McKnight's Roundtable: Taking stock of a field at the crossroads

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McKnight's Roundtable: Taking stock of a field at the crossroads
McKnight's Roundtable: Taking stock of a field at the crossroads
Nursing homes may no longer be viewed as warehouses for the elderly. But that doesn't mean the field has overcome its image problem. Providers have to find ways to share positive stories and data with customers. They also must embrace technology, increase census, and make efficient use of funds amid increased scrutiny and reimbursement cuts.

Those were some of the observations nine long-term care executives shared during a McKnight's Roundtable Forum held in Washington, D.C., on Oct. 16. The participants, who represent an array of facilities across the country, also addressed continuum of care challenges, quality assessment and therapy partnerships.

McKnight's Editorial Director and Associate Publisher John O'Connor and Editor James M. Berklan moderated the discussion. RehabCare, the therapy division of Kindred HealthCare, sponsored the two-hour forum.

Telling better stories

Providers are trying to both recruit residents and change public perception. They need to show their success by producing numbers that reflect their quality approach, forum participants said.

“We have to tell our story better,” said Patricia Kapsar, senior vice president at Bethesda Health Group in St. Louis. “We tell each other we're good, but we don't tell the public well enough that we're good. I don't think we use qualitative data for it. We need to really get our outcomes out there.”

Using abbreviations and healthcare-speak also can leave families confused, said John Korzendorfer, Vice President of Campus Operations for Ecumen, a senior housing nonprofit based in Minnesota.

“We also have to talk in simpler language and use examples the common person can understand,” he says. “When we begin to use all our abbreviations, they glaze over and disappear on us.” 

Employees also are a valuable resource in making Washington lawmakers pay attention, Korzendorfer said.

“I've got 4,000 employees in my system who can do a lot of lobbying on our behalf,” he said. “Senators, congressmen, local politicians, they need to know Ecumen and need to know to pick up the phone and call us. That's a big part of our communications strategy. Lawmakers are trying to do the right thing, but they have no idea what that is.”

That's especially true when it comes to rehabilitation services. Therapy providers have been accused of putting too many patients into high rehab categories, or overbilling amounts of therapy. Providers must educate staff about the importance of demonstrating medical necessity and documenting appropriately. 

“We have not done a sufficient job talking about outcomes. Under the care of skilled providers, patients are doing better clinically and functionally,” said RehabCare President Christopher Bird. “Certainly rehab has been under fire. We need to do a better job of demonstrating that there's a correlation between intensity and frequency of rehab, and how patients are doing, shorter length of stay, independence and getting home sooner. That message has to be clearer in Washington.”

There will be an increased focus on making data sets uniform so that quality can be measured accurately, noted RehabCare's Executive Vice President Pat Henry.

“We do have lots of challenges in terms of selling ourselves,” Henry said. “We don't have a lot of consistent data within the skilled nursing environment, whether it's skilled nursing or rehab-related. Everybody measures outcomes and progress that a patient makes a little bit differently.”

Funding struggles

It's not just therapy companies that feel the pinch. Federal reimbursement cuts also weigh heavily on providers. The Centers for Medicare & Medicaid Services implemented an average 11.1% reimbursement cut that took effect Oct. 1. Add to that declining charitable donations and seniors who may no longer be able to become private-pay residents, and it's a gloomy picture. The economy has caused some seniors to delay selling their homes.

“I think we've recognized that the best days of skilled nursing care are over,” said Carol Irvine, president and CEO of the Abramson Center for Jewish Life in North Wales, PA. “The sooner you recognize that could be true, the sooner you can get on with transforming your organization.”

Maximizing reimbursement should not be seen as a negative, said Jerry Ney, CEO of Aldersgate Village in Topeka, KS. The CMS cuts will mean $37,000 a month for his single-site facility.

“That's real money,” he said. “Receiving appropriate reimbursement that captures the resources necessary to provide care should not be seen as negative. These people have paid for this all of their lives. It's our duty to get them the kinds of therapies that we know they deserve and are a fraction of a cost of hospital re-entry.” 

Additionally, fundraising also is still worthwhile for faith-based providers, Irvine said.

“Fundraising is still a major part of my budget,” she said. By being relevant to the needs of middle- to high-income individuals in a community,  “donations and charitable contributions can still be maintained, if not increased.”

Outsourcing for better service

Having the right systems in place means having a good team, the right technology and measurement and promotion of good outcomes. But it also means not trying to be all things to all people, Korzendorfer said.
“You have to know what you're good at and what you're not good at,” he said.

Sometimes outsourcing traditional in-house service can result in efficiency and savings for a provider. For example, at Evergreen Retirement Community in Oshkosh, WI, President and CEO Ken Arneson found that laundry service was not something his team did well.

“Laundry can be a deal-breaker. We lost a potential multimillion dollar donor because we lost a comforter,” he said. “But there are really good laundry companies out there. We had to take a real hard look at ourselves and what we're good at and what we're not good at. You have to have partners who are going to push you.” 

At Christian Homes, which has facilities across the Midwest, President and CEO Timothy Phillippe, Ph.D., said his company continues to emphasize quality of care in its facilities. Additionally, it has invested in the right billing systems, primarily because of increased government scrutiny. 

“Mostly, everything we're doing will not improve patient care at all on the compliance side,” he says. “All we're really doing is spending another million and a half in overhead to make sure the paperwork is perfect so if somebody comes in to audit, we can prove we did the right thing. That's part of the system we're caught up in now.”

To that end, Arneson said his company brought in a forensic accountant.

“We had that individual go through all of our systems and do things like look for possible ghost employees,” he said. “It's a struggle at times, but we think there are a lot of resources out there.”

