Credit: Kimberly Marselas

This is a condensed version of Rural Peril, a four-part series that originally appeared in the McKnight’s Daily Update.

BLOOMFIELD, NE — Like many of its skilled nursing neighbors in the Cornhusker State, Good Samaritan Society-Bloomfield is teetering between fulfilling its vital community role with special small-town flourishes and succumbing to the financial pressures that come with operating in that same small-town setting.

For 60 years, staff here have encouraged the residents of Bloomfield to “come on up the hill” when they need long-term care or therapy or just want to visit with someone who does. But the community’s population — it shrank to 987 in 2021 from 1,114 in 2000 — means fewer potential workers and less opportunity for those who do live here to receive care locally.

The Bloomfield nursing home still garners many of its worker and patient referrals from neighbors bumped into at the nearby Country Market or over lunch at Misty’s Saloon, six short blocks away on a quintessentially small-town America street.

But there’s an increasing concern that those who need rehab or long-term care will end up going instead to facilities at least 30 miles away, even if many of those buildings also are restricting admissions, their nursing ranks also decimated by pandemic-era occupancy losses.

Meanwhile, many of the technology options that have helped metro-area nursing homes transform the kind of care they can provide still present hurdles for old buildings in far-off locations. And alternative payment models that have started to pump some much-needed staffing and financial resources into nursing homes in population hubs have in large part left rural nursing home operators out of the mix.

In addition, what staff can be lured to rural locales or from competitors in the same geographic regions — especially the travel or agency nurses needed to plug constant holes — are demanding pay that undercuts facilities’ long-term financial sustainability.

The leader of the nation’s largest nonprofit skilled nursing provider says access to post-acute and long-term care is at a “tipping point” in rural America. While one-time Medicaid rate boosts helped stabilize some facilities in recent months, a single catch-up followed by years of more lackluster policy or funding won’t keep doors open perpetually, Nate Schema, president and CEO of South Dakota-based Good Samaritan Society, told McKnight’s Long-Term Care News.

“All it takes is a few things to change, a few levers to be pulled, and I think that rapidly changes. We’re right on the edge,” said Schema, whose organization does 70% of its work on behalf of rural patients. “You have a finite number of people to pull from for workforce, and you’re serving such small numbers of people, but these are critical community care hubs. … We’re out here serving these communities, and there’s just very little margin for error.”

A ‘death’ march for rural facilities?

The biggest lever of concern for many providers is the federal government’s planned minimum staffing mandate, which virtually no rural nursing homes could meet, according to the Centers for Medicare & Medicaid Services’ own estimates.

That proposed rule, Mark Parkinson, president and CEO of the American Health Care Association, said at a recent event exploring rural healthcare needs, is “literally a death sentence for nursing homes in rural areas.”

Rural nursing homes made up 31% percent of all nursing home closures since 2020, according to AHCA data. That rate peaked in 2022, with 37% of that year’s closures involving rural providers, even though 13.5% of the nation’s roughly 15,000 nursing homes are considered rural, according to the Office of Management and Budget.

In some places, the sheer numbers are astounding. Between 2000 and 2022, Oklahoma lost more than 100 nursing homes, even as its over-60 population exploded by 200,000 people, according to Care Providers Oklahoma.

But closures are occurring in all states with rural settings, making this much more than just a heartland issue. For instance, at least seven Maine nursing homes have closed since 2021, despite facilities there staffing at some of the highest rates in the country.

“Rural Maine is as rural as anywhere you’re going to get in the Midwest or the West,” said Robyn I. Stone, DrPH, senior vice president of research for LeadingAge.

“When you’re in a state where all of the young people have left or just flock to the few magnet cities, then you’ve got a much more significant challenge because you’re left with an over-representation of older adults,” she said. “Sometimes, yes, there’s a nursing home still in the community. But a lot of times they’ve closed and then if somebody needs a nursing home, there’s no alternatives for home care. They have to go very far away to go to a nursing home.  … When these places close, it’s even worse because they don’t have any options.”

