The Covid-19 pandemic’s labor crisis forced some nursing home providers to adapt their business practices in 2023, during a time some leaders termed the “year of recovery.” And, as they look ahead to 2024 amid a looming federal staffing mandate, many nursing home providers look to gain from these efficiencies – but are fearful about looming threats.

Marc Zimmet, CEO of Zimmet Healthcare Services Group, is optimistic for the future of skilled nursing in the new year. “SNFs officially enter the post-pandemic era stronger, and wiser, than before the Public Health Emergency,” he said. However, Zimmet also warns that not all nursing home providers are positioned to benefit equally.

Many – particularly those operating in rural markets – aren’t sure about an all out recovery, and are continuing to enforce new plans to work around lingering challenges related to workforce pressures.

Capital investments, telehealth, staff training programs, and new models of care are some of the ways they plan to counter the shortage of workers and other issues in skilled nursing facilities (SNFs).

“Where we can bring together a continuum of services and infuse innovation, the result is a game-changer for our seniors because it simplifies the health care experience,” Nate Schema, President and CEO of The Evangelical Lutheran Good Samaritan Society, told SNN. “This work is especially important given the persistent staffing challenges that are not going away anytime soon, and are more acute in rural areas, where 70% of our residents live.”

In our two-part Executive Outlook series, you will hear from leaders throughout the sector, learning more about their strategies, challenges and opportunities for 2024, especially given that the Centers for Medicare & Medicaid Services’ (CMS) staffing proposal threatens to derail the recovery.

Nate Schema, President and CEO, The Evangelical Lutheran Good Samaritan Society:

As we look to 2024, we are focused on reimagining how we deliver care to meet the evolving needs of those we serve, reinvesting in our communities in America’s heartland to enhance the senior care experience and continuing to set the industry standard for our employee experience. This work is especially important given the persistent staffing challenges that are not going away anytime soon, and are more acute in rural areas, where 70% of our residents live.

As part of an integrated health system, we are uniquely positioned to use technology as a catalyst to expand access to care for our residents. For example, we see tremendous opportunities to complement their care through virtual visits with specialty providers or registered nurses. This win-win opportunity will allow residents to see a Sanford Health clinician without having to arrange for transportation and leave their home – and will help ensure RN and physician shortages in rural areas don’t limit access to care.

We look forward to continuing to implement and scale new models of care to support the quality of life for those we serve. Where we can bring together a continuum of services and infuse innovation, the result is a game-changer for our seniors because it simplifies the health care experience. As one example, we’re looking to expand our hemodialysis den to more locations. The den makes it possible for residents to receive dialysis without leaving home. This model of staff-assisted hemodialysis is groundbreaking, and we are proud to have launched one of the few programs like it in the nation in South Dakota. The den has made a significant impact on our residents by reducing disruption to their daily schedule, including meals and activities, and improving their health and energy levels.

We are also excited to invest more in our leaders in 2024 through a comprehensive leadership and professional development training program we’ve designed and recently launched. On a personal level, I always enjoy traveling to our locations and listening to what matters most to our staff, and then incorporating their input into new employee programs and benefits that support them both inside and outside of their work.

Reinvesting in our communities and providing high-quality care remain central to our mission in 2024. However, the reality is that the final rule that is expected from CMS on minimum staffing requirements will be consequential for our industry – and more importantly for the more than 10,000 residents we serve. There are simply not enough nurses and caregivers available, particularly in rural areas, to meet a one-size-fits-all mandate. If the rule is implemented, rural nursing homes will be forced to reduce admissions or close their doors. We have been encouraged by our federal policy advocacy efforts over the last year and will continue to meet with lawmakers to explore common-sense, meaningful solutions to build a stronger pipeline of caregivers. It will take all of us working together in 2024 to deliver what our nation’s seniors need and deserve – high quality care that’s not limited by a zip code.

Marc Zimmet, CEO Zimmet Healthcare Services Group:

From the business side of the equation, the SNF economy has never been through such a challenging period over the last several years. Providers welcomed 2020 with unbridled enthusiasm, Medicare’s new PDPM system, and free-flowing capital, which elevated SNF valuations to record levels, and the future looked bright. By 2021’s start, however, the industry was near collapse, and for many, desperation for short-term survival replaced optimism about long-term success. We reflected on the government-funded rescue in 2022. This set up 2023 as the year of recovery. As for 2024, it will be about stabilization of skilled nursing.

