The trend toward higher acuity in nursing homes has been at play for so long that nursing homes have turned to providing a growing number of complex services and procedures traditionally done at the hospital level.
Skilled nursing facilities (SNFs) are increasingly equipped to provide everything from sophisticated ventilator care and in-house kidney dialysis to bronchoscopies – procedures once performed almost exclusively in hospitals or long-term acute care hospitals (LTACHs).
Venza Care, ALIYA Healthcare, Cascadia Healthcare and Oakdale Senior are among SNF providers who are expanding the range of complex procedures are their facilities. One incentive has been the opportunity to reap the benefits of value-based care dollars.
CEO Efriam Weinfeld of ALIYA told Skilled Nursing News that his approach of bringing increasingly complex services into his nursing homes, rather than routinely sending residents to hospitals or outside providers, has led to better recovery for residents. But it has required modifying ALIYA’s facilities to exceed standards typical for SNFs.
ALIYA expanded it ventilator care by developing ventilator units through its Thrive subsidiary although these weren’t rolled out across the entire portfolio.
While ventilator care is a higher risk, more clinically demanding service that requires the facility’s own team to manage the full operation, Weinfeld said the goal was to improve care and the patient and family experience rather than simply increase capacity.
“Making a Taj Mahal of vent units was something that we’re now moving towards with our Thrive line,” he said. “We started with one of the three facilities that were required to have that, and the other two will include the vent units there as well.”
The success of ALIYA’s vent program is reflected in metrics for the buildings that deploy it.
“The return to hospital [for] that building is better than in some other subacute buildings,” Weinfeld said, sharing the facility’s rehospitalization rate was around 14% in a recent month, which is remarkable for a facility with a large population of patients with high acuity and over 18 vent units, he said. The national average rehospitalization rate stands at 23.9%, according to data on Medicare.gov.
ALIYA has also grown its in-house dialysis to 12 of its 18 facilities, building dedicated “dialysis dens” to serve residents on-site. The rationale, Weinfeld says, is both clinical and operational: keeping services in-house can reduce competing incentives among outside providers and help the company focus on outcomes such as avoiding hospital readmissions.
At the same time, Weinfeld cautions against trying to provide every complex service everywhere.
“If you try to be good at everything everywhere, you end up finding yourself being mediocre at everything. I’d rather be good at one or two things and not try to be one all be all,” he said.
From a payer perspective, there is a benefit to providing these procedures outside a hospital, and to minimize the risk associated with offering these procedures in a SNF, working closely with hospitals is still going to remain important, Heather Haberhern, vice president of quality at Oakdale Seniors Alliance, told SNN.
“The key is ensuring the nurses and direct care staff in your community are trained and educated to address the clinical conditions of the residents being referred to us,” Haberhern said. “We want to have close partnerships with our referring hospitals and our medical directors to support this step toward caring for an ever-growing higher acute population.”
The partnerships with hospitals will continue to support value-based care as well, she noted.
Oakdale is currently evaluating partnerships to offer hemodialysis services in its communities to cut transportation time and hours spent in clinics, Haberhern said.
Not competing with hospitals for complex care
And similar to ALIYA, Cascadia Healthcare’s residents facing rising acuity has led to more sophisticated vent units, according to Steve LaForte.
“We have several vent units that operate at a subacute level, where they are essentially providing the care that an LTACH would provide,” said Cascadia Chief Financial Officer and Principal Steve LaForte told SNN, adding that the specialization exists currently in a new building in the organization’s Boise, Idaho, location.
Cascadia currently operates more than 61 long-term care facilities across Washington, Oregon, Montana, Idaho and Arizona.
Cascadia is also expanding its offerings in in-house dialysis, he said.
“We need to adopt that on a broader scale [because] taking people out for dialysis, that’s an anachronism,” he said.
And as far as bronchoscopies go, a procedure farely new to SNFs, it is also something Cascadia is considering, and LaForte doesn’t believe hospitals are resisting the move because there is a growing need.
“The market is so broad, the demand is so high, and it’s going to continue … there’s no shortage of care needs,” LaForte said. “We’re not competing with hospitals for heads in the bed. We all need to work together. How do we alleviate bottlenecks in hospitals? [By going] down the chain.”
And Haberhern agrees.
“We are seeing residents who have more clinically complex conditions being referred to our communities due to an expedited discharge from our hospital partners, who are looking to us as a lower-cost setting while still being able to provide high-quality care,” she said.
Complex care gap: Mental health
Venza Care provides higher-acuity medical care through cardiac care, dialysis and dual-diagnosis support. Some of the complex procedures may be on the premises but require close collaboration with hospitals.
“[Complex procedures performance] is an ongoing trend across the industry at large,” noted Lisa Chubb, chief nursing officer for Venza Care. “Whether it’s the inpatient dialysis units, cardiac mapping in certain buildings, [it depends] on what the community at large is in need of, and the local hospital partnerships.”
An underserved area of complex care is in behavioral health services, Chubb told SNN.
“A lot of folks need the dual diagnosis support, whether that’s substance use and or mental health, mental illness needs, but I think that’s a big gap right now in the industry that we’re all trying to solve for, and we certainly are here at Venza as well,” she said.
Companies featured in this article:
ALIYA Healthcare, Cascadia Healthcare, Oakdale Seniors Alliance, Venza Care
