This article is sponsored by American Health Partners. As post-acute care grows more complex, providers are looking for clinical partners who do more than consult; they need boots-on-the-ground support that drives real outcomes. TruHealth was built to meet that need. In this Voices interview, Lisa Hitt, Assistant Vice President of Clinical Operations at TruHealth, shares how their model reshapes care delivery in skilled nursing, what sets them apart from traditional clinical support, and how they’re helping providers navigate today’s pressures while preparing for value-based care in 2026 and beyond.

Skilled Nursing News: What career experience or key insight shapes your approach to post-acute care for seniors? 

Lisa Hitt: I’ve been a nurse for 18 years, and I actually went into nursing specifically to work in long-term care. That decision was shaped by my grandparents and watching our family navigate aging, skilled nursing and the difficult decisions that come with not always knowing what options are available. It gave me an early understanding of how vulnerable this population can be and how important the right support is.

Nursing was a second career for me, and I went straight into long-term care, starting on the floor before becoming a shift supervisor and eventually an interim director of nursing while I was earning my nurse practitioner license.

As a nurse practitioner, I moved into palliative care in the home setting here in Tennessee. Much of that work was through a hospital program and HealthSpring, with the goal of helping people remain at home and avoid unnecessary hospitalizations. That’s also where I became familiar with the I-SNP model through Optum and UnitedHealthcare.

I-SNPs are designed specifically for people living in long-term care settings, so it really brought the two sides of my background together. I understood long-term care from the facility perspective, and I also understood the clinical side of managing complex patients outside the hospital. That combination ultimately shaped my approach to post-acute care and led me into clinical operations for the I-SNP program at TruHealth.

What is TruHealth Clinical Services and how does it change the way care is delivered to seniors?

At its core, TruHealth Clinical Services brings clinical expertise and proactive care coordination directly into the nursing home. Our nurse practitioners are at the bedside throughout the week, so there is consistent clinical support around the patient rather than care only becoming more intensive when something goes wrong.

The population in long-term care has also become much more complex. In addition to seniors managing multiple chronic conditions, we are caring for younger patients with behavioral health needs, people experiencing homelessness who have nowhere else to go and individuals with developmental challenges who may have aged without family support. That means we have to look at the whole person and everything happening around them.

I often describe the model like a clock. The patient is at 12 o’clock, and our TruHealth clinicians are the hands of that clock. Anyone who touches that patient, whether it is the physician, facility staff, family, an outside provider or the nurse on the floor, is part of that picture. Our clinicians should understand what is happening across all of those touchpoints and help advocate for the right care.

That comes from being present at the bedside and having conversations with the patient, family and facility staff about where that person is headed and what the plan should be if their condition changes. Developing that care trajectory and having contingency plans in place can help avoid hospitalizations that are not necessary.

Today, we have about 10,000 members in our plan across 50 nursing homes in 14 states. Our practitioners and case managers work together to bring that proactive, holistic approach directly to the patient. I think that consistent presence and coordination can really change the trajectory of care for someone living in a nursing home.

How does TruHealth differentiate itself from traditional clinical support or consulting models?

One of the biggest differences is that on the I-SNP side, we keep our patient-to-nurse practitioner ratio at about 80 patients. At that size, our clinicians can really know their patients and have meaningful conversations about what I like to call “care in advance.”

I do not necessarily like to call it advance care planning, because it is broader than that. It is about thinking ahead about how we are going to manage a disease, how medications are working and what we will do if the patient’s condition changes. We are looking at medications every week, with a deeper review every month, to make sure something has not changed, another medication has not been added by an outside provider or something important has not been missed.

That proactive approach happens right at the bedside. Our nurse practitioners are working alongside the nurses on the floor, asking questions and making decisions in real time while they are assessing the patient.

We also provide live 24/7 on-call support. There is never a time when the nurse on the floor, the patient or the family cannot reach a nurse practitioner from that state team. That clinician has access to the patient’s contingency plan and understands the goals of care, whether it is after hours, on a weekend or over a holiday.

