‘A Triage’: New Approaches To Tackling Compliance, Sicker Patients in Nursing Homes 

Clinical complexity and rising acuity at nursing homes isn’t going away any time soon so nursing homes are adapting their clinical practices and also renewing ways they train staff – and surveyors.

This trend of sicker residents has led to a hospital-like sorting and prioritizing of patients in a manner similar to a triage, said operator executives who spoke at Skilled Nursing News’ recent CLINICAL conference. Meanwhile, bringing staff up to date with training on ever more complicated compliance issues has become very urgent, they said.

“We are getting patients that are much more sick than they ever have been. It’s like operating a hospital step down unit in many cases. And the challenge really is making sure that our nurses are qualified and trained to support the needs of the patients that we’re getting,” said Delena Stortz, chief nursing officer at Consulate Health Care.


Adding to the burdens on this front, however, is a shortage of surveyors, which has meant more third party surveyors or new and inexperienced surveyors that require more training, these executives said. And in the midst of all this, the prospect of a staffing mandate – with its exclusion of LPNs and a called-for increase in CNA numbers – will likely create an imbalance in care.

Approaches to clinical care

John McFarlane, chief clinical officer at Ignite Medical Resorts, said that Ignite is addressing the higher acuity needs of its residents by relying on approaches developed during the Covid-19 pandemic as acuity levels shifted in the different phases.

“It’s been interesting to see the acuity challenges [and] we’re definitely getting more and more patients sent to us from the hospital systems that are really not stable,” McFarlane said. “So it’s really become more of a triage, I would say, in some cases. When the patient arrives at our facility, a lot of times we’re having to administer medications, labs and such immediately, in order to stabilize the patient.” 


Julie Britton, chief clinical officer of Genesis HealthCare, said that she is seeing a lot more complexity too at Genesis facilities that exceeds what the local community hospital is handling – and nursing homes are also taking better care.

“One of the things we see with complexity when we meet with our directors of nursing … is that in a lot of our centers, we’re doing a lot more than our small community hospitals are doing,” Britton said.

For Consulate Health, an interdisciplinary approach has also proven useful.  

“So we are having to jump right in there. And we are having to follow these patients for at least 30 days just to make sure that we don’t have them bounced back to the hospital. We are really managing the plan of care every single day with the interdisciplinary team approach. And we’ve found a lot of success there,” Stortz said. “Rounding at the bedside and taking the care back to the bedside, that’s really been our focus just to make sure that we don’t miss anything.”

Training on compliance

At both Consulate Health and Genesis, staff undergoes constant training. “Our focus is also on compliance to make sure that our staff are trained, and competent to take care of these complex patients,” Britton said.

Some rules and regulations that most concern these operators in the atmosphere of treating more severely ill residents, stem from mental health related issues, especially found in younger and short-stay residents.

“With the younger population that we are seeing in our centers, it does pose a tremendous amount of challenges, because these folks want to smoke and want to do all these different things, and you have to make sure that you’re practicing very safely, keeping everyone safe,” said Stortz, adding, “It’s a lot harder than it used to be with the younger population.”

New breed of less forgiving surveyors

And it’s not helping that there is a higher number of surveyors who are new and under-trained – and less forgiving.

“We find that lately, there isn’t as much grace as there once was … One thing out of whack is just like, ‘Okay, you’re going to be cited for it,’” Stortz said.

McFarlane echoed that sentiment. “The surveyor relationship has shifted quite a bit. We don’t see as much collaboration as we used to from the surveyors. We don’t see a lot of respect,” he said. Even if a facility has self-identified an issue, and in the process of putting into place corrective measures for past non-compliance, they could still get cited, he added.

And moreover, the new breed of surveyors also seem to be limited in their education.

“In our facilities, we’ve experienced surveyors who don’t have a lot of knowledge around some of the clinical complexities that we take. So if we take like a newer surgical journey … a lot of the surveyors just don’t really understand what orders need to go in place with certain types of clinical complexity,” McFarlane said. “So we’re finding that we’re doing a lot of education with surveyors.”

Staffing mandate adds a wrinkle

In the midst of all this, the federal minimum staffing proposal’s exclusion of licensed practical nurses (LPNs) can potentially throw off balance the types of clinical staff needed – the optimum ratios may be unique to each facility based on the variations of acuity levels of residents.

The proposal is also calling providers to carefully assess their resident populations for level of acuity, cultural and clinical needs, and staff accordingly.

For addressing this issue, the executives said that they all complete the facility assessment for needs diligently, and it’s been challenging.

“So we’re really dependent on making sure that the facility assessment is done … that we’re having training at our centers that are taking certain types of diagnoses. And then we are making sure, of course, that the staffing levels are safe to take care of that type of patient. So it’s been a challenge,” said Stortz. “We make sure that our goals are still aligned with the types of residents that we are taking.”

In addition to the facility assessment driving the type of population being served, it helps identify the tools, training, education and the competencies to cater to that population more efficiently, said Britton. 

For McFarlane the facility assessment is “a gold standard,” giving insights into the clinical picture of the care.

But another practice that is very important – especially in light of the looming staffing mandate – is constant communication with floor staff.

“So you’ve got CNA acuity, and you’ve also got licensed nurse acuity. And those two things are very different, right? So we want to have those conversations with the floor staff and make sure that the assignments that they have are safe, that the interactions with our residents are positive, that we’re providing care to them appropriately,” said McFarlane.

All that could change.

“The staffing mandate, as it’s proposed today, I feel doesn’t include the whole continuum of caregivers that are providing care in the facility,” said McFarlane, referring to the exclusion of LPNs.

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