Steven Littlehale

One of my favorite lyrics from the musical “Ragtime” is “We can never go back to before.” The character Mother sings about no longer being a slave to societal expectations; she is confident, moving forward into this new age. 

However, this lyric finds its way to my lips as I think about our dwindled resident census. Will it ever go back to before?

This was the theme of a recent presentation I hosted at the 72nd AHCA/NCAL Convention & Expo. With my cherished colleagues Stanley Wang, data science manager at PointClickCare, and Thomas Martin, director of post-acute analytics at CarePort, we presented a session titled “Post-COVID Data-Driven Occupancy Strategies.”

Our goal was to identify the key drivers of resident volume specific to each market and understand which quality measures have gained importance to your referral partners.

What has happened to census?

Well, no surprises here: Occupancy dropped. In some markets, there was an insidious drop in occupancy prior to COVID-19. However, almost all markets also saw a more dramatic drop post-COVID. Regardless of what data you use to measure occupancy, directionally it’s the same — there was at least a 12% drop in occupancy. 

The “good news/bad news” here, as noted by Tom Martin, is that while we’ve seen a semi-return to normalcy in inpatient hospital volume, discharge patterns to post-acute care have shifted, with home health being the clear winner.

Is this an artifact of our industry’s “black eye” or merely an acceleration of pre-COVID patterns? It’s difficult to say; however, consumers’ preference for home health over SNFs is clear. Tom Martin’s analysis of post-acute discharge patterns also found changes in the typical patient seeking SNF care.

“One repercussion of this shift away from institutional care towards recovery at home is the profile of the patient seeking care in a SNF has become more acute. Among patients discharged from an inpatient stay to a SNF we’ve observed a 9% increase in the average comorbidity score between 2019 and 2020.”   

What are the high correlates to occupancy?

I previously reported in McKnight’s Long Term Care News on the high correlation between the Five-Star Quality Rating System and occupancy in most markets. Many of the professionals attending this session were not surprised to see the strong positive relationship between overall Five-Star rating and occupancy, but curious to learn how the higher-reimbursing payer types also correlated with Five-Star. Even in markets with few SNFs, these relationships held true. 

Everyone agreed that there were material differences between, for example, a 3-star and a 2-star facility, and there was also significant dialogue around CMS’s role in influencing market forces that go well beyond quality. Requiring a minimum of 3 stars to participate in an Alternative Payment Model even though there is little relationship between a facility’s star rating and rehospitalization rate is the perfect example of this overreach. 

Still, I delight in the alignment between clinical and financial stakeholders: Improve the outcomes associated with Five-Star and increase your occupancy.

What early post-COVID insights have emerged?

Stan Wang analyzed whether these Five-Star correlations continued as we began to recover from COVID. Short answer: yes. Looking at data through 2021 shows a clear relationship between Five-Star and occupancy rates. But he also uncovered some other key metrics that were associated with occupancy.

“We see a relationship between average weekly resident COVID cases and occupancy. Those with higher COVID cases had lower occupancy,” Stan noted. “In terms of resident and staff vaccination rates, we see that those facilities with a higher vaccination rate have a higher occupancy rate as well.” Clearly, the vaccine mandate may alter this finding. 

Stan also explored whether infection control survey results, which began in April 2020 and continue onward, had a role in occupancy. Looking at national findings, those without any IC citations had the highest occupancy rates, compared to those with one or more citations. 

In sum, while we are still challenged with lower occupancy rates and seemingly more consumer preference for home health over SNFs when it comes to post-acute care, the role of publicly available “metrics that matter” cannot be denied. 

Five-Star continues to have a high correlation with occupancy in almost every market. COVID rates, vaccination and IC deficiencies also seem to garner the attention of consumers. While not all markets may be able to “go back to before” in terms of their census, there appear to be solid strategies that may help. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.