I once asked a friend who runs a consulting firm what he looks for in new hires. His terse reply: Brains on sticks.

Small wonder consultants tend to be so helpful. Most are a bit smarter than your average bear. So when a consulting firm like Health Dimensions Group predicts the top issues providers will wrestle with next year, it’s worth taking note. Or at least getting a copy, as you can do here.

There’s just one small problem with their list of 11 items though. It’s too much. Ever try to fix about a dozen problems at once? It can be the mental and physical equivalent of spinning car tires on an icy patch. Lots of effort, but little real progress.

To be sure, each item on the Health Dimensions Group list is justified. But the collective weight can be a bit overwhelming. So in the interest of service journalism, I have taken the liberty of picking out the three issues that will be most deserving of your attention next year. Why these three? Because if you don’t deal with them, the rest of the list won’t much matter.

So here’s the proverbial best of the best:

1) Occupancy

It’s no secret that census levels in the skilled care sector are down. Occupancy actually fell below the 82% mark in the second quarter. As they say in the cheese business, that’s not Gouda. The reasons for the ongoing slippage include the usual suspects: new choices for hospital discharge planners, aging buildings, poor management and some fairly bizarre reimbursement incentives, to name but a few.

This downward occupancy trend poses nothing short of an existential crisis for skilled care. Why? Because declining residents quickly translates to declining revenue. That cycle continues long enough, and it’s game, set and match. Unless you are one of those rare operators with more business than you can handle, stemming the bleeding must be your top priority next year.

2) Staffing

Which brings us to the sector’s second-biggest challenge: inadequate staffing. Never mind the relatively few (or is it really relatively few?) bad apples who intentionally under-staff on nights, weekends and whenever else they can. Finding enough people to carry out the needed work has arguably never been a bigger challenge in this sector. And it just might get worse. Without going into the contributing internal and external reasons, suffice it to say most facilities need more help.

You are probably going to have to pay workers more next year. Improving their working conditions probably wouldn’t be a bad idea, either.

3) Risk management

This challenge is admittedly a bit more opaque than the first two. But there is little doubt that shared risk will soon be the new game in town. The push will come from Uncle Sam, who wants you to deliver better care at a lower cost. But you’ll feel it from partners and would-be partners as well, as they are under similar pressure.

The new initiatives designed to make this happen carry a variety of non-lethal sounding names. And more will be coming. But make no mistake: Avoiding risk sharing arrangements could eventually put many operators out of business.

So there you have it. Three things to put at the top of your to-do list for 2019. Or not. The choice is yours to make. Which is more than can be said about the possible consequences.

John O’Connor is McKnight’s Editorial Director.