Case study in looming closures

It’s a nightmare scenario that Bloomfield Administrator Madison Ternus thinks of often as she performs her 8 a.m. rounds, greeting each resident by name and checking in with her crackerjack staff.

To mark her first year at GSS-Bloomfield,
Ternus was gifted a crushing staffing collapse that required her and her director of nursing to cover nearly every shift to ensure continuity of care. At the time, she feared the facility might have to close its doors, and that fear returned with a vengeance when she learned about the CMS minimum staffing proposal unveiled in September.

“You can’t help but to think about it, and to think about where these people would go,” said Ternus, 22. “Everyone knows everyone here. They’re my family. I see them every single day.”

Fears have turned to reality in many communities already. Strangled by staffing shortages amid lagging Medicaid payments, 15% of Nebraska nursing homes have closed since 2018, said
Kierstin Reed, CEO of LeadingAge Nebraska.

“Our losses here started before the pandemic did, and most of that was due to cost of care and the Medicaid rates not being where they needed to be,” said Reed, noting a drop from 217 facilities to 187, with the majority of closures in the state’s sparsely populated western two-thirds. 

Sixty of the state’s 93 counties have two or fewer nursing homes. Another 18 have none. That includes Cherry County, which boasts a population of about 5,500 spread over 6,000 square miles. It has a lone assisted living facility to care for seniors, according to Reed’s data.

Plenty of other residents may be facing similar conditions but have no idea that their cozy, quiet nursing home may have to shut its doors if it’s filling only 40% to 50% of its beds for months on end. Reed estimates 80% to 90% of her members are limiting admissions due to staffing — self-limiting their occupancy rates and their opportunity to cover their fixed costs in the process.

A place for everyone

GSS-Bloomfield is licensed for 70 patients. After finally hiring late last summer, the facility hit 30 residents — a level not reached for the past three years.

Sometimes, Bloomfield is helped when other facilities suffer the same staffing impossibilities. “Full” buildings in Lynch, an hour away, or Yankton, SD, on the other side of the Missouri River 30 miles to the north, also are operating under capacity, sending a trickle of patients to Ternus and her team.

Back down to 26 patients when McKnight’s visited last fall, Ternus offered an optimistic-but-realistic outlook. The young administrator knows that among the recent Nebraska closures were three buildings operated by Good Sam.

The organization has increased pay, boosted benefits and otherwise tried to make nursing home jobs more attractive. But the same issues dogging Bloomfield are rampant in the sector, and some jobs have remained open not for months, but for years. In October, Ternus was advertising six openings, including daytime and overnight shifts to try to open more beds.

“It’s tough to get people in here, but everyone needs a place to be,” she said, noting that her workers also need an employer, given that there aren’t many in the area.

Staffing needs mount

Non-traditional hires like Candace Carey offer providers hope in a time of deep despair. 

For much of her working life, Carey, 58, had been a caregiver to her own children while juggling jobs ranging from daycare assistant to receptionist. When she moved her mom, Margaret, to Bloomfield, she offered to pick up hours if the facility were in need of a housekeeper. Then she enrolled in classes to become a certified nursing assistant in case an opening became available.

In August, Carey left her job of eight years — monitoring eggs at a nearby chicken farm for nearly $18 an hour — and instead took a pay cut to tend to human beings.

“It’s such a rewarding job, but there are just not enough people out there who want to do it. I don’t know if it’s because of the money or because of the demands [of the job]” Carey told
McKnight’s. “I probably couldn’t work here and support myself, but I’m one of the lucky ones: I have a husband.” 

Nationally, nursing homes were short 148,700 workers in late 2023 and could need to hire an additional 102,000 full-time employees under the proposed staffing rule, the industry estimates. 

Rural skilled nursing providers have been among the most deeply affected by pandemic-era losses, a fact acknowledged by a provision in the mandate that would give them two extra years to hire needed staff.

