Heading into 2025, EF Senior Care continues to seek opportunities for expansion after acquiring nursing homes in the last two years, signaling a positive trend for smaller-sized outfits in the sector, especially those looking to leverage their consulting experience.
The Massachusetts-based provider, which started out solely as a consulting firm before purchasing two skilled nursing facilities to operate in the state, has been able to grow its footprint despite facing staffing and other challenges, its CEO Michael Nickolaus told Skilled Nursing News.
But it wasn’t always smooth sailing at the start of the company’s transition into owning SNFs. EF Senior Care was able to stabilize operations only after acquiring a second facility in December 2023, which has now positioned the company for a successful refinancing with HUD in 2025, Nickolaus said.
The acquisition strategy for the company is based on turning around properties using efficiencies developed through its consulting arm. With this knowledge, EF Senior Care was able to put in place corrective actions that improved the status of a 2-Star facility to a 3-Star one, for example, but not before a dip in ratings – and some lessons learned.
And now, expansion remains a central goal for EF Senior Care, particularly in Massachusetts.
“Unfortunately, we’re seeing a lot of disruption and owner fatigue in Massachusetts but we’re well positioned to help those who want a proven manager, or to explore a confidential sale,” Nickolaus said.
Looking ahead to 2025, EF Senior Care’s priorities are clear: securing more HUD refinancing, expanding the company’s portfolio through additional acquisitions and management contracts, and maintaining its reputation as an employer of choice, he said.
To address the ongoing workforce challenges in the long-term care sector, the company has made strides in recruitment and retention. By redesigning its hiring processes and offering incentives like paid training and enhanced staff amenities, the EF Senior Care reduced reliance on agency staff by 77% in 2024. These efforts have not only cut labor costs but also improved care quality, demonstrating the company’s commitment to both its staff and residents.
Nickolaus spoke to SNN about his company’s plans going forward, including on improving operational efficiencies and adding new service lines, confident that EF Senior’s continued focus on growth and quality will position the company for success in the years ahead. He also spoke about dealing with the challenges of staffing, surveys and growth of Medicare Advantage.
The following interview has been edited for length and clarity.
SNN: Can you reflect on your organization’s 2024 and describe one win that EF Senior Care and its team has achieved over this year?
It’s been a very good year. In December 2023 we purchased our second facility so much of this year was focused on stabilizing operations and financial performance so that we could refinance with HUD in 2025. I’m happy to say that’s been accomplished through the hard work of an incredible team.
SNN: And can you describe one big challenge you faced over the course of 2024?
This was the first facility we owned that accepted Medicare, and we weren’t as well versed in certain aspects of the 5-Star System as we thought. It was a 2-Star when we bought it and we briefly dipped to a single star this summer which caused a lot of concern. Luckily, we quickly corrected the course, and are now a 3-Star. An important lesson learned.
SNN: Now, looking ahead to 2025, what are your top priorities and goals as CEO?
To successfully refinance with HUD, acquire additional buildings and management contracts. We also aim to continue as an ‘employer of choice’ at all levels of our organization.
SNN: Are there plans to expand?
Absolutely. Unfortunately, we’re seeing a lot of disruption and owner fatigue in Massachusetts but we’re well positioned to help those who want a proven manager or to explore a confidential sale.
SNN: Are you looking to downsize anywhere?
No. We’re in full growth mode.
SNN: Are there any metrics you can share related to how your organization has been able to bring down systemic health care costs, reduce hospitalizations, et cetera?
I don’t have metrics, but I can share a number of steps we take to manage health care costs. We are collaborating with physicians to ensure we’re appropriately utilizing high-cost tests and procedures, such as through imaging studies and intensive scans for residents in hospice. We are also encouraging utilization of doctor-approved lower-cost generic medications as well as facilitating telehealth consultations.
We also continue to encourage patients to receive preventive screenings such as mammograms and colonoscopies so as to avoid unforeseen health disasters. All of this is to say that our focus is on improved care coordination for more efficient care.
SNN: Any thoughts on I-SNPs and extending into that arena?
