Some nursing homes are becoming more reluctant to admit patients with complex health and treatment needs to avoid the risk of survey violations, according to sector observers.
“Facilities are more leery to take difficult patients,” Brian Ellsworth, vice president of Health Dimensions Group’s Public Policy and Payment Transformation said during a webinar Tuesday. “There’s a fear of incurring that kind of risk on surveys.”
Violations can come from not having the right mix of clinical staff to meet patient needs or state staffing rules, he added.
Ellsworth said that while the census in LTC facilities is rebounding in many markets, it is still not at pre-pandemic levels and whether it gets there remains in question. The sector faces numerous challenges, such as workforce shortages and having to limit or pause admissions, which are reverberating throughout the healthcare continuum. The “wildcard” remains the federal staffing rule that has yet to be released by the Centers for Medicare & Medicaid Services.
“Long-term care operators need to make important, strategic decisions,” Ellsworth observed. That could include selling facilities to hospitals or repositioning SNFs as assisted or independent living facilities.
The daily census in skilled nursing facilities remains down by approximately 9% over the last three years, according to information presented during the webinar. The number of beds is down 2% and occupancy is down 6%, while the share of beds going to Medicare-eligible patients has gone up by approximately 7%.
At the same time, Medicare Advantage has seen a 22% increase in its market penetration.
Ellsworth said with that shift, there has been a “fundamental change” in the number of discharges from hospitals to home health agencies compared to SNFs. That is leaving facilities on the losing side of the equation, he explained. Further penetration of Medicare Advantage would contribute to that pendulum swing.
“There is an incentive to ‘skip the SNF’ and send referrals home,” Ellsworth said, adding that there is a higher risk of readmissions [from home settings] if the infrastructure does not exist to keep patients stabilized.
Medicare Advantage is more likely to have authorization delays, which can create hospital backups and lead to lost revenue for post-acute care providers plus delays in rehabilitation services for patients, Ellsworth said.
Hospitals and SNFs need better communication
Despite their need to work closely, John Capasso, executive advisor for senior care for HDG, said that hospitals and nursing homes do not understand each other’s businesses. There is high-level knowledge, but not the specifics of what makes each successful, he said.
“Hospitals don’t understand the rating system or how stars are achieved,” he said. “They do understand when there are concerns at the patient level in their markets.”
Hospitals are also trending out of the business of owning nursing homes, Capasso noted. In 2020, hospital-owned nursing homes declined by 17%, according to information from the American Hospital Association shared during the webinar. There were also 150 publicly announced nursing home divestitures in 2020 and another 139 in 2021. The presenters cited ongoing labor shortages, declining reimbursements and an inability to control operating costs as the leading reasons for the offloading of those facilities. Most often, real estate investment trusts and private equity companies are making the purchases, they added.
“The pandemic was a major disruptor to the healthcare sector,” Capasso said, encouraging nursing homes and area hospitals to form standing committees that meet regularly to discuss issues and challenges so there can be more success to all entities in terms of admissions and caring for patients.
He cautioned that the committee should be no larger than the number of people who can be fed by a single pizza so as not to stymie conversations or create top-heavy committees that do not show success. And long-term care leaders should be heartened by at least one aspect.
“Hospitals will be receptive to conversations about how to improve the continuum of care,” Capasso said.