Stability requires rational funding, and here, Medicaid takes center stage. Dozens of states have seen enough closures to increase funding. This may seem like great news, but it’s also dangerous. The poorly targeted enhancements only perpetuate the structural deficiency in SNF-economics. Funding is only half the equation. We need Rate Construction reform. We’re working with associations on a universal model that considers market realities and aligns payment with policy initiatives like enhanced staffing and Medicaid private rooms. The bottom line: All SNFs are not positioned equal.

Meanwhile, things are coming to a head on the Medicare Advantage front and SNFs are in deep. The industry is cheering new regulations around MA plans … [However], MA is one of the factors driving costs back to states. Medicaid relied on generous FFS reimbursement to subsidize inadequate program funding for decades. In a reversal of fortunes, states must now subsidize giant insurance companies’ inadequate SNF funding. In other words, MA is pushing FFS to irrelevance in many markets. The deep pockets of Private Pay have left the SNF table to sit with assisted living. Now, FFS leaves the party and MA replaces it. This means that Medicaid gets stuck with the whole check. How much does MA cost the industry (and

ultimately states)? We estimate $13 billion in 2023, and even more in 2024. And note too, that nothing will change until the federal government steps in because states are preempted from intervening in MA.

So, the pressures are enormous relative to the pre-Covid era, but the SNF-economy is stabilizing and maybe, just maybe, I sense some optimism creeping in there as well.

Lisa Musgrave, Senior VP of Post-Acute and At-Home Service at Ascension Living:

We share the goal of ensuring access to the highest quality of care in our nursing homes, and one of our top priorities in 2024 at Ascension Living is to return to fully-employed staffing. But in this environment, that goal is a formidable one.

Moreover, the proposed staffing rule works against this shared goal and puts America’s nursing home residents at risk by failing to address the chronic reimbursement challenges and workforce shortages plaguing the long-term care continuum. Without additional resources or waivers, this mandate would only exacerbate the current access to care crisis that so many seniors face. Any action on staffing mandates must be paired with fair adjustments to our reimbursement rates to allow for the necessary investment in workforce development, recruitment and retention.

In 2024, and in order to achieve needed quality and safety outcomes, we believe that the Biden administration should first work with our industry to develop a workforce strategy and a complete understanding of the financing impact and reimbursement changes. This is a necessary step to ensure a successful roll-out of any staffing mandate.

While Ascension remains committed in 2024 to our senior services and simplifying the care journey by bringing multiple levels of care to patients where they live, we are providing a consumer-satisfying alternative to multi-facility care through one integrated program and reserving the facility for those requiring higher acuity services most appropriate for an institutional stay.

The vision for these future services includes a network of options to best suit each person’s needs. For someone relatively healthy but experiencing an illness, this could be an urgent care visit in their home. For a person with a chronic condition, like heart failure, it may start with an urgent care visit in the home but may include a journey of care including a “hospital at home” stay with intravenous medications and advanced imaging of their heart, then a transition to skilled nursing care at home with therapy to help the person regain strength and nursing to help with medication management.

And finally, Ascension is going forward with a care management program with remote patient monitoring and virtual nursing support to avoid future returns to the hospital. This initiative will ensure that the person is living life that includes the things that matter most to them. To this end, Ascension at Home partnered with Compassus in early 2023 to launch a SNF in the Home in Austin, Texas. This integrated program offers a combination of home health rehab, skilled nursing and personal care, and as-needed remote monitoring, meal/nutritional support, durable medical equipment, and medications.

Tim Fields, CEO and Co-Founder, Ignite Medical Resorts:

We continued to grow in 2023 with smart and strategic growth, ending this year with 21 facilities in 7 states, including a new state for us – Indiana. While 2023 certainly had its challenges, it also proved to be rewarding. For Ignite, 2024 will present a number of challenges and opportunities. We continue to not know where the staffing mandate conversations will go and we will be in an election year. I would love to see CMS turn its attention to solutions and address the root cause of the issue instead of just talking about punitive measures, fines, and mandates. We as an industry need help loosen the burden to get foreign caregivers here on our front lines and get creative solutions to allow us to do more nursing and nursing aide training programs to grow our own from the community. We also continue to have a radically broken 5-star rating system and a more punitive and vindictive regulatory environment with our surveyors. One of our goals in 2024 is to continue our political outreach, both local at the state level, and federal, to continue to change the narrative. The way to address staffing, star ratings and upholding regulation is by working together with CMS hand in hand on solutions.

