Touchstone COO: Future Rests on Thinking Differently About Staffing, Going Beyond 4 Walls of Nursing Homes

As Touchstone Communities maintains its focus on building a continuum of care, the well-being of its staff members – and allowing them to work on “top of their licenses” – remains a foundational philosophy for the organization.

Leslie Campbell, COO for the Texas-based company since 2020, spoke about the importance of engaging Touchstone’s clinical workers to be at the bedside and practicing specialized skills, a strategy that has helped retention and growth as the sector tries to put the pandemic’s woes behind it.

And with over two decades of affiliation to the nursing home sector, Campbell — a physical therapist — has learned that taking care of the staff will continue to be the main driver of success at nursing homes, but that it’s also time for the sector to rethink approaches to staffing shortages.

“The environment mandates that we think differently … if we don’t think differently about how we attract and retain team members, we won’t have team members,” Campbell said on the latest episode of the Skilled Nursing News RETHINK podcast. “[Labor] challenges us on many fronts, but just at every level of the organization, culture and purpose is important and every member of the organization has to deal with how their role impacts our overall purpose, our overall mission. And then money matters.”

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

Besides the recruitment and retention initiatives that are helping Touchstone, Campbell also spoke on the podcast about some wins, including the Medicaid add-on in Texas, cost-saving efforts and initiatives launched to improve key health metrics.

Highlights of the podcast, edited for length and clarity, are below. Please note that the episode was recorded just before the proposed federal staffing mandate was announced. Subscribe to RETHINK via Apple Podcasts, Google Podcasts, or SoundCloud.

Can you reflect on Touchstone’s summer and describe one win for the company in the last three months or so?

So when you say the word summer and you’re talking to someone whose company is based in Texas, pretty much all you think about is triple digits and the air conditioning units making it through the summer. So that’s been a win, but in all seriousness, I think when we look at our biggest win across the summer, it was the solidification of the Medicaid rate add-on in Texas.

Medicaid rates in Texas have lagged for many years. It’s been a decade or so since we’ve had a material increase to our Medicaid rates. So the dissolution of the skilling-in-place waivers and other help that we got through the public health emergency, along with ongoing expenses associated with prevention of Covid within our communities, it was just a mandate for survival to get that built into our ongoing Medicaid rate in Texas.

And so, it was a huge win when the sector and Texas came together and just really had a grassroots, full-court press effort in influencing government policy in the state of Texas and we’re just so very grateful that we were heard and so very grateful for this permanency with the add-on.

And looking ahead to fall, what are your top priorities and goals as COO?

In our sector, I hear a lot about the ongoing recovery. I hear it from an occupancy perspective and from a revenue perspective. I look at it just a little bit differently. And I have defined for my team two primary objectives, the first being continued stabilization of the workforce, and the second one being, we must become experts at care management. In this context, it starts with contract negotiations, referral processing data, getting that initial authorization, admission, and contract management, in discharge and post discharge care.

… We can’t hope for recovery until those two things are solid. So we built quite a few strategies around those two major initiatives, realizing that a lot of other things begin to fall in place when those two things come to fruition.

You’ve said that PDPM has led to “a resurrection of nursing” and caused Touchstone to take a look at building nurse competencies in specialty areas. Can you expand on that? And what are some ways you’re building out specialty care for higher acuity patients?

In Texas, RN staffing is a particular challenge, but we really endeavored to get our arms around the strategy to increase the number of RNs within our communities. And so we just laid down some basic non-negotiables. To start with, the [Directors of Nursing Services] would no longer be one of two or three RNs within many of our communities. We needed to stabilize the DNS position. So that meant the nurse managers being RNs, the MDS Coordinators being RNs, the DNS being RNs, and we did this through [reducing] attrition. We also did it by supporting LPNs with enrollment in RN school and then helping them pay for that education, and we’ve seen a significant shift just from those non-negotiables in the profile of our team.

Additionally, we installed directors of clinical education, an RN, in every one of our communities. We made this investment realizing we needed an expert in every single community to help build out competencies to help us address a greater level of acuity.

Then we built competencies and approaches in specialty complex units within certain communities based on market needs. So for instance, we installed a ventilator unit in one of our communities. We have a few in-house dialysis units. We have installed a few dedicated transitional care units that provide care to medically complex patients. We instituted a nursing focused, respiratory prevention program that requires advanced clinical skills to care for patients with respiratory complications and disease processes, as well as to identify those risks. We invested in our wound-care program, including getting nurses certified for wound care to achieve better outcomes for those more challenging and complex patients.

And then lastly, we [recognize] the need to make Touchstone an attractive place to work for nurses. Let’s not compound [the nurse’s job] by unnecessary paperwork or clerical types of things. Let’s allow nurses to practice at the top of their licenses. Let’s surround them with infrastructure that supports that philosophy and then let’s streamline workflow, so that they have more time at the bedside of their patients and residents.

