The rising acuity at nursing homes alongside increasingly stringent government regulation, is raising operational risk – and litigation – leaving facilities “overwhelmed” in its wake.

As residents increasingly age in place for longer, they are arriving at skilled nursing facilities with more serious health conditions. This trend, combined with regulatory pressures and heightened scrutiny from external payers, including Medicare Advantage plans, has amplified the risks of running a nursing home, experts said. 

“Long-term care and senior living operators are dealing with a confluence of factors. It certainly is a very interesting – and evolving – turbulent time right now,” said Nisha Hammel, VP of reimbursement policy and population health at the American Heath Care Association (AHCA). “Individuals are coming in later into long-term care and skilled nursing, older and sicker, with multiple comorbidities.”

As a result, the level of acuity has continued to increase pretty rapidly, she said.

“This is certainly creating an environment in which SNFs and senior living operators are feeling overwhelmed,” she said.

While falls risk tops the list of reasons for litigation, other common issues putting providers in legal trouble include pressure ulcers, medication errors, infections, abuse and neglect, dehydration, and malnutrition, Hammel said at a recent webinar hosted by Skilled Nursing News titled, “Proactive Risk Management: How the Right Clinical Team Can Be Your Secret Weapon.”

Moreover, the rising prevalence of cognitive impairments, such as Alzheimer’s disease, further complicates matters, she said.

There are solutions to counter this problematic shift, however, Hammel said. 

Given that the operational risks are largely driven by clinical concerns, providers have broadened their response by organizing into provider-led clinically integrated networks to focus on quality and engage with payers, Hammel noted. Others are starting their own health plans, which enable them to embed nurse practitioners, in turn enhancing care at the bedside and allow clinical interventions. 

Providers are also mitigating risks by better documentation and improved communication with patients and families, understanding that this is of critical importance in setting realistic expectations.

Steps that facilities can independently implement without partnerships include monitoring of Quality Assurance and Performance Improvement (QAPI) files on a monthly basis, said Mimi Rossi, senior VP at Ziegler.

That said, identifying the level and scope of acuity is an important first step and sometimes carried out better with partners.

A comprehensive risk management plan begins with a thorough assessment of the facility’s capabilities and limitations. Facilities must evaluate their ability to manage different levels of acuity and adjust their services accordingly.

“Do an assessment of what your bench strength is, and who you can clinically, actually take care of. Now, sometimes those are difficult conversations [but] that you should have frequently,” she said. “There are things that you can do now with your risk management and clinical team to implement process measures to help you have better outcomes later,” Rossi said.

Clinical Interventions through technology

Nate Aumock, chief population health officer at Curana Health, which is an organization that helps long-term care organizations manage a plan for care coordination to mitigate risks, highlighted several critical areas where clinical interventions can help minimize risk and enhance care outcomes.

For example, simple regular balance assessments and modifications to living spaces, can reduce fall rates and improve resident safety, he said.

And, implementing more efficient disease management programs for chronic diseases like diabetes and COPD, reduces the need for emergency interventions and hospitalizations, Aumock said

In addition, accurate and timely documentation is crucial for both regulatory compliance and risk management. Facilities must ensure that their clinical teams are diligent in recording all aspects of care, including routine visits and any changes in resident conditions. This documentation supports quality care and reduces the likelihood of regulatory penalties and legal issues.

A large benefit for comprehensive documentation is also helpful in predicting risks. And so in maintaining detailed records, facilities can use data to identify trends and potential issues before they escalate, Aumock said.

Operators are embracing technology and the use of artificial intelligence (AI) has really helped in minimizing risk as well, Aumock said.

Facilities are able conduct remote patient monitoring through devices such as heart rate monitors and scales, along with cutting-edge visual and radar-based sensors, which are being used to track patient health without direct interaction, enabling early detection of potential issues.

Operators are also using AI Tools to help track patient movements between hospitals and facilities to ensure timely support and reduce the risk of readmission, Aumock noted.

Also, providers are deploying AI-driven documentation and communication tools to streamline administrative tasks, allowing them to focus more on patient care and improving overall outcomes.

“Standardizing care, so providing consistent care from patient to patient, that helps obviously, with making sure patients get what they need, and that buildings know how to work with your clinical partner, participating in [QAPI] activities and plans,” Aumock said. “This can be a key part of your risk mitigation strategy [and] your clinical team can be an important contributor to that,” Aumock said.

Incorporating technology into risk management can greatly enhance the effectiveness of clinical interventions, experts said. Remote patient monitoring devices, for instance, can track vital signs and other health metrics in real-time, allowing for early intervention if a problem is detected.

Meanwhile, predictive analytics tools can identify residents at higher risk for hospitalizations. By analyzing historical data and current health indicators, these tools help clinical teams prioritize care and prevent emergencies and readmissions.

Bringing tech and clinical teams together

And while the use of these AI tools is growing to improve quality and reduce risks for falls and readmissions, integrating their use with existing practices means training of clinical teams, according to Mike Emery, executive VP of senior living at Curana Health.

“How we utilize these tools is so important,” said Emery. “Some of the responsibilities seem simple [but] the follow through and follow up on achieving those [is key].”

Timely and correct completion of regulatory visits seems simple on the surface, but clinicians should be making sure that they are sharing that chart information with operating community partners.

“Because if we complete a note, and we’re not publishing it to where it’s accessible, we’re actually limiting communication … Communication is the foundation of a great relationship where we achieve outstanding clinical results,” he said.

Screenings and proactive care coordination is the way to go rather than always being “reactive” to acute situations, Emery said.

“We really focus a lot of our efforts and positions and training on screenings and proactive care,” he said.

This program for such organizations as Curana means getting ahead of a patient’s health care needs and making sure they remain well alongside enabling a model of care that makes it easy and accessible to patients when they need it, Emery said.

Successful risk management relies heavily on strong partnerships between clinical teams and facility staff, he added.

Moreover, regular training for both clinical and facility staff ensures that everyone is on the same page regarding risk management strategies and best practices. This training should cover everything from preventive care to emergency response, ensuring that all team members are well-prepared to handle various scenarios.

“We train our staff to be that extension, to be that team member, someone who’s picking up an oar and rowing and helping accomplish the mission,” Emery said, with the goal to reduce risk and management.

Beyond this, the right referrals and correct staffing, use of interdisciplinary teams to solve problems and incorporation of resident and family feedback, are all ways to reduce risk in long-term care settings, he said.