Providers lament limited labor pool

Parkinson has called staffing “the metric that will matter most” for rural healthcare over the next five to 10 years.

“There are a finite number of nurses and certified nurse aides and occupational therapists … and unfortunately, that number may be declining,” he said.

That’s partly because many rural towns are losing population: From 2010 to 2020, some 970 of the nation’s 1,336 rural counties lost at least 5% of their residents. That rate was triple the previous decade’s shift.

That flight to the suburbs has set up a situation that pits interdependent hospitals and nursing homes against each other when competing for staff. In many rural locations, hospitals also struggle with timely discharges of patients needing post-acute care — at a cost that can average $1,000 a day.

“Not surprisingly, staffing requirements ramp up the issue for rural facilities,” said Alan Morgan, CEO of the National Rural Health Association. “It makes the potential to keep rural nursing homes open extremely problematic, and it makes it even more difficult on the financial end to keep rural hospitals open.”

Mandate realities

The CMS staffing mandate would require $6.8 billion in annual spending, according to an analysis commissioned by AHCA. Federal regulators want all nursing homes to have round-the-clock RN coverage and provide 0.55 hours per patient per day of RN care and 2.45 hours of daily CNA coverage for every patient.

“Given that there are fewer rural LTC facilities and a higher percentage of rural LTC facilities have greater distances between neighboring facilities, if a facility was not able to comply with the staffing requirement, it can have a more pronounced impact on access of care,” CMS acknowledged in its proposal.

The agency estimated that rural providers would be on the hook for an additional $1.27 billion in costs just for the first 10 years of required 24/7 RN coverage. It also said it expects facilities will need more time to comply, and it included a
waiver process that would allow those that can’t find RNs to seek exemptions.

Nationally, the mandate would require more than 80,000 new nurse aides and 22,000 new RNs for nursing homes, according to the
AHCA analysis.

The questions on everyone’s mind are: Where will these new nurses come from and who will pay for salaries that keep ratcheting up as demand increases? For many providers, the only real options are hiring costly temporary or agency staff, or luring them away from hospitals that also need them.

Carey and her co-workers are acutely aware of their administrator’s struggle to balance the revenues coming in against the cost of hiring and retaining staff. It feels like an unfair situation to be in simply because their building has a smaller population to pull from.

“Everything is based on hours and occupancy, but each resident requires a different kind of care,” Carey said. “My mom is pretty independent, but there are some residents where you have to spend 15 to 20 minutes with them, and when there’s only one CNA, and there’s the radio going off and lights going off, you’re only one person. These CNAs, they need help.”

In pursuit of RNs

Nurse aides can train in as little as two weeks. But how these same facilities might amass thousands of better educated RNs in time to comply with a mandate within five years is really anyone’s guess.

An RN degree is typically completed in two or four years of full-time schooling. And nursing schools are turning out fewer RNs, with enrollment starting to slide in 2021 as many faculty retired due to COVID. Even when students do go away to nursing school, few are motivated to move to or return to rural America for work.

Bloomfield Director of Nursing Services Christina Mahoney trained in Iowa and came back to rural Nebraska to be close to family. Without that link, she might not have ended up at Bloomfield. Since becoming the DNS, she has at times been the sole RN, even working every single day last August when agency nurses were unavailable.

Trying to find fellow nurses remains a top priority; she has hounded friends, retired nurses and those who left for other fields to come work
with her. 

According to an internal Good Sam analysis, Bloomfield would need to hire three additional RNs and three CNAs to comply with the mandate. Across the organization, facilities would need to hire 215 additional RNs and 398 additional CNAs.

In Nebraska, providers will have to recruit in the face of major RN shortages. Nine of its 93 counties have zero RNs in any setting, while another three have only one, according to LeadingAge’s Reed. Statewide, 6.3% of RNs work in nursing homes. Those who play key roles are so “overwhelmed” amid the current shortages, Reed said, that statewide tenure for a SNF director of nursing averages only 17 months.

