Steven Littlehale

Spending 20 as a principal in an analytics company, you might think I contemplate predictions in terms of sophisticated statistical models, but this isn’t the case. Instead, I lean on my clinical and overall industry knowledge to predict; then, as able, validate well-honed hunches through data analysis.

Most often my hunches are right, but sometimes not. Fortunately, being wrong is just as interesting, as I wrote about two years ago when, to my surprise, we found no meaningful correlation between the hospital and skilled nursing facility Five-Star ratings.  

Some of my colleagues with no clinical or industry experience utilize large, complex, and diverse datasets along with sophisticated modeling to derive their own predictions. Judgment aside, their approach isn’t necessarily better than mine, nor mine theirs. However I maintain that one without the other is like a one-handed clap: a lot of effort, but no impact.

I am a cockeyed optimist. (Literally. Not only do my eyes not align, but I tend to lean more on the optimistic side of the spectrum, despite having recently given up an internal organ to make more room for sarcasm.) So I mean it when I say 2019 holds so much potential and promise for post-acute care, especially skilled nursing. I believe skilled nursing has “got the goods” and the market needs us as much as we need them. Demographics are in our favor, and with emerging payment reform along with transparent metrics, skilled nursing will be the clear winner.

I did an informal survey around the office to get a broad set of the top 13 predictions for 2019 and I’d like to share them with you. There is some cheek in these predictions, but all are grounded in solid insight.

  1. There will be a 35% increase in PDPM experts. This seems almost impossible considering the influx of experts lining up to offer advice since the proposed rule was released last spring. Buyer beware! Stick with trusted sources with whom you have existing relationships, especially your professional associations. Constantly ask yourself, “What’s in it for them?” to understand some of their messaging; but, in all cases, do get help if you need it.
  2. Ridiculous PDPM statements will decrease. We’re all getting better educated and do not tolerate shooting from the hip. Some of my favorites from 2018: “I’m just going to cut my MDS staff!” “This is the end of therapy in skilled nursing.” “We have to get ready to care for the ‘new resident’ that is coming …”
  3. ICD-10 training and certification programs will pop up like mushrooms, and it’s not a bad thing. PDPM requires more coding sophistication than we’ve had to offer. Experienced coders warn against transitioning a hospital coder to skilled nursing.  
  4. Swallowing evaluations will increase exponentially and mechanically-altered diets will become a standing order. OK, that’s over the top snarky, even for me. But like the child who runs with scissors or the adult who speeds during a snowstorm feeling invincible in her SUV, there will be bad actors who emphasize coding for dollars versus accuracy. They are few in numbers but ruin it for the rest of us.
  5. Greater focus on overall hospital utilization. In addition to rehospitalization and re-admission, we now include the hospitalization of long-stay residents in our reduction efforts. The new Centers for Medicare & Medicaid Services quality measure for hospitalization will be added to Five-Star this spring. The measure focuses on how well we care for our long-stay population and how well we prevent unnecessary hospitalization. Currently, the national rate for hospitalization is 14%.
  6. New survey outcomes data from the new survey process will start to count in Five-Star around quarter two. Since November 2017, survey outcomes data has been sitting “in the freezer” waiting for the big thaw. With survey deficiency counts on the rise, and an increase in scope and severity around the country, CMS will likely adjust the cut points much like they did when PBJ data was used in place of self-reported data.
  7. Additional PBJ derived staffing metrics will make their way to Nursing Home Compare. CMS will focus on disparities between weekend and weekday staffing and the use of contract/agency staff. We might see a broader representation of staff types reported in public data, as well.
  8. Telehealth utilization in skilled nursing will increase as CMS becomes more flexible in how this is reimbursed both for Medicare and Medicare Advantage residents.
  9. There will be an increase in risk bearing arrangements between SNFs and accountable care organizations. Greater flexibility afforded to ACOs under “Pathways to Success” will motivate greater downstream risk sharing in one form or another.
  10. The volume of mergers and acquisitions will continue to increase. Correctly or not, providers are considering it unsurmountable to meet the requirements of PDPM successfully and on their own. In addition, multi-site portfolios are divesting properties that are perceived as “real corkers” in payment reform.
  11. More states will migrate toward value-based care incentives to motivate better, more cost-effective care for their Medicaid populations. Though the jury is still out on whether these programs actually reduce cost, at first blush the outcomes associated with the programs are hopeful.
  12. REIT monitoring and monitoring by other external stakeholders will continue to broaden to encompass the spirit of “volume-to-value” care delivery that is inherent within healthcare reform. The metrics that matter go well beyond occupancy and survey and measure, for example, hospitalization, rehospitalization rates, and satisfaction. PointRight’s work with SABRA and now CareTrust provides further examples of this shift.
  13. Skilled nursing facilities will redefine what diversification means by rocking our worlds with creative liaisons both within the healthcare environment and the greater community. “It takes a village” models will emerge for eldercare and stun us by their creativity.

And there we have it, yet another list of predictions to ponder. I suspect you have some of your own to add to this list, or maybe disagree with mine. In all cases, I sincerely wish you a joy-filled 2019.

“Your success and happiness lies in you. Resolve to keep happy, and your joy and you shall form an invincible host against difficulties.”  — Helen Keller

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.