The Ciena Group is poised to open its latest newly built skilled nursing facility in Troy, MI, this fall, just one way the substantial provider is looking to further grow in 2023.

With more than 9,000 beds in four states, Michigan-based Ciena isn’t focused on size alone, but rather on programmatic additions and building design innovations that will attract new partners, residents and staff, says Senior Vice President Amy La Fleur.

“My personal opinion is we’ve been regulated for quite some time to have home-like environments. And we got lambasted for having COVID in the nursing homes, where we have congregate meals and group activities,” says  La Fleur, who joined Ciena early in 2021 after years at SavaSeniorCare, Trinity Health Senior Communities and HCR. 

“Now with new construction, with HVAC and what we know now about better ways to manage [infections], it’s really going to influence design. We probably will take more time to think about how we work with our architect and our physical plant folks to try to have a home-like environment but also be able to manage infectious disease more efficiently. Any new construction will have to take that into consideration.”

Amy La Fleur
Amy La Fleur

While La Fleur says Ciena leaders are eager to bring new concepts to the market, regulatory changes and economics will need to combine to give the company and the broader sector room to improve.

Ciena is planning to expand its behavioral health and substance abuse disorders programs in the year ahead. Those services will complement the kinds of clinical services Ciena has become known for, including in-demand dialysis and ventilation programs that have spurred physical expansions at multiple nursing homes in its network.

But while regulators have been promoting changes such as private rooms, there’s been some early conflict in trying to build programs and facilities with behaviorally diagnosed patients in mind. Design for those patients includes more elopement and egress prevention and other considerations.

Serving behavioral patients in a traditional nursing home, as the Centers for Medicare & Medicaid Services has insisted must be done in policies that promote trauma-informed care and access to substance abuse treatment, isn’t necessarily an easy sell to state officials.

“In some markets, nursing homes are the solution for a lack of low-income housing for people that have chronic mental illness. They wind up living in the nursing home at the age of 50, which isn’t really appropriate,” La Fleur acknowledged. “It’s not every facility, but that definitely leans into regulatory issues when you’re caring for that nation’s grandparents and the nation’s homeless folks in the same location.”

New techniques to staffing

Another huge hurdle in caring for complex patients is, of course, staffing. It’s a major area of concentration for Ciena, La Fleur says.

When the company created an agency elimination taskforce, it learned through staff feedback that many frontline workers felt unprepared to care for patients with increasingly complex needs, whether those patients had COVID diagnoses, dementia or substance use disorders.

“We really took that very seriously and started pursuing staff training with our partners. We were doing dementia training, and we were doing a lot of clinical training. But there were definitely some pockets where we needed to beef up our staff training so they felt more prepared,” La Fleur says.

“We’ve worked through that to a great degree. Then pivoting that to recruiting around that expertise, it’s something we have some opportunities to do in 2023.”

The company is now 90% out of agency. It has increased wages and taken a new approach to recruiting, one using internal recruiters who base their approach on census-building techniques.

“When you think about census, you have liaisons out in the market to keep it flowing. We needed to do the same thing on the recruiting side, to manage Indeed and to manage Apploi and all of those things most effectively,” La Fleur says.

In addition to increasing wages to remain competitive, the company also listened to worker feedback and added OnShift for daily pay access and to digitize scheduling and make it more flexible.

Ciena also built more career pathways and tracks in everything from phlebotomy to dietary and beefed up its corporate grant writing capabilities to go after fresh funding opportunities.

“We’re really having to build up our workforce capital system around grants that are available,” she said. “The states have a lot of money for those grants and we need to figure out how to operationalize it.

“These are the kinds of changes we’ve made systematically to not just get out of agency one, time but to get out and pretty much stay out,” she adds.

Staffing dictates growth 

Ciena is also taking a closer look at local labor markets as it explores potential deals.

“Our process of looking at them has changed a little,” she says. “There may be a lot of upside on the performance enhancement that you can do, but if you can’t staff the building because the labor market just isn’t there, then obviously you’re going to be more conservative on that. I don’t know that that weighed as heavily in an acquisition pre-pandemic as it does now.”

Even with locations that have almost-guaranteed volume, such as on a hospital campus, if there’s not enough staff, acquisitions will be tough to optimize, La Fleur adds.

Facing economic and regulatory headwinds, more providers will leave the sector, she predicts. That will result in resizing, particularly in markets that are overbedded, such as Ohio. That state is home to the majority of the Laurel Health Care facilities Ciena picked up in 2016.

In other markets, though, particularly in Michigan, Ciena sees opportunity for growth and new construction. That includes wings and additions needed to serve higher-acuity patients in niche programs, but also big, new buildings meant to appeal to partners and patients.

“We’re excited to do new construction because we feel like so many of the limitations that affect how well you operate are, in part, physical plant,” La Fleur says.

In Detroit, the company moved licenses from two other locations to create a new campus, the Regency of Shane, in 2020.

Pursuing similar projects, after completion of the building in Troy, will depend on several key factors: staffing, reimbursement and demand.

“We love new projects, and our CEO, Mohammad Qazi, loves to do new things,” La Fleur says. “But projects are taking a long time [due to ongoing COVID- and supply-related constraints] and costs are rising…. The economy’s going to have to change a little bit.”