For Mahoney, the stress of having to find those additional nurses or risk fines and potential closure adds to the daily demands already weighing on her.

She’d like to have more RNs in the building, but she also wants her licensed practical nurses to count toward hourly standards — LPNs are conspicuously and completely absent from the initial CMS proposal. Mahoney sees the call for 24/7 RN coverage as overkill in a building like hers, where most patients are long-stay and fairly low-need.

Hot competition for few nurses

Jill Gengler, administrator at Wisconsin’s 50-bed Chippewa Manor Nursing and Rehabilitation, said she feels “really strongly about having our RN in the building for constant assessment and oversight because we’re taking some pretty acute folks.” But even with that philosophy, she’s found she has to settle for an experienced LPN on the night shift.

Gengler previously worked in Colfax, WI, which has a population of about 1,500. But even with a population about 10 times larger in Chippewa Falls, the same problems persist. There simply aren’t enough nurses in the area to cover existing needs.

“We’re not drawing people in from more than a 10- or 15-mile radius, so recruiting can be really difficult,” Gengler confirmed. “There are three hospitals in our community and, of course, their wages and their wage scale, it’s just not something we’re able to come close to.”

She’s also competing with major manufacturing centers that offer higher wages and full-time work split over three days, a flexibility that nursing homes can’t necessarily match. 

But even if pay were the deciding factor for RNs, nursing home providers in rural states (and across the US) say they remain at a distinct disadvantage compared to hospitals with more favorable
reimbursement policies. The Bureau of Labor Statistics reported late last year that the mean hospital RN salary is $90,600, while the same job in a nursing home nets an average of $77,190. 

“Where is the justice there?” Mahoney asked. “Why don’t we get to pay our nurses more? Why don’t we get to pay our aides more?”

Patchwork solutions

Despite their desperate pleas to CMS to abandon the mandate, many organizations are getting creative in their attempts to hire and retain.

Good Sam has developed a nursing council to be more responsive to staff needs as it designs new incentives. The company also relaunched its administrator-in-training program to develop stronger building leaders, who are shown to improve staff retention.

LeadingAge Nebraska last year started an eight-month Nurse Leadership Academy to strengthen the DON workforce through additional education and peer support.

Others are focusing more broadly on getting people into the field, even in the early stage of nurse development. For those individuals, Stone said, wrap-around services like transportation subsidies or childcare can be critical.

Such patchwork programs, though, help only the providers who fund them. Ideally, Stone said, the federal government would make a long-term investment to address worker shortages in identified target areas without a large enough pool of job candidates.

“Can you identify these shortage areas and then figure out either a two- or three-year program for people who are willing to either return there or move there?” she asked. “You’re not going to have people, necessarily, who are going to move back for the rest of their lives, but you could have it for sustained periods as they do with physician shortages and hospital shortages.”

A loan forgiveness program also could be used to entice nurses to nursing homes and rural locations, specifically, Stone said, and so, too, could a Peace Corps-like rotation.

That theory is being tested in Kentucky, where officials have launched a Health Corps program to place 200 part-time workers in 50 healthcare facilities that support seniors and people
with disabilities.

Modeled after AmeriCorp, students volunteer for two years, after which they have more options to enter healthcare or seek higher education. Such exposure to senior care is critical for recruitment, said Mahoney, who hears all the time from candidates who think skilled nursing is a boring job.

“It’s not,” she said. “Every day is a new adventure. I have a lady across the hall who was so routine all the time, and now she’s not. So we have to figure this out. What is going on? Let’s jump in and use our critical thinking and get this done, and I have 12 hours to do it, and I’m taking care of 26 other people. Long-term care is hard-core care.”

Can telehealth deliver?

Proven healthcare technologies could help nurses like Mahoney improve patient care and boost staff confidence, but in many rural areas, one major impediment remains: lack of high-speed internet. 