We will continue to look to invest in technology that helps our staff. We have plans to invest in robotics and virtual reality technology within our therapy departments this year. 2024 will continue to be a year of data and how we can perfect our internal Dashboard. To put meaningful data in the hands of our decision makers to identify trends to celebrate success and course correct issues.

Clinically, we are enhancing our specialty programs and working to link them to our acute care hospital partners and physician groups. This year’s focus will be on cardiopulmonary, renal, and infectious disease and sepsis. We continue to push the acuity boundaries looking to add things like inotropic cardiac drips and peritoneal dialysis . We are also going to be working with our acute care hospital partners on their issues- such as how to lower their LOS and admit without managed care authorization.

Strategically, we want to continue to work with our managed care organizations to take on more risk, to align ourselves clinically and financially to them more. We are having some great conversations on how our model is of value to them by lowering total cost of care, lowering utilization of higher cost Acute Rehab/LTAC settings, and by providing great outcomes.

And most importantly, culturally, we want to continue to build on our amazing culture. We are launching vacation bonuses, manager of the year bonuses and continue to add to our Superhero in Scrubs reward and recognition program. Our number 1 focus will always be how to recruit and retain the best employees, for without that, our model does not work. In July, our leadership team had a retreat and we went on a journey focused on the book Good to Great by Jim Collins. Each of our teams has now developed Good to Great strategic plans for 2024 and we look forward to seeing all their amazing work executing their plans to ensure each Ignite resort is not just good, but great, in 2024.

Lori Porter, Co-Founder and CEO of the National Association of Nursing Home Assistants (NAHCA):

Many of our current challenges will continue in 2024. There will still be staffing shortages, and we will continue to hear stories about CNAs who are overworked and overwhelmed. While the retail and hospitality industries will continue to woo CNAs away from health care with better pay and benefits, we are starting to see organizations pay attention to ways they can attract and retain CNAs and other team members. We also will see more career pathways and ladders. Those organizations that continue with business as usual and just wait for the staffing crisis to pass will find themselves falling behind in both census and quality.

CMS has recognized that there is a need for some action on staffing, including ensuring facilities have enough CNAs to provide daily care. We were pleased to see the proposed rule on minimum staffing standards for long-term care facilities and Medicaid Institutional Payment Transparency Reporting.

NAHCA understands that the current staffing crisis and lack of sufficient reimbursement to pay for quality care has impacted nursing homes nationwide. We also know there are no easy answers. However, we are committed to working with others to find ways for our nation’s nursing homes to obtain adequate funding to properly staff their buildings. National initiatives such as those put forth by the Moving Forward Coalition as well as state-specific efforts such as the Ohio Governor’s Nursing Home Quality and Accountability Task Force are all great efforts towards that goal.

While there are still staffing shortages, we have proven over the past three years that there are thousands of quality individuals who want to be professional CNAs. We are prioritizing efforts to bring these individuals into our facilities and enable them to take on the role of effective care team members.

We are working on a career lattice for CNA specialties in areas such as infections or dementia, which we hope to roll out in 2024. We also have developed our 2024 Technology Road Map, which includes launching turnover management programs for employers and CNA recruitment services to help fill job openings.

At NAHCA, we will be attending to the minds and spirits of our members and CNAs everywhere in the coming year. Of course, we will be working to ensure that CNAs have the skills, tools, and resources they need to be effective professionals. We will continue to have a strong educational program featuring monthly webinars on clinical, leadership, and other topics. Additionally, our Table for Two programs will continue to bring our members together with national leaders and top experts to talk frankly and informally about everything from stress management, conflict resolution, vaccine updates, and more.

We also are planning programming to educate and prepare CNAs to take on new roles such as mentors and team leaders, infection preventionist assistants, medication or dietary aides, wellness experts, and more. This is essential, as we see expanding the roles for CNAs and enabling them to use cutting-edge clinical knowledge as one way to fill care gaps in facilities.

While the pandemic is mostly in our past, we are well aware that Covid is still an issue. We also are seeing a rise in RSV and other infections. We will continue our efforts to educate CNAs about vaccinations and help them make educated, informed decisions that will protect their residents, their families, and themselves.