Even as his organization has become a hub for a swath of aging services, The New Jewish Home CEO Jeffrey Farber, MD, says certain elements of senior care need to be singled out to allow for more innovative — and better funded — models.
For too long, residents who need vastly different types of care have been lumped together in the same facilities, with payment for one group often offsetting the costs of caring for another, Farber said in a wide-ranging interview with McKnight’s Long-Term Care News Thursday.
At the Manhattan-based The New Jewish Home — a health system serving 4,000 seniors daily through affordable housing, outpatient programs, senior living and skilled nursing services — there’s an effort to begin delivering care in more segmented arrangements. The hope is that the system will be able to drive patients and residents to the right settings with the specific services they need.
Farber sees a future where mostly Medicaid-supported long-term care patients and post-acute care patients are treated in different places, by different staff with different levels of training and in physical spaces that reflect their varying acuity levels.
Last year, his organization began working with the Green House Project to develop an eight-floor post-acute care center using the small house model for short-term residents only. Once built, after careful planning and a multi-year fundraising drive is complete, It will be the first of its kind.
While some operators are already targeting the higher acuity Medicare model because it’s easier to turn a profit, Farber is interested in collecting evidence needed to convince policymakers that major reform is needed. That could lead to a national effort to address how two classes of nursing home residents (plus homeless patients with disabilities who are often kept in SNFs because they have no other options) are treated from a policy and payment standpoint.
“The truth is that the nursing homes are providing services to really markedly different types of people. People don’t understand that I think when you think about the nursing homes of today,” Farber said. “The incentives and our disconnected health system, which isn’t really a system but a patchwork of different Band-Aids, have been refined over many years. Of course, it doesn’t make sense. Of course it doesn’t work for the majority of Americans.”
Providers, Farber said, have “no other choice” but to begin strengthening the post-acute and long-term care systems from within, while they wait for government leaders to recognize and begin to address the larger problems of care silos.
“We have to innovate and we have to do things differently than what we’ve been doing because what we’re doing just simply doesn’t work,” Farber said.
“We’re faced with an opportunity to do so much better for a growing segment of our population. The fundamental underlying challenge is this overarching societal ageism that relates to the underpayments, that relates to the poor perception of the field, socially and within the medical health system, to our status and rankings.”
Get well, go home
The New Jewish Home already specializes in short-term rehab or skilled sub-acute care, which Farber refers to as the “get well, go home” crowd. They’re older residents who’ve had an unanticipated surgery or exacerbation of a chronic condition, have gotten better in the hospital but still need highly skilled and supportive care to regain function.
“We do a lot of that, probably more than most,” Farber said. “But there’s no really good reason it should be happening in a place called the nursing home. They don’t have the same goals as [long-term care patients.]”
But for now, nursing homes largely take both sets of patients. That division of resources, Farber said, is stopping innovation “because we’re trying to plug the gap” on massive and chronic Medicaid underfunding, by as much as 30% in New York.
“That’s why I think we’ve got to separate these things down the road,” he added.
To that end, Farber is expanding on an adaptation of a small-house model already being used on its Westchester campus, where 50 of 300 beds were converted into semi-private rooms split into neighborhoods.
Nationally, Green House residents are typically long-term care patients, often with cognitive or other specialized needs. They benefit from private bedrooms, share common spaces with a neighborhood of fellow residents and have consistent staff who take care of their daily needs.
But the model can be prohibitively expensive; it’s often found in rural communities where land is inexpensive.
That’s one reason Farber wants to explore the model’s ability to meet the demands of the short-stay post-acute patient, for which reimbursement will better support private rooms and higher staffing.
Meanwhile, he envisions a new label, possible Compassionate Care Homes, to those patients who need lighter, but longer-term care.
That division would allow for a better concentration of public resources for people who have the opportunity to regain quality of life and return home.
Strengthening the medical model
A key to that model is pouring medical resources into the post-acute setting.
The concept builds on The New Jewish Home’s long commitment to creating a deep and broad care network for its seniors.
Founded in 1870, it was New York’s first long-term care provider and has often led the way on changing the standard of care. Officials with the nonprofit organization said it was the first nursing home to employ a social worker and full-time doctor, starting in 1938; the first with an accredited department of rehabilitation, in 1956, and the first to have a teaching system to train geriatric professionals, in 1985.
Farber has trained many of the system’s current geriatricians as a professor at Mount Sinai.
He believes the role of a full-time physician provider, rather than an on-call or rounding doctor, is a critical one for modern nursing homes. And he believes 24-hour registered nurse requirements proposed by federal regulators “make sense” given the needs of many of his patients.
The Green House facility, he said, will have essentially all the equipment needed to qualify it as a long-term care hospital, if that need arises in the future. The goal, Farber added, is to avoid sending patients out to the hospital, where they can get lost in the system.
It was a lesson learned before COVID but reinforced during the pandemic. The system kept 92% of its COVID patients in-house and was able to support recovery without acute-care assistance.
“If you build the infrastructure and you adapt your model, like we’ve done already with our full-time physicians, full-time nurse practitioners, full-time staff speech and swallowing department … you can deliver care here. You can have urgent care, you can have observation medicine delivered,” Farber said. “There’s a lot you can provide if you’ve got full-time onsite doctors and capabilities in a short term setting.”