Medical Complexity, Documentation Stretches Nursing Home Clinicians Thin

As specialty services and higher acuity cases continue to challenge nursing home clinicians, industry leaders say it takes a special kind of employee to really understand, deal with and plan for the variety of patients seen nowadays.

Nicole Croteau, director of clinical services with SALMON Health and Retirement, said there aren’t many nurses who can turn on a dime to treat 15 different types of ailments in a day, making nurse retention all the more important – and turnover even more devastating.

Clinicians in skilled nursing facilities (SNFs) are wearing “all kinds of hats” now, added Robin Mitchell, chief nursing officer for Diversicare.


Nurses are delivering more direct care, she said, including bathing and other general activities of daily living that they weren’t doing before, because they had other team members to help them.

Experienced nurses are having to do basic tasks that may have been assigned to them at the beginning of their careers rather than benefiting their organizations with complicated duties, such as utilizing their expertise towards diagnosis — a term Croteau calls “theoretical” care.

In other words, they work less on care plans, discussing cases with physicians to ensure quality care from the top down.


Management tactics have undergone a change given the staffing shortage and complex patient needs, she said.

But some nursing home providers don’t necessarily see it as a bad thing that the roles for nurses with more skills and experience are getting redefined in the post-Covid era.

“We’re really just seeing more complex hospital patients,” noted Stu Almer, president and CEO of Gurwin Healthcare System. “That’s an overall reality that we’re facing. So that produces a greater challenge for us in dealing with workforce shortages, and being dependent at times on agencies, we’ve got to work harder, integrate better.”

More clinically complex patients in nursing homes have forced silos to break down, he said, between bedside care and medication management, while also keeping cost of care in check while maintaining the same quality of care.

All the while, the SNF space continues to be a very misunderstood and rapidly evolving part of the health care system with ever growing acute needs, the leaders said. The rise in acuity is complicated by the fact that residents who would normally go to a nursing home with lesser needs are now foregoing services. The desire to stay at home and avoid institutional care has led to a growing trend of residents delaying services too, leading to a need for more complex care if conditions worsen upon entry into long-term care.

“You’re left with a myriad of patients … you have five over here that might have dementia, you have three over there, who have behavioral health issues and maybe have substance abuse problems,” said Croteau. “It’s very difficult for a nurse to be able to do well, versus if I was in maternity, right, I would be able to focus on that and that alone. It’s a pretty consistent thing.”

Finding nursing home clinicians who manage to keep up with clinical complexity while also maintaining a focus on quality of life are few and far between, she said.

“Sometimes you lose those good people,” she said.

Flexibility required in the nursing role

In addition to providing a multitude of services to residents, some clinicians have also expanded responsibilities to also tackle in-house education for less experienced staff while also grappling with more complicated documentation to avoid litigation.

Almer said this has required a tremendous amount of flexibility among Gurwin’s nurses.

“We have dedicated nurse educators. They’re the individuals who are doing the training of our clinical team; they’ve had to become more flexible in their role,” said Almer. “The individuals who do our education are providing floor care, they’re providing supervision, they’re involved in team meetings … We’ve made work more complicated for folks, but I think it’s created better integration.”

In other words, there’s a closer tie between sales and service, Almer said. They’re not just providing education then sending people on their way, they’re working with them throughout the process, he said.

In a best case scenario, he said these nurse educators go on to serve in higher level management positions.

“All the issues that we’re facing post-Covid, with complexity of care and staffing concerns, is just driving us to work harder, work creatively, so that the outcome is still positive,” he said.

From a documentation perspective, nurses are spending more time ensuring this diversity in services is accounted for – with litigation always looming, Mitchell added.

“We have seen litigation increase. The nurse has always documented care but I think the scrutiny around that has increased, and so the nurse has to be super careful to include every piece of that care,” said Mitchell.

These days, nurses seldom fulfill their specialty roles, and the same nurse can be expected to provide total patient care on top of providing detailed documentation: Nurse are doing the bathing, the charting, and taking on substitute roles when they don’t have other team members to rely on due to a general shortage of staff still.

“It’s a really long day to make sure the patient gets the care they need, and the documentation has to still be there,” said Mitchell.

A significant role, significantly underpaid

One example, she said, would be a resident that has behavioral health issues at the forefront, but when that resident is stable, nurses still need to treat hypertension and diabetes, on top of a schizophrenia diagnosis and opioid addiction.

What’s more, actual nursing care is only a small fraction of what nurses do every day, she said. Out of 20-plus hours in the day, only a couple hours are dedicated to actual nursing care – medication pass, care centered on activities of daily living, feeding.

“Another significantly underpaid role that is so significant is the ability to engage people to have a purposeful and meaningful life – so the other 20 hours of the day,” said Croteau. “It’s that quality of life piece. You’re lucky to keep nurses and nurse aides. It is rare to be able to keep and sustain a quality program that provides current and modern engagement for all levels of people who are there.”

SNF operators say what they’re able to pay – dictated by reimbursement levels – is far below what staff deserves.

Post-pandemic, nursing home operators are facing the greatest economic challenges in post-acute care, Almer said. New York in particular went 14 years without a Medicaid rate adjustment.

Operators in the state look forward to a better adjustment based on decisions this year, but it can, “nowhere make up” the shortfall seen in order to provide care to more complex patients, Almer said.

The NY Medicaid shortfall is about $80 per patient per day, and Gurwin is seeing more complex patients.

“It’s a very tough formula for a provider to accept. The economics have to change or we’ll see a deterioration in provision of care and services,” Almer said.

Diversicare has reevaluated what each role does at every level and increased pay accordingly, Mitchell added, in order to stay competitive in various markets. But, policymakers need to know what operators are working with and adjust accordingly as well.

“We are struggling to find people who have that commitment,” said Mitchell. Delaying the federal staffing minimum mandate is a start, she said, while also agreeing with Almer and Croteau that reimbursement needs to meet cost of care for more complex patients.

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