Gary Blake regrets that Creative Solutions in Healthcare did not bring on more nurse practitioners sooner, saying the decision has been a turning point for the skilled nursing provider.
“I’m not too proud to say I stand corrected on the use of nurse practitioners,” he said. “I actually can’t say enough great things about them within our organization.”
This was a top point that Blake made during an interview featured on the Skilled Nursing News Rethink podcast. Blake is the CEO of Creative Solutions in Healthcare, which operates 170 facilities in the state of Texas.
With regard to addressing staffing challenges more generally, Blake said that getting a realistic viewpoint from workers is a difficult but important element in driving improvements that lead to retention.
“You think people are drinking the Kool-Aid within your company, and they’re not, they’re giving you lip service,” he said. “And it’s been something to realize. But you know what? Once we know it, we do something about it. That is a huge focus for us.”
The following transcript has been edited for length and clarity. Click here to subscribe to RETHINK via Apple Podcasts, and scroll to the end of this article to access the complete audio of the Gary Blake episode.
SNN: Can you describe one big challenge that Creative Solutions has faced over the course of 2025 so far?
Blake: Taking a look at recruiting and retention, we realized we were getting the applicants in the door, and they responded to sign ons and benefits and all that to retain them [but weren’t sticking around].
So you start drilling down, and you realize your onboarding is not up to par. Your orientation is not up to par. And then you have to start taking a look at the same market. Do we have one building that does really great? Their turnover is low, and then the sister building right across town, it’s deplorable. It’s management, and you have to address it. Employee retention is a management issue.
That employee knew exactly what they were going to be making. So to come back and say they need more money, we’re not paying enough, no, that’s not it – you’re not treating people well enough, you’re not treating people like they should invest the best years of their career with you.
We are digging deep, and it has an emotional side to it, that you think people are drinking the Kool Aid within your company, and they’re not, they’re giving you lip service. And it’s been, it’s been something to realize. But you know what? Once we know it, we do something about it. That is a huge focus for us.
Are there any metrics that you can share with us related to how Creative Solutions has been able to bring down systemic health care costs?
I will tell you when we lit the fire to hire and retain more nurse practitioners to work with physicians, that was a turning point for us. There is a point where you think you’re hitting all the marks, and then you realize, to add that layer of nurse practitioner, it has been life changing for the residents. It has cut down on the return to acute care and has certainly helped with customer satisfaction.
There’s a point when even though they’re still technically your patient, your resident, when you discharge them to the hospital, you lose control. By control, I mean we can’t make sure the patient’s incontinence has been managed. We can’t make sure that their hydration is maintained. We can’t make sure that they got a meal. They can’t advocate for themselves in that E.R., and it’s loud, and it’s noisy, and there’s too much going on.
The addition of nurse practitioners has greatly enhanced that. And I am so grateful that we have plentiful nurse practitioners in the state of Texas, and we have an environment where they can thrive and practice a gift, a true gift.
How have you been able to attract the licensed nurse practitioners?
Blake: We have more than 70 nurse practitioners throughout the company. Part of what we do is help break down any barriers with our directors of nurses; our nurse managers, they’re here to help. They don’t want to be a director of nurses. They may have been a director of nurses in a prior time in their career, so understanding that everyone has a very unique and specific role to play, and how to communicate effectively, is the key.
You don’t just plug and play. Just because you’re a nurse practitioner doesn’t mean you’re going to plug and play perfectly with one particular facility. It’s personalities, too. And once everyone is on board with that, you start seeing the results within days and weeks. I’ve been truly amazed.
I have been disappointed with myself that it took until this stage in my career to really see the full need. I’m not too proud to say I stand corrected on the use of nurse practitioners. I actually can’t say enough great things about them within our organization, and from a recruitment standpoint, we have to create an environment that they want to work in, and we have to make sure that we’re progressive and that we listen.
Then, once our nurse managers and our staff nurses realize their voice matters – we may not have mattered to a hospitalist that was coming through, or someone that serves as a medical director that just comes in, writes orders and leaves. The nurse practitioners as a whole, really care about the outcome for the patient.
How are staffing pressures?
The pressure is still there.
So, like I alluded to earlier in one of the questions, how we onboard, how we have our managers, our department managers, participate in the orientation, and how we make that employee feel continuously okay – they don’t have to feel great, they don’t have to jump up and down and be a cheerleader every day, but they need to be good with their decision to come to work for you every day. Because we should … not have a problem saying, “You know what, you have a choice where you get to work, and I appreciate you choosing us. If there’s ever a way I can make your job easier or better or less burdensome? Bring me your ideas.”
They’re the front line. They’re the ones cooking, cleaning, folding laundry, delivering care to your patients. Take care of the ones that are doing that, and you’ll see your turnover go down, and you’ll see your quality go up, because people want to be a part of that and not be void of leadership in that process.
Say I’m the administrator of this facility, or I’m the director of nurses, or I lead the dietary department, and this is how you’re going to be an integral part of this team. Share all that. It’s not a secret to be a nice person. There’s no secret to that. Being genuine is important, and they need to feel that. And they’ll come to work for leaders, and they’ll come to work for people that are genuinely concerned about them and their families. Be that employer.
Are there certain workforce initiatives that you have in place right now?
Yes. When we did our deep dive, we realized that our relationships with the community colleges and local universities were not what they could have been. We did a very poor job of articulating our needs to these nursing schools, to the culinary schools. If we didn’t already operate an in-house program and we’re using a commercial training program for CNAs, we did a pretty lousy job, to be perfectly honest, [in] what we were saying, the weaknesses that we were seeing, the nurses that were applying to us.
A good school of nursing wants to know the issues and needs, like developing IV skills or spending more time on oral hydration training.
You as the administrator or the CEO of your facility and your company should know about those people. You should welcome those students. Make them feel welcome, encourage them to start their career with your company and tell them, “This is what you can expect from us.”
I got this great advice years ago: State the problem. State what you’re going to do to fix the problem. Let them know what they can expect from you to keep the problem from ever coming back again. That is the easiest way we have found dealing with nursing programs.
It’s time for change. We want to be on the forefront of it in Texas. We want to learn from other operators. I love and get along with every single other nursing facility operator in the state of Texas, because I’m not too proud to say, “Yeah, I think we’ve really dropped the ball with this, but you guys seem to really be winning.” People love to talk about what they’re doing great if you’ll be the first one to say what you’re not doing well and how they can help you. They’ll help you in Texas, I can only speak for Texas. I have a slew of peers in Texas, and they’ll take your call any hour of the day, just as I would take theirs.
How have surveys been going for Creative Solutions?
So, in a word, it’s been horrible. Horrible. The turnover within the surveyors has been awfully high. They’re in staffing crunches as well, right? … The [now-retired] surveyors, it was their career, and they did beautiful jobs in those careers. That’s not what we’re seeing now, particularly in Texas.
More IJs [immediate jeopardy citations] are written in Texas than any other state. Now we have had to escalate that to the governor’s office, to the lieutenant governor’s office and with our lobby groups in Washington.
I had a recent conversation with one of my peers, and she said, you know, G-tags aren’t even being written anymore, they go immediately to an IJj, and she’s right. She’s always right, but in this case, she’s extremely right.
When you know something’s not right – and it is not – we are letting everyone know. Now, some IJs are deserved, absolutely deserved, and we will be the first industry to say, that really was a lapse of judgment … someone had a lapse in judgment, did not respond appropriately, didn’t follow up, didn’t assess. But we are struggling in Texas, for sure.
Many of these IJs, you’re saying, are not from these types of mistakes?
It is a lack of training on the surveyor part.
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