concerns amid labor shortages and pending legislation on minimum staffing standards. However, operators also shared optimism over their innovations in corporate and clinical practices as they continued to confront higher acuity and tighter regulation.
Guidance from panelists — ranging from a representative of the Centers for Medicare & Medicaid (CMS), heads of provider organizations and clinical chiefs, and a leader with the industry’s largest trade group — focused on these key areas.
As we reflect upon their advice, concerns and insights amid this changing landscape of how business is done at skilled nursing facilities (SNFs) in the post-Covid era, here are some of the top takeaways from the event.
Image by Merz Photography for Aging Media NetworkCovid showed CMS the value of nursing homes in continuum
Nursing homes faced some of the greatest challenges in attending to a higher acuity patient during the Covid-19 crisis, but they also demonstrated their importance within the overall continuum of care, according to Dr. Shari Ling, deputy chief medical officer for CMS. Now, the time is ripe for more integration of SNFs into the health care system with policy and planning reflecting this trend, she said.
“How do we improve the throughput when people do need unscheduled acute care?” Ling asked. “The solution is both in front and in back, upstream and downstream. And I think nursing homes are a really important part of that solution.”
Ling also told SNN that CMS is weighing operator comments and data on staffing very seriously as the federal agency prepares to finalize a proposal on the federal staffing minimum in the spring.
“CMS is working on and has fielded a staffing study and also put out a request for other sources of information to help us shape what staffing requirements look like,” Ling said.
Staff training phase for MDS switch
As nursing home providers ready themselves for the changes coming on Oct. 1 for the Minimum Data Set (MDS), providers said they were gearing up to use existing information about residents as they acclimate their clinical staff to code correctly under the new system, a byproduct of the switch to the Patient Driven Payment Model (PDPM).
The uncertainty related to these changes – notably including a shift from Section G to GG, with details still under review – could impact surveys and star ratings, and ultimately reimbursements, panelists said. MDS changes may clash with the existing workforce shortage too, as it may be particularly difficult to train temp agency staff on the changes.
“Are they going to continue to look at how we address residents with functional decline? Are they going to base that off of G or are we going to have to change that methodology and figure out how that’s going to be impacted from Section GG? There may be a risk of our CNAs or our team members not coding that information accurately, putting us at risk for not having accurate assessments and accurate pictures of the residents,” said Heather Haberhern, SVP of quality at Health Dimensions Group.
Subsequent to the event, CMS released more resources related to training on MDS changes. Joel Van Eaton, EVP of post-acute care regulatory affairs and education at Broad River Rehab, suggests that nursing home leaders involve and educate their entire workforces, not just MDS coordinators. For example, everyone could watch the CMS-provided training videos together and discuss the changes, he told SNN.
Mertz Photography for AMNInnovations on managing labor
Not all is grim amid the uncertain environment created by regulatory reform and staffing shortages, however. Industry executives also spoke about how these shifts were transforming clinical teams, with staff stepping outside their areas of expertise with greater agility.
In fact, all nursing levels, and even dietary and housekeeping staff, are working together to ensure that a facility is providing the best patient care, Amanda Johnson, Lifespark’s VP of operations, and Ja’Nay Crippen-Derry, VP of clinical services at CHI Living Communities, said at CLINICAL.
“You can’t just think of the clinical team as being RNs, LPNs, and CNAs. It really is everybody … That includes social services, community life, wellness, recreational therapy, down to our ancillary services, housekeeping, laundry. Everyone is part of that person’s care plan, and how do we engage them in every aspect of a person’s care?” said Johnson. In asking this question, Johnson said it has led her organization to create a new value-based position called the “life care manager” at Lifespark.
This life care manager role is very person focused, and its purpose is to inform the clinical team of any other ancillary services a resident might be receiving, Johnson explained. The position also ensures the team is meeting regulatory requirements, keeping up with the care plan and care conferences and other factors that could detract from staff time. And it’s a critical role, given that Lifespark’s model is one of integrated care across the continuum, with outcomes tied to reimbursement through various value-based care frameworks.
Staffing challenges were compounded during the pandemic, and the industry is reeling from the impact. But a way that providers got past some of these challenges was by cultivating a culture of care, not just for residents but their employees as well – as a place of “safe harbor,” as Longo put it. This approach increased retention at Cantex facilities, he said.
“[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,” Longo said.
Meanwhile, truly valuing staff members, acknowledging their concerns and simply bringing joy into the workplace is important as well, panelists advised.
Innovations on the clinical side: ‘More hospital like’
As nursing homes take on a greater variety of patients with complex clinical conditions, the “Super SNF” – marked by expansion of advanced care specialty programs – is another innovation taking root in the sector, leaders said.
“The term Super SNF has been a popular term. And absolutely our hospitals, the managed care companies, they’re looking to all of us to be that one next step down from the hospital. And so in order to be able to do that, specialty programs are needed,’ said Heather TerHark-Monreal, VP of Ancillary Services at Vivage Senior Living – Beecan Health Colorado. “We are all becoming more and more hospital-like.”