Technology bandwagon

The right types of software, IT systems and employees who can use the technology are no longer a luxury, but rather a necessity.

“If you're not leading with technology, you're not leading,” Ney said.

Still, providers can get caught up in the “new new” thing and forget to test software to make sure it's a good fit. Lutheran Homes of South Carolina piloted two resident monitoring sensor-based systems and picked the one that worked best in their care process, said CEO Thomas E. Brown, Jr., DrPH.

“Up until about five years ago, basically we had accounting software, and we were using stone tablets everywhere else,” he said. “Since then, we really have focused more on program development, and then software to support the programs, not IT for IT's sake.

“We're certainly about testing things so that gives us an opportunity to learn how we use it.”

Providers also can't constantly shift systems or software and expect staff to jump aboard, Korzendorfer said.
“You can't change clinical nursing systems very often,” he said. “It's a monumental challenge. All systems have their flaws. You have to help your vendor understand your needs.”

Arneson is hoping the next step in technology will be software that can decode texting abbreviations, similar to the way medical shorthand can be transcribed.

“Our biggest challenge with technology is our staff: They chart like they text, they talk like the text, and it doesn't match up,” he explained.

Future of bundled pay

Establishing a relationship with a hospital system takes time, providers said, but it is likely going to be increasingly important, especially as CMS pushes its accountable care organization models. 

“Hospitals will have so much more power to control our referrals than they have in the past,” said Phillippe. “We need to be able to show the quality we provide. … The relationships going forward in the future will be with the C-Suite level, the medical director of the hospital, not just the referral source in the future as the discharge planner.”  
While she has some hesitation about the government's ACO model, Irvine said she believes a bundled payment system is the future for nursing homes.

Each SNF has an opportunity to look at a local hospital system to figure out what its needs are, as well as what it can offer, she explained.

“If you look at that, maybe what they really need is somebody to manage their really chronic care patients out in the community,” Irvine said. “There's not one answer that is going to fit every hospital system.”

Flexibility is the key to success, Ney agreed.

“You can't cherry pick. You've got to be able to take that admission at 5 o'clock on a Friday afternoon if you're going to get a whole bunch of other good ones,” he said. “We have to be in partnerships with the hospitals. It took me almost a year to develop these relationships with the two major referral hospitals in my region.”

Arneson compared building a referral base with local hospitals as “an arranged marriage where we want them eventually to fall in love with us.”

“We've said, ‘What do we have to offer that's unique in our business model that's going to bring value, whether it's swimming pools, tying it into art therapy, how do you tie it into technology,'” he said. “Doing that has been very beneficial.”

Changing CCRCs

The model of CCRCs was based around a continuum of care, but facilities have had to adapt to meet residents' desires, roundtable participants agreed.

“Several years back, we would almost insist that they would move to a different level of care if we felt that they had needs that were beyond what we traditionally thought of as ‘independent living,'” Kapsar said. “We've taken a complete about-face with that. We are providing services to them in that home so they can stay there as long as they possibly can.” 

The traditional CCRC model is now more than 30 years old and tired, Ney said. In the midst of great trumpeting over how it would be the future of aging, proponents mistakenly assumed that residents would buy into a continuum of care system where they would move from level to level as they grew more ill, he said.

“Everyone misjudged human nature: Nobody wants to move,” he explained. “If you are fortunate enough to get them in a facility at once, that's the new model. Instead of worrying about building bricks and mortar, we have to build a product and service delivery that meets them right where they are.”

Phillippe concurred, saying that even residents coming to independent living are doing so because they have a need.

Henry added that the labels for the different levels of care are “getting gray.”

“Assisted living, as we define it today, is becoming much more like skilled nursing, and we'll probably see that continue,” she said.

“We almost have two types of skilled nursing now, the more traditional skilled nursing and the transitional care units,” she added. “The million-dollar question to me is: How do all the pieces fit together in a new reimbursement environment?”

Increasing census

As operators struggle to balance their budgets, there's pressure to fill rooms. Growing census requires having outstanding sales team, providers said. 

“On the not-for-profit side we've been a little lazy at times, kind of like, ‘Build it and they will come,'” Phillippe said. “We have to be as aggressive as the best for-profit in selling what we do.”

For most facilities, cutting staffing expenses is a non-starter, as are pushing off quality improvements, Kapsar said.

“Without [growing the census], we can't provide the care and maintain the outcomes that we want,” Kapsar said.
Following through on patient and customer satisfaction surveys is also a way to achieve goals, Korzendorfer said.

“What matters changes. Today it's dining, tomorrow it's management's response to issues,” he asserted.

In tough economic times, it can be tempting to push off upgrades, Arneson said. But providers make a mistake when they underestimate aesthetics, he warned.

“People shop with their eyes,” he said. “People aren't driving the same car as 20 years ago.”

Kapsar agreed, noting that her facility created private rooms and entrances, and separate dining rooms, largely for image.

“We did a survey in the St. Louis area and people did not want to come into nursing homes for their post-acute,” she noted.

Looking forward

While no one knows what will happen in Washington over the next 10 years, or when the economy will bounce back, SNFs have to be ready to adapt, providers agreed. Skilled nursing facilities are going to look like hospitals in less than two decades, Phillippe predicted.

“If we want to prepare for that, we need to get doctors and nurse practitioners on board,” he said. “The average age of a person moving in will be 92.”

Preparing for the future involves creating a solid leadership team, Korzendorfer noted: “You can put together a strong enough team to adapt and react to the market.”

Providers also need to earnestly and diligently invest in the workforce, Irvine added.

“Nursing will have a whole new realm of critical thinking, and they'll look more like acute care and critical care nurses,” she offered. “I think the whole idea of a transient medical staff will go away in five years. It won't be a feasible model.”