For years, Administrator Kyle Smith thought about expanding the use of telehealth at his 125-bed nursing home in Decatur County, TN. Available services could help the facility, about 100 miles west of Nashville, link up with outside clinicians in case a patient’s condition changed unexpectedly, he said.

Otherwise, waiting for an ambulance and delivering a vulnerable patient to the closest emergency room in the rural area might be a 45-minute ordeal.

American Health Communities, owner of AHC Decatur County and 28 other facilities in Tennessee and northern Alabama, had tried to do its part. It had increased investments in technology, particularly since starting
partnerships that integrated a mix of on-site and remotely connected advanced practice clinicians
and specialists.

Yet it wasn’t until the pandemic that the state of Tennessee made a critical public investment that turned out to be a significant one for Decatur, too. The facility was one of the first to benefit from a nearly $450 million program to bring broadband access to more than 150,000 unserved rural homes and businesses.

Operators believe such access could be a real difference-maker for rural nursing homes disadvantaged by low occupancy, Medicaid underfunding and a labor crisis that has left staff desperate for tools that improve their workflows. How quickly technology resources get to facilities like rural Decatur will help determine whether they falter or flourish against increasingly tough odds.

“We’re now utilizing [technology] more and our nurses are able to put real-time data into the hands of specialists, like the wound care specialist, or able to, conversely, get real-time information on how to provide care specifically to that patient. We’re not waiting around for multiple days,” Smith said. “We’ve seen firsthand how that’s improved patient care.”

Future resource uncertainty

Still, questions remain about how much providers will be able to rely on telehealth, remote monitoring and other technologies to come in the years ahead — and whether the government will make the needed legal, regulatory and reimbursement changes needed to
sustain services.

Much of the telehealth available today in nursing homes has been conducted under waivers issued during the pandemic and extended by Congress through the end of 2024.

“All these things are not permanent yet, and that means there is always going to be a little bit of hesitancy about the degree of expansion and investment in these programs, given the cloud that hangs over it,” said Kyle Zebley, senior vice president for public policy at the American Telemedicine Association. 

“While Congress is very supportive on a bipartisan basis of virtual care and telehealth, the dysfunctionality of Congress and the ease with which action can be stymied are kind of our biggest barriers as it stands right now.”

Basic access still impeded

Smith’s facility is covered 24/7 by a nurse practitioner group provided by American Health Communities. The company also has pushed out more tech tools through a COVID-era grant-
writing campaign. 

Sonya Pusser, assistant vice president of clinical operations for the chain, described an evolution from using tablets specific for virtual visits during the pandemic to the purchase of telehealth carts stocked with vitals-monitoring tools to support virtual visits in
patient rooms. 

Those tools were outmoded quickly, however, by access provided through handheld devices. Costs associated with constantly changing or updating tech tools can dampen enthusiasm and usefulness. A 2023 study found that, nationwide, 28% of nursing homes failed to scale up, spread or sustain technology they adopted between 2019 and 2021.

AHC has turned its focus to converting to a more robust EHR system that will provide deeper patient insights and interoperability. Pusser said investments in training and building a culture that appreciates and embeds telehealth services will be a critical part of creating sustainable solutions. Streamlining approaches as much as possible for busy frontline staff makes them more comfortable and willing to turn to the added resources, she added.

Left ‘shaking their heads’

But even for providers able to invest in devices, services and training, internet quality still too often limits potential reach. More than 22% of Americans in rural areas lack quality, high-speed internet coverage, compared to only 1.5% of Americans in urban areas, the Federal Communications Commission found in 2020.

In 2018, the federal government launched a multi-year project to pump hundreds of millions of dollars into rural telecommunications infrastructure to support residents and businesses, including healthcare settings. The program was renewed twice during the pandemic, providing loans and grants to states and community organizations to build better networks in areas with populations under 20,000.

Should federal and state initiatives pay off with major connectivity improvements, proponents of telehealth believe it could be a game-changer for preserving long-term care access. But the government needs to make devices and services affordable, they said.