The newly merged Colorado-based Vivage-Beecan has 42 skilled nursing communities under one integrated network of care, with nearly 3,600 combined licensed beds across the state.
Physicians in specialized fields – from pulmonology to nephrology – routinely round at the Vivage-Beecan’s facilities, TerHark-Monreal said, noting, “I absolutely think that that’s our future. From a post-acute standpoint, it is very much specialization across the board.”
Moreover, the rising acuity in nursing homes has led to innovations where SNF clinical teams are more closely coordinating with hospitals.
“One of the key points of having a successful behavioral health program is having strong clinical collaborations with partner hospitals,” said Zachary Palace, M.D., medical director of the Hebrew Home at Riverdale in New York. The organization’s clinicians coordinate closely with the geriartic psychiatry fellowship programs at New York hospitals, he said. Hebrew Home is a very large facility with 843 beds, and is part of the RiverSpring Living organization.
Adapting to shifts to PDPM or Medicare Advantage plans pushed nursing home providers to incorporate a greater use of technology, resulting in efficiency and meaningfulness for clinical staff.
“[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,” said Lisa Chubb, chief clinical officer at Brickyard Healthcare.
Mertz Photography for AMNInnovation on operational side: Portfolio diversification to the rescue
Skilled nursing operators that began the process of diversification prior to the pandemic now find themselves in a position of strength, panelists said.
Executives from Cantex, Touchstone Communities and Brickyard Healthcare said that more than anything, the challenges of regulatory reform and Covid pushed them to embrace diversification, technology use and deepen connections with staff, which ended up helping with retention rates.
Notably, the diversification meant the increased operational expenses, especially at a time of high inflation, resulted in the ancillaries rescuing the SNFs, said Peter Longo, principal and managing partner at Cantex Continuing Care Network.
“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.
‘Still not recovered’
Despite these innovations, staffing troubles – amid inadequate federal funding for the skilled nursing industry – are at crisis point and leading to ever-increasing facility closures, CLINICAL conference panelists warned, pointing to the trend of nursing homes having to refuse patient referrals from hospitals.
Panelists also said that as they look to attack these problems with some new and old approaches it will be crucial to get the federal government’s help on expediting and increasing immigrant visas, improving funding and doing away with outdated rules such as the 3-day hospital stay requirement.
Tom Syverson, director of government and external affairs at the Evangelical Lutheran Good Samaritan Society, said that he hasn’t seen a staffing crisis like the one skilled nursing is currently facing in the 36 years he has worked in health care.
“We had one patient in one of our hospitals that was there for over 200 days,” he said. “What kind of quality of life is that for a person? But what are the incentives for skilled nursing facility providers to take those admissions when you do not have staff?”
Good Samaritan closed its 13th facility in the last 18 months, all but one of which were located in small, rural communities, Syverson said.
But while some operators are closing or divesting communities, others are in rapid growth mode — including through the acquisition of struggling mom-and-pops.
Executives from Creative Solutions in Healthcare and PACS said that their organizations are among those that have been scaling rapidly. Creative Solutions operates 120 nursing homes in Texas, while PACS – the administrative support service arm of Providence Group – operates 177 facilities, making it the fourth largest skilled nursing operator in the United States.
Joseph Lee, Senior VP of support services at PACS, said that “mom and pop”’ skilled nursing operators who have accumulated physician and community trust can likely continue to survive in today’s market. But scale, he said, is helpful to absorb loss.
“Most facilities we acquire are distressed financially and clinically,” he said. “In most cases, it’s simply that they are financially distressed.”
PACS has a large footprint in California and a growing footprint in South Carolina, Ohio, Kentucky, and continuing to acquire in those markets will be a strategy going forward, Lee said.
“If we keep acquiring in those states, there is enough bandwidth to absorb losses and give buildings a chance to get financially viable,” he said.
These leaders said scale enables a company to absorb short-term losses until facilities are turned around, and also noted that larger companies have the benefits of other efficiencies, including more favorable group purchasing pricing.
Growth at this pace is not easy, but leaders with the two providers agreed that scale is becoming increasingly important to success in the nursing home business, not only creating more financial resiliency but opening up opportunities to drive clinical strength.
At the end of the day, all strategies aside, the one thing that never fails is to remind staff why they chose their clinical roles in the first place.
According to Leslie Campbell, COO of Touchstone Communities: “It’s a dreary world out there now, and so just really [focus] 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.”
Companies featured in this article:
Brickyard Healthcare, Cantex Continuing Care Network, Centers for Medicare & Medicaid Services, CHI Living Communities, Creative Solutions in Healthcare, Evangelical Lutheran Good Samaritan Society, Health Dimensions Group, Hebrew Home at Riverdale, Lifespark, PACS, Touchstone Communities, Vivage-Beecan
