A centralized clinical approach and operational changes that put patient care first are critical for building a forward-thinking and sustainable long-term care organization. Those hands-on elements are guiding Edwin Cabigao, PhD, RN, director of clinical services at Generations Healthcare.

The chain operates 30 skilled nursing, transitional care and assisted living facilities in California and Nevada.

The 24-year-old for-profit is recommitting to its strategy of smart growth while also bringing pandemic-era lessons on flexibility and leadership into the mix. Cabigao, who led Generations’ COVID-19 response, insists patient care must continue to guide operators even as the pressure of understanding the virus is replaced by overwhelming staffing and fiscal challenges.

“If you put clinical at the forefront of the business, if you put patient care at the very front of operations, everything will follow,” he said.

In the months leading up to the pandemic, Generations broke ground on a new two-building campus in Temecula, CA. The 116-bed healthcare facility’s opening was delayed by COVID, but not deterred. It opened last summer and is largely focused on transitional care as partner to a nearby hospital specializing in advanced cardiac services and stroke care.

Generations also offers its Special Treatment Program in some settings, providing psychiatric care for patients who need skilled nursing services. Its goal is to return patients to the community and to limit or reverse functional deterioration. Some facilities are adding space to accommodate additional beds, while a new companion program developed by Cabigao will seek to bring better behavioral health competency to all Generations facilities.

Next specialty frontier

Within weeks, Generations plans to advance its next specialty care frontier: a three-facility pilot of a respiratory program, “Just Breathe,” to complement existing work with pulmonary patients.

Nearly 25 years ago, the Centers for Medicare & Medicaid Services removed respiratory therapy as a billable service for nursing homes, but needs in the skilled nursing sector persist. In some situations, Generations has denied referrals requiring extensive respirator support because the needed care is “highly complex.”

Just Breathe is built around respiratory treatment modules that give nurses the tools and resources they need to deliver higher levels of care with additional training and the support of a company therapist.

“Nurses are expected to do nebulizer treatments, to do tracheostomy care as part of our scope of nursing practice,” Cabigao said. “We are training nurses in these, giving them the confidence, giving them the competency they need so that they can assess, they can accurately document, treat and care plan these respiratory treatments that are required.”

Edwin Cabigao
Edwin Cabigao, PhD, RN

The Patient-Driven Payment Model reimburses some respiratory services at a higher level, but the existence of the program should drive needed admissions, too.

“With this program, we’re now able to admit [complex patients], No. 1. And No. 2, once we admit them, the readmission rate will be reduced because we have highly trained nurses that can actually treat these residents. … Our hospital referral sources are excited about this.”

There’s a third benefit in addition to healthier patients and happy partners: Staff also get to work at the top of their license with confidence.

“Helping your residents breathe and breathe better, that makes everybody feel good,” said Cabigao, who has worked as a nursing home nurse and holds a master’s degree in gerontology.

Freedom to lead

Cabigao will mark five years with Generations in August. He started as medical director for the company’s Northern region and was in that role for about 1½ years before being promoted to director of clinical services.

In the pandemic’s earliest days, he was in San Diego working on strategic planning when Generations’ top human resources exec and other leaders asked him to spearhead a conference call about COVID with corporate staff and administrators and directors of nursing from all facilities.

“I knew that I had to be at the very front of what’s happening,” Cabigao said. “I’m focused on the clinical aspect of what’s happening, and I have to do my own spin on this. What will be the impact on patient care? What will be the impact on staffing and I have to really let them know that, ‘This is it. We have to take care of each other and we’re here for you.’”  

Although Generations has six clinical consultants that he worked closely with, Cabigao believed centralized messaging would be key during the pandemic.

“I just felt like it would be easier for everyone to have one point person that can receive information and guide them through. There’s one message. I started looking at the (state) and CMS protocols, and I could see right away there was such discrepancy. I’m thinking, OK, if a facility will be calling one consultant, the other consultant will probably have a different interpretation.”

Cabigao said Generations backed his patient-first approach, which strengthened the company’s ability to respond with speed. For example:

  • He called for universal masking before federal officials did.
  • He implemented expanded isolation periods before the Centers for Medicare & Medicaid Services did.
  • He created protocols to put up exposed staff and workers at a COVID-unit in hotels and to pay for forced leave.

“I expected they would at least say to me, ‘Well, do you know how much that’s going to cost?’ The questions were more of the compliance side. It was never about the money,” Cabigao recalled.

For two years, he attended an 11 a.m. daily meeting in which he reported on “every single exposure.” He remains the main point person for COVID-related clinical questions. But being able to better control and now treat COVID has allowed Generations to return to growth mode, and Cabigao to focus on the specialty programming “he loves to do.”

The idea of educating and preparing front line staff to care for future patients is now driving the kinds of ideas he takes to fellow Generations leaders. To move forward he said, operators must learn to address lingering concerns about COVID even as they put resources into new initiatives.

“I know we’ve been focused on COVID, but there are a lot of these areas that we really need to focus on in addition,” he said. “I think COVID will stay with us. We’ve gained a lot of knowledge and expertise the last couple of years, and just like any other illness, we should treat it as an additional area of expertise, but also prioritize others.”