Our clinical infrastructure has helped us accelerate in building excellent clinical competencies and achieving outstanding outcomes for our patients and residents – and regulatory outcomes as well, quite frankly.

For Touchstone, have staffing pressures eased at all over the course of 2023?

When I look at 2023 in the context of 2022 and 2021 as the pandemic began to surge, then I would say that [staffing pressures] eased a bit. And while pressures have not materially changed, our approach to those staffing pressures has.

So what are some workforce initiatives that Touchstone has undertaken to improve recruitment and retention?

We view this as an organizational priority. And therefore at every level of the organization, all hands are in the huddle. And to that end, we have approached our HR function with renewed vigor. We believe that having strong HR business partners, besides our operational leaders, is paramount to tackling this challenge. And so we’ve looked at our infrastructure as a whole and we’ve invested in regional HR business partners in every single community.

I believe culture is really important in attracting best-in-class team members and stabilizing the workforce. We did a root cause analysis, and really set on a course to make sure we had consistency of cultural elements throughout the entire organization. And we shifted a little bit to ensure that our cultural pillars of purpose, mission, vision, and attitudes, values [would] resonate with everyone in our organization, and [staff] can understand how their particular roles directly contribute.

And we’ve made it simple … head knowledge eventually becomes heart knowledge [and] when that connects, then it’s manifested through our hands. And it’s been really powerful to see that take place. And we’ve been holding on to team members as a result.

Head knowledge eventually becomes heart knowledge.

Another big thing is we’ve moved from the traditional solo relationship with Indeed to utilizing a job aggregator to post all of our positions. And instead of us putting our open positions out there and hoping people would come to us, this job aggregator uses artificial intelligence to put our postings where the applicants are. The quality of our applicants and candidates and our conversion ratio has increased. Therefore, our open positions have gone down.

[To prevent] losing [new hires] in that first 90 days, we issue surveys via text message, share the results of those surveys with the hiring the administrators, the regional vice president, and myself and our chief human resources officer, and we’re able to intervene directly if someone doesn’t have a good orientation or weren’t feeling welcome. We’re able to zoom in right then and intervene and correct … We’re seeing really positive results.

And then last, we moved to a centralized orientation model in one of our biggest markets, where we had the biggest agency utilization, the biggest turnover. We bring every new team member in this market in San Antonio to our centralized office for orientation one day, the first day, every week, so we’ll provide transportation, we bring them in, we make a really big deal out of it. We know their story before they get here. That’s made a big difference as well. Our retention rate within that first 90 days in this market has skyrocketed as a result of some of these things.

And how have surveys been going for Touchstone? We’ve been reporting on concerns over survey processes as many surveyors are recent hires.

While Touchstone continued to perform better than state and national averages on surveys, we have definitely seen increased scrutiny and deficiencies being written in 2023. We’ve seen increased trainees. We may have a 100-bed building and 10 surveyors come in for the annual survey and three or four of them are trainees. And we’ve seen instances where in certain pockets of Texas, they’re sending in an independent team to oversee the local surveyors … So in other words, there’s increased pressure to cite deficiencies.

Another thing that we’ve seen is that in the IDR process, and we’ll go and dispute a deficiency according to the process and be successful with that, the independent reviewer will say, yes, we agree, and overturn the deficiency, but then the state agency will unilaterally disregard the independent reviewer’s decision and uphold a deficiency. And so, many times you scratch your head and say, ‘Well, what’s the point of an IDR?’

We have really instilled a sense of broad stewardship within our leaders, that sense of corporate responsibility … Throughout the course of the last couple of years, we have brought our rehospitalization rates down well below the national average to 18%. Our acute care markets are moving a little more swiftly than our long-term rural markets. We’ve also seen our average length of stay for our managed care population come down and all while achieving great outcomes.

On antipsychotic utilization, we brought that down [and] costs [related to it] down to 6%.

We launched some initiatives this year that include de-prescribing. We’ve all seen the [high] cost associated with medications, and then the number of meds being delivered. So de-prescribing helps us on a whole host of fronts as far as taking costs out of the system.

And this podcast is called RETHINK. What’s something that you think leaders in nursing homes need to rethink?

The workforce environment. If we don’t think differently about how we attract and retain team members, we won’t have team members … Now more than ever before, the answers to our greatest challenges in this sector are not around a boardroom table. ​​The answers to our greatest challenges are closest to the bedside of patients and residents. Therefore, every voice on our team matters.

And then lastly, we’ve got to shift our paradigm. Yes, care within our four walls is important, but we have to build systems, processes and approaches that allow for visibility and involvement with care outcomes outside of our four walls. That really is the future of our sector, and so we’ve got to rethink along those lines.

To listen to the complete episode, click below:

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