Balancing the needs of seasoned and new clinicians in the nursing home sector, along with prepping them for residents with more complex cases has been a huge challenge for clinical leaders lately.
This challenge comes on top of survey backlogs that, in some cases, span several years, resulting in outdated star ratings that unfairly mar a nursing home’s reputation.
In addressing the sector’s clinical challenges, leaders are urging a different approach to surveys, with clinical practices driven by what is right for residents rather than by reactions to survey processes.
Robin Mitchell, chief nursing officer for Diversicare Healthcare Services, said during a webinar hosted by Skilled Nursing News on Tuesday that the Tennessee-based operator’s top clinical challenge is recruitment and retention of a committed team, both from a leadership perspective and bedside. And, she is seeing more of a difference between seasoned nurses versus nurses that are newly trained and coming into the workforce now.
“There’s different levels of education and critical thinking that we see, but also a different level of accountability and ownership to our residents, particularly in some of our newer, less seasoned nurses that we’re bringing on board,” said Mitchell. “We need both clinical competency and someone committed to long term care, we need someone with a heart for long term care.”
Mitchell spoke about these clinical challenges alongside fellow chief nursing officers DeeAndra Sandgren of Good Samaritan Society and Antonio Costa of Saber Healthcare Group, based in South Dakota and Ohio, respectively.
Beyond competency and commitment to the sector, Sandgren said new and seasoned nurses need to have the proper training to care for residents with behavioral health issues related to substance abuse and also be educated in trauma-informed care.
“We’re seeing so many referrals for folks that have substance abuse issues, mental health issues, traumatic issues that have happened in their lives, and we want to be able to care for them properly,” said Sandgren. “But folks aren’t coming out of nursing school prepared for that.”
Basic competencies aren’t enough
Trauma-informed care, education on caring for residents with substance abuse and behavioral health issues – they are more layers on top of basic competency in the sector, she said. Clinicians have a lot of balls in the air, dealing with such complexities that intertwine with a resident’s overall health.
Recognizing these same challenges, Saber formed a program for its directors of nursing to focus more on what isn’t happening, what clinical teams don’t have, and creating an 84-page playbook as a jumping off point to reduce turnover and recruit staff for the long haul.
“We lose just as many today through the back door as we’re bringing in through the front door. When you look at the data month over month, the numbers are almost equal on both sides,” Costa said of turnover and new hires.
Having experienced administrators and directors of nursing who remain in their roles for extended periods of time and work regularly together is the secret sauce to distinguishing a high-performing facility people want to join and grow with, Costa said .
Stability between the administrator and director of nursing extends to department heads and frontline staff, and everyone has clear expectations and accountability is maintained, he said. It’s easier to focus on quality improvement and sustain high performance over time if these roles are solid.
Massive effects of survey backlog
States within Diversicare’s footprint are struggling with survey timelines and followup too, creating challenges for the operator’s clinical team, Mitchell added. Some facilities haven’t been surveyed in five years, she said, dating their five-star ratings and causing negative ripple effects with admissions and financial outcomes. Families and prospective residents look at these outdated ratings to make their decisions too, and industries including value-based care companies monitor these ratings.
Some Saber facilities haven’t had a survey in up to four years, Costa added.
“The staff that have been in those buildings may never have been in that building for a survey before, they may not have been in the industry in the last four years,” said Costa. “So there’s a big learning curve there for our communities as well.”
Costa said some families have even turned to other ways of ranking nursing homes aside from five star, including ratings offered by Google.
“Consumers are relying heavily on what [a facility’s] Google rating is, determining whether or not you’re a high-quality provider. It’s reputation. Reputation within your community, how your community feels about your facility,” said Costa.
Reputation can build slowly and positively, but be taken down in an instant if something negative happens, he said.
Sandgren said clinicians and leadership need to completely rethink the link between clinical practices and surveys to bring accountability and confidence back to the bedside. Clinical processes need to be driven by the fact that it’s the right thing to do for the patient, rather than a clinical decision driven by what surveyors are looking for or what they have noted in the past.
“When we can move that language back to talking about, this is the right thing for the residents, and taking away that survey fear. I think that helps us keep people in the buildings longer,” said Sandgren.
Coupled with regulatory changes are documentation requirements between CMS and states, Mitchell said, oftentimes overlap and if they’re not done properly, affect reimbursement.
“It’s not that old adage anymore of, if it’s not done, it’s not documented. Now, if it’s not documented, it’s not done, nor is it paid for, and sometimes taken back,” said Mitchell.
Facilities are limited in their ability to get paid for the quality of care they’re providing, Costa said, referring to five-star ratings linked to quality incentive programs.
“We operate in Ohio and Virginia; both have pretty significant quality incentive programs tied to their Medicaid programs, and in both cases … our overall survey rating impacts our ability to participate and benefit from those programs financially,” said Costa.
Companies featured in this article:
Diversicare Healthcare Services, Good Samaritan Society, Saber Healthcare Group
