When it comes to value-based care models and appropriate reimbursement, nursing home operators must think about the care team behind the model. Whether it’s Institutional Special Needs Plans (I-SNPs) or accountable care organizations (ACOs), a robust clinical team is crucial to aligning with positive quality outcomes.

That’s according to Mike Bailey, president and CEO of American Health Partners. Mike sat down with Skilled Nursing News for the latest RETHINK podcast, and discussed value-based care as well as the staffing mandate, survey woes and public perception of the industry.

“The secret sauce in an ACO or an I-SNP, or any of these models, is having the right clinical resources to provide the care. For us, that’s TruHealth, our clinical services team,” he said. “Those people, our physician assistants and nurse practitioners deliver the coordinated bedside care in the nursing home or assisted living facility. Without those clinical resources, it’s really hard to deliver on any value-based care model.”

Any value-based model is only viable if you have the right clinical resources in the right place at the right time, he added.

American Health Partners is a diversified health care company based in Franklin, Tenn. and focused on post-acute health care for seniors. The team operates 29 nursing homes across Tennessee and Alabama, along with five psychiatric hospitals and a long-term care pharmacy.

American Health also offers Medicare Advantage (MA) and Institutional Special Needs Plans (I-SNPs) in 12 states and has a clinical services division called TruHealth that provides coordinated bedside care for members of its MA plans.

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

SNN: Explain to us a little bit more about the care teams with TruHealth.

Mike Bailey: We’re really excited about the growth potential for our TruHealth Division, that is the division with providers at the bedside. It’s a dedicated team of nurse practitioners and physician assistants that focus on proactive and coordinated care for long-term care residents, who are members of our I-SNP plans across these dozen states. They work closely with nursing home staff to improve outcomes and the quality of life for the seniors. Our approach to this has led to fewer hospitalizations and ER visits, which has caught the eye of our partners in those 12 states who want to expand our model to their new groups.

We’re eager to take our TruHealth services beyond long-term care, possibly reaching folks in assisted living, or even those at home to qualify for our care model. Our goal remains the same: provide top notch care wherever it’s needed the most. TruHealth offers an important innovation, we believe in caring for seniors, and it has a ton of potential future growth.

How have partnerships and staffing initiatives at American Health Partners evolved to be competitive?

We’re very engaged with our local community colleges and the technical schools, where nurses and CNAs are provided training programs. We have programs where students can do their rounds in our communities and achieve their required clinical hours. In addition, our communities offer various training programs to help train certified nursing assistants and we provide support programs that help CNAs get their medical technician credentials. We also have our own American Health Partners Nursing Scholarship Program. We call it our PEN scholarship, which stands for partners for excellence in nursing. Through that program, we have provided grants to more than 35 of our employees in the last two years to help them advance in the nursing education and earn their RN or LPN or their nurse practitioner credentials.

Any thoughts on the future of Medicare Advantage, its trajectory and evolution?

In our part of the country, we don’t really think that the growth of Medicare Advantage shows any signs of slowing down. There’s just too much forward momentum with that program, largely because the value proposition to the members is so strong. Members benefit from excellent coverage and a broader range of benefits and little to no additional cost. In our American Health Plan’s Medicare Advantage I-SNPs, every member has a member advocate who is at their side to help them navigate their benefits effectively and maximize the value of their plan.

There is a lot of regulation around Medicare Advantage plans, but that’s where we can step in to help our nursing home partners by staying ahead of regulatory changes and making necessary adjustments; it’s a real value to our partners. Nursing home operators interested in owning a Medicare Advantage plan, but concerned about the complexity and the regulation should really talk to us. They can benefit greatly from our expertise in navigating regulatory complexities. With our help, they can do this – it’s exceedingly difficult to do it all by yourself. If a nursing home isn’t thinking about owning a Medicare Advantage plan, they’re leaving a lot of opportunity on the table to enhance their clinical programs and improve their bottom lines.

Anything you’d like to add about administrative pressures surrounding Medicare Advantage? What about I-SNP growth?

The best way for nursing home operators to handle these pressures is to get into the game themselves. Don’t wait on the sidelines and be at the mercy of the rates dictated to you from these large, multinational insurance companies. [Operators] should become an owner of an insurance company themselves. That’s really our model, we partner with nursing home operators in our 12 states to create joint ventures that empower them to own and operate their own Medicare Advantage I-SNP plan. As an owner of a Medicare Advantage plan, the nursing home operator is no longer at the bottom of the reimbursement food chain. You have more control over your operations and with the support and expertise of our TruHealth clinical team, you then have the clinical resources to deliver better care. That results in financial rewards. We paid out more than $11 million last year to our partners in shared savings, which is a tremendous amount for us.

The I-SNP sector continues to grow, and operators know and understand the model much better now. They are eager to learn more. We get inquiries from operators from around the country looking to start their own I-SNP. And while the I-SNP sector is growing, it still remains a small percentage of the overall Medicare Advantage market. We believe there’s still plenty of runway for I-SNP growth.

