‘A Lot of Noise’: Cedar Community CEO Touts Success in Rehospitalizations, Staffing Amid Medicare Advantage Challenges

As staffing challenges persist, operators are striving to make nursing homes a more attractive place to work and some simple, tried and true tactics are at play.

Gauging employee well-being through annual surveys – administered quarterly for new hires – and acting on the feedback is proving to be a technique that has turned out to be a turnover buster at Cedar Community, according to Nicole Pretre, president and CEO of the 70-year old, five-campus community that offers skilled nursing. 

Although time consuming, the employee surveys have allowed the Wisconsin-based nonprofit to cut back on its agency labor use to the point where agency staff is employed only as substitutes for time off.

“The agency staff was costing us more than $300,000 per month at its height. Today, we’re down to about maybe $10,000 to $20,000 per month,” Pretre said on the latest episode of the Skilled Nursing News RETHINK podcast.

The success of this workforce initiative has to do with not only allowing employees a platform to address their concerns, but also conveying a sense that they have a voice. 

“You can’t necessarily accomplish or even afford to do everything, but the important part was that we communicated back to those staff members and they felt heard, and they felt valued,” Petre said. “That transparency from both the staff and the administration has really helped us to rebuild the trust across the board. And, from that point on, our internal staff recruiting of new team members has really skyrocketed. We’ve continued to use that survey tool.”

Pretre said that it is critical for post-acute care organizations to become better at validating employee concerns.

“How we genuinely model empathy is really critical,” she said. “The old surveys used to be all anonymous and nobody wanted to answer them. And when we introduced this, we made it clear that we were prepared to hear the good and the bad and yes, even the ugly.” 

The completion rate for the employee surveys is over 80% on average, according to Pretre.

“Of those survey results, 94% of our team members say they feel appreciated here and that they are considered organizational advocates for Cedar Community, which is just absolutely incredible,” she said.

As Pretre looks ahead to 2024, she sat down with SNN to discuss some wins on the staffing front and new methods of funding. She also talked about ongoing challenges in the post-Covid era both in tackling disease but also through the penetration of Medicare Advantage plans, which are eating away at long-term skilled care. 

“This is going to be a rough year with a lot of noise going on in the world around us, and we really need to support our people who are caring for our residents and patients so that they can provide the highest support and care to those individuals,” Pretre said.

And yet, short-term rehospitalization rates for Cedar Community remain about 11% below the national average, while the rate of return home or to the community is nearly 37% higher than the national average, she said.

Highlights of the podcast, edited for length and clarity, are below. Subscribe to RETHINK via Apple Podcasts, Google Podcasts, or SoundCloud.

SNN: If you can reflect on Cedar Community’s last year and describe one win for the organization or you or your team, what would that be?

Nicole Pretre: By far the biggest win for Cedar Community this past year has been navigating the staffing challenges that we obviously are all facing right now. We have been able to eliminate all of our long-term contracted agency staffing, which is not only incredibly expensive but it impacts the quality of care and the culture of an organization. The agency staff was costing us more than $300,000 per month at its height. Today, we’re down to about maybe $10,000 to $20,000 per month for very occasional [as needed] coverage for vacations or illnesses. And I have to say this was a total team effort here at Cedar Community, and a huge win for our organization this past year for sure.

SNN: Can you describe one big challenge that you have faced over the last several months?

Nicole Pretre: I know everyone is kind of sick and tired of hearing about Covid, but truthfully one of our ongoing challenges has been to continue to navigate the impacts of Covid as well as the other respiratory illnesses that we’ve been experiencing across the country, and how they can really impact our staffing with the CDC recommendations for health care workers continuing to sometimes mean days or weeks off the job for folks who become ill. This can really stress staffing levels – and we have definitely seen small outbreaks in all of our locations here and there over this past fall and winter. However, the good news is it does seem to be improving now. 

For most long-term care organizations, we have these systems in place for dealing with these illnesses and the staff shortages since we’ve been doing this for four years. That said, the bad news is that we are still under increased scrutiny as an industry while the rest of the world has moved on from Covid, including the CDC, outside of long-term care.

SNN: Looking ahead to 2024 what are your top priorities and goals as CEO and president?

Nicole Pretre: I would say that I have both internal as well as external priorities for 2024. Internally, we’re really continuing to support and enhance our team members’ and residents’ well being; [that] is a major push for us in 2024 and for myself. I believe that it’s so very important to focus on mental health and to provide tools and resources for those who may need some extra support.  Telling people, ‘This is hard work in our world and it’s okay not to be okay 100% of the time.’ 

Externally, my top priority is to continue to explore strategic opportunities for Cedar Community to develop diversified and sustainable revenue; that could include strategic partnerships or maybe affiliations or continued repositioning of some of our current programs and services, as we’ve been doing this past two years. 

We also have to find ways to grow and serve older adults both within our organization, but even more so within the greater community as the demographics of older adults continues to grow– that’s going to be really critical for that home-based services component.

SNN: Have staffing pressures eased over the latter half of 2023 and going into 2024?

Nicole Pretre: Yes, staffing pressures have eased. As I mentioned earlier, we really put a laser focus on staffing. We really began that in the spring of 2023 I’d say, and that continues to today. Obviously we did see more individuals applying for jobs than in the past several years. And fewer individuals who are ghosting us in the interview and hiring process – I’m sure many people have experienced that as well.

Once we did get people hired, more team members really stuck around once they got here. And while we did eliminate that long-term contracted agency staff, we also simultaneously filled more than 40 open full-time positions within our organization in this past year. I’m very proud to say that we’ve maintained a 91% retention rate of those individuals. I can tell you that as of today I have one open full-time position in my skilled nursing facility. I am fully staffed in all of our assisted living in independent living communities.