We haven’t looked into forming an I-SNP, but we’re a founding member of Massachusetts Senior Care Quality Partners Network (MSCQP), an Accountable Care Organization (ACO) organized by Massachusetts Senior Care Association members with support from the [American Health Care Association] that launched in October. We’re focused on leveraging that network in 2025.
SNN: Have you added any new services? And, what was the company’s strategy in adding them?
We’re always adding new services in response to client and market demand. At one of our facilities, we’ve added a wound-care capability and a cardiac capability and built out several ‘executive suites’ for patients seeking a concierge-level private rehab experience.
In September, Massachusetts Governor Healey signed a law containing the most substantial reforms to the state’s long-term care industry in over 25 years. This creates new opportunities, but also imposes new requirements and risks. Our consulting business is developing specific offerings to help clients take advantage of these changes.
SNN: Have staffing pressures eased at all over the course of 2024?
They still exist, for sure, but we are seeing some relief. But it’s a weekly struggle to find quality frontline staff. Facilities that aren’t ‘employers of choice’ will continue to struggle.
SNN: Are there any workforce-related initiatives that you have undertaken to improve recruitment and retention? If so, can you describe them? Any metrics to share on the workforce?
When we bought our second facility a year ago, they were averaging 1400 hours of agency per month. We redesigned our recruiting and onboarding systems and practices. We increased spending to attract applicants.
We implemented an applicant tracking system integrated with Indeed that generates an immediate outbound acknowledgement to the applicant at any hour of the day or night. Within 12 hours, and often within 1 hour, our administrator sends a personalized email requesting a phone screening on the candidate’s preferred timeline. Our average time from receipt of an application to confirming an interview is now under 48 hours.
On the retention side, we’re focused on treating our staff right. We give them the first choice of shifts and fill in with agency. We offer paid training for staff who want to upgrade their skills including infection control and wound-care certifications. We converted the staff lunchroom into a café with free drinks and snacks. Together, these initiatives have contributed to a 77% reduction in agency staff in 2024.
In addition to reducing labor expenses, replacing agency staff with permanent, valued employees absolutely improves the quality of care we deliver to our residents.
SNN: We’ve heard a lot of concern about the rise of Medicare Advantage as a payer for nursing homes, including operational pain from increased paperwork, audits, appeals, et cetera. Are you feeling this pain, and if so, how are you responding?
Q-Mix has always been a challenge and Medicare Advantage plans can exacerbate that. It’s incumbent on our facilities to understand their markets including the payers and work constructively with them.
We’re responding by widening our admissions profile area and our referral network. While that may increase competition, we’ve been able to become a facility of choice for standard Medicare referrals beyond our immediate market. We’ve also added 40 hours a week to our admissions department to support increased marketing efforts and intake tasks, as well as helping with updates, appeals, and audits.
SNN: How have surveys been going for you? We’ve been reporting on concerns over survey processes, as many surveyors are recent hires.
Because of our consulting business, we’re in constant contact with surveyors across dozens of client sites. We find it’s essential for facilities to build relationships with their surveyors, understand their individual backgrounds be it as a registered nurse (RN) or in dietary care, we want to be forthright and responsive.
We’ve served as CMS/DPH-approved temporary managers and clinical monitors so we see the aftermath when things go wrong. Before it gets there, know the expectations, assess your weaknesses, develop a plan to address them, and follow through before the surveyors are on-site.
It’s easy to bemoan the survey process, but if you’re honest with yourself, transparent with the surveyors, and build good relationships with DPH, you can turn it from a punitive process to a partnership.
SNN: As we approach the end of 2024, what word would you say best describes the year so far for your company and why? Would you choose the same word to describe the year for the sector as a whole so far?
For us, the word is ‘Promising.’ We’ve grown our owned and managed facilities. We’ve grown our consulting business in partnership with great clients. We’ve hired great people. And, we see more opportunities ahead.
For the sector, the word is ‘Cautious.’ There have been some positive developments with reimbursement increases, improved occupancy and reduced inflation, but staffing remains a challenge. Federal mandates are unwelcome, and some owners are just burned out. Hopefully, we can turn the corner with some of these in time to deal with the wave of citizens who will need our services in the decade ahead.