[Value-based model profitability] really depends on the market, of course, but it mainly depends on people’s ability to execute. The incentives around value-based care, such as an I-SNP, are geared toward better performance and improved clinical outcomes. With that said, if you execute the model of care, and deliver enhanced care with fewer rehospitalizations and better outcomes, it’s a very profitable model. If you don’t deliver on the model of care, your bottom line will suffer but really, that’s how it should be. You need to deliver on better quality of care, and you’ll get better financial results.

What other value-based care models have caught your eye?

I believe that ACOs are a very viable model. For folks who don’t think the I-SNP is the right fit at this moment, an ACO is a good alternative. But the secret sauce in an ACO or an I-SNP, or any of these models, is having the right clinical resources to provide the care. For us, that’s TruHealth, our clinical services team. Those people, our physician assistants and nurse practitioners deliver the coordinated bedside care in the nursing home or assisted living facility. Without those clinical resources, it’s really hard to deliver on any value-based care model. Any value-based model is only viable if you have the right clinical resources in the right place at the right time.

What is payer mix like for American Health Partners?

Today, more than 75% of our patients are on Medicaid. That’s been the case for a while. It’s not really a new trend for us. We don’t shy away from caring for Medicaid patients, that’s really not going to change, we don’t believe, and that’s an important part of who we are. We serve the underserved and the most elderly and frail people in our communities. We’re one of the few places that actually welcome Medicaid patients. They come to us seeking care, and we need to be there for them. We even take patients that are not currently on Medicaid, and help them get qualified to receive the Medicaid benefit. That’s a really important initiative for us. 

We’ve embraced the fact that Medicaid is here to stay, and traditional Medicare is shrinking. The shift that’s really happening is the shift from traditional Medicare to Medicare Advantage. We do see that trend continuing.

What implications do you see in terms of the finalized staffing mandate?

Like everyone in skilled nursing and long-term care, we’re facing a staffing shortage. We’re working hard to recruit, hire and train more clinical staff. It’s very, very challenging, because in a lot of cases, especially in the rural areas we serve, qualified candidates simply aren’t out there.

Imposing a staffing mandate in the face of a serious labor shortage seems only to put nursing homes in a more vulnerable position than ever before. A lot of nursing homes are in a financial crisis. This will likely make matters even worse, we may see more operators going out of business or being forced into bankruptcy, which would really be catastrophic for the sector. Our population is aging, and we need more long-term care options, not less. We need a more holistic approach and better reimbursement so we can improve salaries and compete for the clinical talent. We need more resources to train nurses and CNAs and we need to elevate the profession in a way that helps us attract the best people.

I do think there’s a chance for legislation to help create more effective policies to address the staffing crisis in nursing homes. We as Americans are divided on a lot of issues, but I think everyone agrees that our seniors need the best care we can provide. Effective legislation that provides real solutions and provides more resources to improve the funding and staffing of nursing homes is really a winner for everybody on both sides of the aisle.

What insight do you have on the current survey process, and how to repair the relationship between surveyors and operators?

There’s a really troubling lack of consistency from region to region in surveys – there needs to be more focus on education and providing guidance to nursing homes on best practices. Surveyors should be required to have worked in the nursing home setting prior to becoming a surveyor.

Uneven interpretation of regulations causes discrepancies and confusions from region to region and from surveyor to surveyor. We should always remember that the objective of the survey is to make the nursing home better. We shouldn’t be afraid to open the door when a survey team shows up. Fear makes people behave in ways that aren’t healthy. In the best interest of quality care, a more collaborative approach and process really geared toward learning and continuous improvement would be more effective than a system that’s too geared toward punishment and finding fault.

In my opinion, it would be beneficial to have a survey process that is more like the Joint Commission accreditation process [for hospitals], which is in itself very challenging, with very, very high standards for quality and safety … but it’s a collaborative process. The Joint Commission process involves a surveyor flagging deficiencies and areas of improvement, and then helping to create action plans for continuous improvement. There’s a lot of communication back and forth, and a shared sense of mission.

How has public perception changed, and might industry discussion in upcoming elections affect that?

Nursing homes are really often the target of unfair criticism, but I think it has gotten better in recent months. We probably hit our low point at the height of the pandemic, with visitation restrictions in nursing homes. People were venting their frustrations on us, which really wasn’t fair. We were doing what we had to do to keep our people safe in a very, very difficult situation.

People are starting to realize and acknowledge the important role nursing homes play in caring for some of our most frail and elderly neighbors. It’s difficult work. And it takes a special person to care for these folks with patience, compassion and clinical expertise.

I hope the long-term care industry doesn’t become a political football. We account for a very small percentage of Medicare spending. I think it’s important that everyone on both sides of the aisle recognizes the critical role long-term care facilities play in our communities. We have an aging population, and for many, especially low income elderly people, we’re the only ones who can care for them, their families are overwhelmed. The goal really should be to transcend the political divide, and be something we can all agree on.