The Super SNF Comes of Age: Advanced Care Programs Expand, Yield Results

The “Super SNF” is not a new concept, but is taking on new and deeper meanings as skilled nursing facilities take on a greater variety of patients with complex clinical conditions.

“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.”

From behavioral health management and cannabis use to bedside kidney dialysis and respiratory care, SNFs are breaking new ground to deliver high-quality care and evolve their business models, executives said at Skilled Nursing News’ recent CLINICAL conference in Washington, D.C.


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.”

Coordination with hospitals

Rising acuity in nursing homes has led to innovations where SNF clinical teams are more closely coordinating with hospitals. And this includes patients with more severe mental health needs, for which partnering with the wider community becomes important.


“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. Hebrew Home is a very large facility with 843 beds, and is part of the RiverSpring Living organization.

As an example of Hebrew Home’s mental health programs, Palace points to a “closely engaged” partnership with a geriatric psychiatry fellowship. “And through telemedicine, we have several floors that are covered exclusively by the geriatric psych program. So it’s a very academic approach to caring for the patients.

Palace also said that this system allows for better monitoring of antipsychotics.

“We will know the drivers we have in place right now in terms of reducing psychoactives and the implications for the Mega Rule,” Palace said. The Centers for Medicare & Medicaid Services (CMS) issued the Mega Rule in 2016 aimed towards improving the care and safety of long-term care facilities.

“In looking for ways to be able to engage with collaborating facilities and the synergies between the two facilities, we can really accomplish a lot in terms of improving quality of care and avoiding the use of medications and engaging more in non-pharmacological approaches,” Palace said.

As for Vivage-Beecan, the increase in the number of residents with more complex needs, particularly behavioral health diagnoses, has spurred more collaboration with hospitals and other provider partners.

Dr. Palace and Heather TerHark-Monreal speak at CLINICAL Merz Photography for AMN
Dr. Palace and Heather TerHark-Monreal speak at CLINICAL

“We see more referrals from the hospitals coming to skilled nursing with behavioral health and it’s [about] partnering with your county mental health, state mental health, with having telehealth psychiatry, making sure your staff has the education, the training and the resources,” said TerHark-Monreal.

In order to successfully handle residents with dementia behaviors or other mental health issues, Vivage-Beecan makes sure that the staff is trained in crisis prevention and intervention.

“It can be scary, sometimes for nursing staff that had not had experience with behavioral health to care for them. So by having that extra additional training, it can be a resource to them,” TerHark-Monreal said.

Vivage-Beecan collaborates with Denver Health Medical Center, a ”safety net hospital” for long term patients. “We jointly start on the forefront in the hospital … where we provide the psychosocial activities while they provide the nursing,” TerHark-Monreal said. ”We’ve done some unique partnerships, not only in our buildings.”

Vivage-Beecan is not alone in expanding its behavioral health programs, with many providers across the United States stepping up in recent years, creating more structured approaches and even hiring dedicated staff members to elevate care in this arena.

Reducing psychotropics: sleep routines and cannabis

Since the state of New York approved the use of medical cannabis, Hebrew Home has been using it in creative ways to cut down the use of narcotics and other habit-forming medications.

“Having this new modality that we can incorporate into our clinical armor seemed like a very good approach,” said Palace.

But, Hebrew Home’s clinical team had to cleverly work around the limitations – with legal consequences – of the approved use of cannabis. One of these challenges was that staff could not be in possession of it.

“We developed a policy procedure that allows patients to store it in their room, in a lockbox that they only have access to, so it’s in their possession. And [we required] that they have to be able to to self administer or be able to assign a caregiver,” Palace said.

This cannabis program has been in place for six years at Hebrew Home, Palace said.

“We’ve seen incredible results, particularly patients with chronic pain, where they would have a significant CBD and we’re able to get them off of narcotics,” he said. “We’re able to get them off of a lot of other medications.”

An area of concern for older residents with dementia is seizures, and Hebrew Home’s management of cannabis use within its facilities has been particularly effective here, Palace said.

“We’re able to give them cannabis and see that our seizures significantly improve or go away. We’ve done up to six surveys with it and we’ve never had any issue in terms of our policy procedure and the way we’ve been handling it,” he said.

Another problem area is sleep management, which in turn can cause an increase in medications. By simply engaging patients in social activities, Palace said his organization was able to cut down use of sleep drugs.

“One of our interventions was to try to reduce the sedative hypnotics in addition to the antipsychotics, so we took an approach … working with therapeutic activities, working with nursing, trying to reconfigure the timing of patients receiving their medications so that they weren’t getting stimulating medications that evening. That they were taking less naps,” Palace said.

In about eight years of implementing this program, Hebrew Home has brought down the rate of sedative hypnotic use by about 75%.

“It’s a culture change. It didn’t come overnight. But working closely with the DON and working closely with therapeutic activities, we’ve been able to make these changes and been able to sustain these changes,” Palace said.

In-house specialty therapy programs

In-house dialysis has been one of the most popular programs for skilled nursing providers to add in recent years, as they have sought to elevate their clinical offerings, and Vivage-Beecan is no exception. The organization saw tremendous success and growth in its in-house dialysis program, especially during the pandemic. Costs and social benefits can be garnered from having residents complete dialysis at facilities, such as reduced risk of disease, less tired patients and lower transportation costs. And within in-house dialysis, TerHark-Monreal pointed to dialysis done at the bedside.

“We have in-house dialysis in a couple of our communities and it truly enhances the lives of the residents,” she said.

Other therapy programs provided by Vivage-Beecan in-house include PT, speech therapy and substance abuse. The organization works with a specialized physician group that enables patients to receive medications such as suboxone and methadone, TerHark Monreal said.

The benefits of having this range of services in-house are many, including better communication between teams, infection control and the ability to receive additional rehabilitation.

“Clinically, they are not having to be on van transportation, [and] having the nephrologists that are rounding in the facility increases communication with your staff, with your team,” TerHark-Monreal said.

All in all, she said, “It really enhances their plan of care and their ability to receive the best treatment for what their specialized needs are versus this big communication gap that often happens.”

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