SNN: And tell us a bit more about how your workforce initiatives and how you drastically cut staffing agency use.

Nicole Pretre: I would say that one of our biggest workforce initiatives has been the importance of transparency from both a corporate level and right down to the frontline staff members. [In the past], at Cedar Community there was maybe an occasional staff survey here and there but nothing was ever done in follow up to those surveys. They just kind of went into Never Never Land. When I stepped into the role of CEO a few years ago my first priority was really to reestablish trust and transparency with both I’d say team members and residents. So we really started utilizing a survey tool for our team. 

And we were not sure how, quite frankly, it was going to be received, but in the first round over 90% of our team members responded, which is incredible for a survey response. But [we realized] people are not going to continue to give you that feedback unless you communicate back …. And so our human resources team reached out personally to every single staff member who shared a concern in that initial survey round and they continue to do that today.

And believe me, that’s an investment in time, but I would say one that’s well worth it when you look at the cost of turnover. We’ve been able to affect some really incredible changes through that feedback.

We continue to use [the tool] with new hires.

SNN: When we spoke to you in fall, you mentioned some new initiatives on obtaining funding. Can you speak more about these?

Nicole Pretre: We’re working on what we like to call venture philanthropy initiatives as we look at opportunities to develop funding for future projects. I can’t go into too much detail at this point because we’re still working on some confidential programs and putting those all together. But I can say that one area that I continue to see is a challenge for operators in the nonprofit space is that the operators are not leveraging their donor potential from a capital perspective. We think about donors from donations and estate gifts which are obviously incredibly important to us as nonprofits but many of those high net worth donors are very venture capital minded. We’re missing this opportunity to work with those individuals and have them think about how to work with nonprofits from that venture capital perspective.

SNN: We’ve also heard a lot of concern about the rise of Medicare Advantage as a source of frustration for nursing homes, including operational pain from increased paperwork, audits appeals and so on. Is Cedar Community feeling this pain, and if so how are you responding?

Nicole Pretre: Medicare Advantage uptake is very high in our geographic region. The MA penetration is at about 61% of eligible adults in our geographic region, and one [MA] provider alone holds 58% of that market share in our market. Overall there are three Medicare Advantage programs that have captured 80% of the MA market in our area. So as you can imagine, there are very few players involved and with the amount of work involved in these admissions combined with their very short stays in many cases … that’s a real financial challenge for us. There’s no question about that.

I’ll tell you honestly, we’re currently evaluating if it even makes sense for us to continue our short-stay program which is really unfortunate for those who really need those services. But, it really has become financially unsustainable in its current state.

SNN: And turning to surveys, we’ve been reporting on concerns over survey processes as many surveyors are recent hires, and then there is the issue of third-party surveyors. So, how have surveys been going for Cedar Community?

Nicole Pretre: We’ve heard and seen some third-party surveys in our state as well. But we’ve been very fortunate that our last several surveys have been very positive outcomes. We’ve got good relationships. We have long-term relationships that help. We have an administrator and a director of nursing who’ve been with us combined for more than 60 years. And so they know our state officials very well. We reach out and we’ll ask questions and they will respond to us.

SNN: Are there any metrics you can share related to how Cedar Community has been able to bring down systemic health care costs, reduced hospitalizations, etc.?

Nicole Pretre: Our short-stay rehospitalization rates remain about 11% below the national average. So that’s been fantastic. And in spite of some of our Medicare Advantage challenges, our rate of getting folks to successfully return home or to their community is nearly 37% higher than the national average and we’re very proud of that. Obviously that speaks 100% to the incredible quality and care that our teams are providing.

We continue to remain highly focused on quality outcomes and metrics and maintaining our 5-Star rating. Our administrator and director of nursing as well as our QAPI [Quality Assurance and Performance Improvement] team are constantly evaluating those metrics. And we work very closely with our acute-care partners in this space to make sure that they know and understand what those metrics look like as well.

SNN: Can you describe any value-based care initiatives currently being pursued by Cedar Community?

Nicole Pretre: Yes, in fact, we have actually been part of an ACO [Accountable Care Organization] with one of our local hospital systems for years, one that they’ve developed a number of years ago. When Covid happened, that kind of got a little on the back burner. But they have recently really upped their focus on their post-acute care partners, and we are very fortunate and very blessed to be one of the top care coordination partners in our area with that particular hospital system. So we’re really starting to see the value-based ACO program really kick into high gear.

We’re also exploring other value-based programs as part of our ongoing strategic planning that I mentioned earlier including serving older adults who want to remain in their homes as long as possible.

We’re also exploring how AI and technology is going to really impact that value-based care space and how we can work at Cedar Community to be at the forefront of utilizing technology to help improve quality outcomes for folks.

SNN: This podcast is called RETHINK. What’s something that you think leaders in the nursing home sector need to rethink?

Nicole Pretre: In reflecting on everything we’ve talked about and on what we’ve been doing here at Cedar Community in the last year or two, my message is to rethink how to empower and engage your frontline staff. Staffing equals census equals revenue.

I go back to saying it’s about building trust through transparency and the key to that, I believe, is sharing the ‘why’ behind key decisions or directions that you’re making as an organization and then how you are messaging those changes because people need to hear what you’re doing and why you’re doing it.

Making sure that your team knows that they are heard and appreciated, giving your team a sense of pride and ownership in the success of your organization, honestly, [has been] our best recruitment and retention tool. It’s going to mean better quality outcomes and it’s going to mean financial sustainability for your organization. So just rethink trust and transparency.

To listen to the complete episode, click below:

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