The team rotates that responsibility so when one nurse practitioner is off, another can pick up the baton without losing continuity. That consistency helps us follow the care plan, respond quickly when something changes and continue honoring the patient’s goals.

How do you measure TruHealth’s impact?

We really focus on the outcomes that matter most. Is the patient in better shape today? Are we managing that disease process effectively on a daily, weekly and monthly basis? Are we avoiding unnecessary hospitalizations? And are the care teams equipped to manage these complex needs where the patient is?

That means understanding what resources are available at the facility, what can be done after hours with things like labs or fluids and how to respond when a patient presents with new symptoms. We want clinicians to really hone in on the differential diagnosis and make the right change at the bedside whenever possible. It comes back to the right care, in the right place, at the right time.

But behind every metric is a person. When we reduce hospitalizations, that may mean someone avoided an unnecessary trip to the emergency room where they could spend hours under bright lights, away from the people who care for them every day and in an environment that can be especially difficult for someone who is frail or immobile.

That is why avoiding unnecessary hospital transfers stays at the forefront of how we think about care. The goal is not simply to improve a number. It is to intervene earlier, alleviate symptoms where the patient is and create a better experience for that person.

How does TruHealth support providers facing staffing challenges and regulatory and financial pressures?

It is a real challenge, especially since COVID. We recognize the constraints our partners are under. There is still a nursing shortage, many facilities are relying on agency staff and some nurses may be walking into long-term care without being fully prepared for the complexity of the patients they are going to manage. These facilities are almost like mini hospitals now.

At TruHealth, we try to extend the clinical capabilities of our nursing home partners rather than putting all of that responsibility on the facility team. We host skills fairs for bedside nurses and spend time explaining the “why” behind different interventions so they are not simply following instructions, but building their own knowledge and confidence.

That support continues after hours through telehealth. Our clinicians can walk a nurse through an assessment, talk through what they are seeing and explain why a particular intervention may be appropriate. We really try to be that calm, teaching voice when the nurse needs additional clinical support.

We also work with each partner to understand what they already have available and where there may be gaps. That includes reviewing supplies and medications in their emergency kits and making sure nurses know what resources are available and where to find them.

Our TruHealth clinicians are leaders at the bedside and within the facility, and that partnership helps make these pressures feel less like something the nursing home has to carry alone.

What do you think will separate the organizations that thrive in 2026 from those that struggle to adapt?

Organizations that thrive will bring together three things: great people, aligned incentives and technology that actually makes their people better.

Talent will be critical, especially in senior care, where expertise, judgment and relationships matter immensely. If a clinician is not someone the team and families know and trust, they are less likely to call when something starts to change. We tell our nurses at the bedside that no call is too small. It does not have to come from a nurse either. It could be a CNA, a social worker or anyone who notices something different.

Organizations also need financial models that align with quality outcomes and efficiency, not just volume. That ties back to the ratios we discussed earlier. You need enough clinical capacity to actually know the patient and respond before a small issue becomes a bigger one.

AI and other technologies are also coming into this space quickly. The important thing is making sure those tools support what nurses are seeing and help alert clinicians and facility leaders when something may be changing. Seniors can decompensate very quickly. Minutes matter, hours matter and days absolutely matter when the difference may be treating someone in the facility versus sending them to the hospital. Identifying risk sooner can reduce administrative burden and help people make better decisions.

Ultimately, the organizations that thrive will be willing to challenge the way things have always been done while staying grounded in their mission. Great people, smarter technology and a relentless focus on better outcomes will be what separates the organizations that succeed.

Editor’s note: This interview has been edited for length and clarity.

TruHealth, a division of American Health Partners, is redefining how care is delivered to seniors in long-term care settings. By embedding clinical expertise, coordinated care management, and data-driven insight directly into day-to-day operations, TruHealth shifts care from reactive to proactive. This integrated model improves outcomes, strengthens continuity, and enables providers to deliver higher-quality, more personalized care—while succeeding in today’s value-based care environment. To learn more, visit ourtruhealth.com.

The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact [email protected].