“Even if we get all of that [broadband] investment out the door as quickly as possible, there are still going to be some inhibitors. There will still be some communities that haven’t closed the gap,” Zebley said. “Many of our facilities will still not have the needed investment to make sure they are deploying the right kind of devices that will allow for the full, robust ability to access telehealth modalities that are now available and will continue to expand and in future.”

Zebley predicts telemedicine of the future will lean heavily on tools that support continual monitoring of patient vitals to prompt needed care through communication with frontline staff. Those routine checks can help ease overworked aides in short-staffed buildings.

“Telehealth won’t create new healthcare workers, but it can right-size the need with the supply,” he said. 

Staffing mandate alternative sought

One allowance several rural providers are seeking is the use of remote consultation by off-site registered nurses or other advanced clinicians to comply with the proposed federal staffing mandate that calls for 24/7 RN coverage. For facilities that can’t hire RNs because of local unavailability, such a solution could bring additional oversight and assistance to an in-building licensed practical nurse, as needed.

Gengler said she sees the remote RN solution as appropriate for rural nursing homes whose patient populations are relatively low-need. But she worries that some solutions have and will continue to be stymied by regulatory rigidity.

“There are already ways we can monitor folks electronically with surveillance tools. If they’re engaging in a risky behavior, we can intervene sooner,” she said. “But regulations are going to have to be a lot more nimble. 

“They’re so restrictive right now that it’s hard to be responsive to a new environment of technology and ideas when the [surveyors’] expectations are so set in stone. We really have to see some more innovation by the regulators to be able to explore those options.”

‘Crying wolf’ or dying breed? 

New technology policy isn’t the only change providers say they need. Many of the financial and operating strategies meant to prop up the sector have often left the most isolated, resource-strapped facilities with nothing gained.

Several new federal payment models and insurance programs are designed to allow skilled nursing providers to take on financial risk, tap into new revenue streams or access additional staffing and clinical resources.

But they have largely failed to take into account the unique conditions of rural facilities.

Rurals have fewer patients to attract needed payers and create needed critical mass for some new programs, for example. 

Additionally, they have a lower share of Medicare patients, whose care is paid for at a higher rate. A staggering lack of physicians and clinicians needed to care for more medically complex patients also plagues isolated facilities.

With Medicaid penetrations of 90% to 100%, there is little room for “extra” spending on staff recruitment, technology or additional clinical staff that could help them expand care and land more referrals for patients whose care is reimbursed at a higher rate.

A 2023 federal report found that state Medicaid programs covered as little as 62% of a nursing home’s per-patient costs, and 81% of nursing homes nationwide reported they were underpaid for the Medicaid care they delivered.

Advocates argue that lack of fair funding creates a vicious cycle. But there have been few initiatives that either boost payments to rural nursing homes or support their goal of caring for a broader range of patients.

Meanwhile, accountable care organizations and specialized Medicare Advantage plans — seen as a potential financial lifeline by some in the sector — aren’t necessarily set up to attract plans into underserved and underresourced communities.

“Value-based programs are certainly the wave of the future for population centers,” acknowledged Good Sam’s Schema. “The value isn’t the same in those communities when you’re serving a Medicaid population of at least 50 or 60%. Low-volume locations are inherently at
a disadvantage.”

Lack of rural clinicians

For Mark McKenzie, CEO and founder of Focused Post-Acute Care, a lack of physicians and advanced practice clinicians to care for patients at his 26 Texas facilities is the most pressing issue. If the government would pay more for them to drive to and treat patients at his mostly rural facilities, he could work with hospitals to capture more of the locals being sent miles away from home for skilled care.

Nationally, the only physician add-on available, however, is for doctors associated with rural clinics, or those willing to create a clinic of their own.

“No physician’s going to do that for one patient. Delivery of healthcare and being reimbursed for healthcare as a provider should not be that difficult … but we make it difficult in our processes,” said McKenzie, who has for years lobbied lawmakers on the idea of a critical access label or “safety net” designation that sends more financial resources to rural nursing homes at risk of closure.

Those efforts, though, have gained no traction. In the meantime, McKenzie last year gave up five facilities he’d been operating to ensure that his company survives. He said he’s been part of several organizations that viewed their rural facilities as “loss leaders,” operating with little to no margin simply to fulfill a mission in a given community.

 But with post-COVID inflation, that strategy has become too costly and threatens organizational livelihood. Good Sam, the nation’s largest nonprofit skilled nursing provider, last year announced it would scale back its operations to seven core states.

“I don’t think lawmakers understand rural healthcare in general, and I think when they hear us [skilled nursing operators] talk about the magnitude of the problem, they assume that we are crying wolf,” McKenzie told McKnight’s

“The lawmakers want to know, if it was so difficult and dire and you were on death’s doorstep five years ago, how have you managed to make it today? I’ve been asked that same question, and at least two times, my answer was, ‘Well, the other three nursing homes in town closed, and I gathered all their employees and all of their
remaining residents.’” 

‘Paradigm’ shift needed

For CMS, much of the focus of the last decade-plus has been on moving patients into value-based care arrangements. The models align pay with performance, but they’ve mostly been designed so that insurers flock to markets with a high number of Medicare beneficiaries to spread out risk and improve their chances of earning profits.

Nursing homes have been largely left out of those models, including, until recently, accountable care organizations that are typically focused on primary care. In an ACO, providers that meet performance goals and help save the Medicare program money bank a share of those savings.

“As we see ACOs and this new long-term care ACO model starting to pick up, and Institutional-Special Needs Plans, we haven’t seen as much development in rural markets,” said Fred Bentley, managing director of ATI’s post-acute/long-term care and senior living practice. “So much of the I-SNP and ACO development is really driven by specialized health plans who are the ones going out and knocking on doors, and building up networks and building partnerships with these facilities. They’re driving this.”

ATI is working with a group of rural facilities to create a larger consortium that could better position the members to land value-based care contracts, but Bentley knows they might have to turn the tables and go knocking on the plans’ doors themselves. Insurers looking to grow in an increasingly competitive value-based care market, he said, recognize that they need lives just about anywhere they can get them.

And the National Association of ACOs seems ready to move. It acknowledges that too few rural settings are involved and in January asked CMS to refine how it provides incentives and rewards in rural markets for alternative payment models.

Special Needs Plans grow

Some rural skilled nursing providers are making a run at risk-taking with I-SNPs offering special coverage and benefits targeting long-term residents of nursing homes.

Tennessee-based American Health Partners has made it a core mission to target rural areas with its plans, which started in the facilities run by its sister company, American Health Communities. Today, it has about 7,000 beneficiaries in I-SNPs across 12 states with 35 joint venture partners — most of them in rural areas.

“Population health models are just much more difficult when it’s a disparate population in terms of being able to get them clinical resources,” said Hank Watson, American Health’s chief
development officer.

“The nursing home population, they’re all in one place and we can really have a meaningful impact. Because of that, you can make investments in clinical programming even if the nursing home is only caring for 40, 50, 60, 70 folks at a time,” said Watson.“We were providing care to these folks 24/7 in rural settings already, and so the incentive just allows us to invest more heavily in that clinical model.”

In other words, the I-SNP can get around some of the volume problems other alternative payment models bring with them to rural markets.

Still, plans have to very carefully figure out how to map travel times and allot resources, says Bridget Grover, vice president of TruHealth. The company places nurse practitioners in American Health Plan-affiliated communities, and increasingly it’s being called on to float CNAs between the locations it supports. Those extra resources can amount to improvements in patient outcomes and quality of life. And the facilities are able to earn a critical incentive when they prevent rehospitalizations.

“A big part of this is linking that clinical model to a financial model that pays the facility for the outcomes that they’re driving,” Watson added. “It’s a real key.”