When Virtua Health has a COPD patient ready to leave one of its New Jersey hospitals but not yet ready for home, discharge planners are able to tap into a growing network of rehabilitation specialists.

Those specialty providers happen to be skilled nursing facilities with dedicated pulmonary units featuring onsite, board-certified pulmonologists; staff respiratory therapists; access to lab and radiology services; and seven-day-a-week therapy.

They include places like Laurel Brook Rehabilitation and Healthcare Center, managed by Marquis Health Consulting Services, one of many providers nationwide using specialization to maintain or grow local post-acute market share.

While specialty programs have a long history in skilled nursing, the latest iterations depend largely on bringing advanced practice clinicians and hospital staff into buildings and implementing technology that drives outcomes — while making results easily reportable. Those strategies are key differentiators as providers look to secure hospital referrals and stay in network with insurers, especially crucial as COVID-19 continues to riddle the U.S.

The pandemic accelerated the push of somewhat healthy patients toward home, leaving the sickest of the sick for skilled nursing. Against that backdrop, delivering high-quality care for high-needs patients might be one way to limit acute care’s reliance on alternatives such as hospital-at-home.

“You’ll continue to see more and more of this,” says Jennifer Hertzog, vice president of marketing and business develop- ment for Marquis. “COVID was reinforcement that specialized programming, enhanced acuity-management partnerships and collaborations via this specialized programming work.” 

The rise of accountable care organizations and the steadily increasing prevalence of managed care are also creating opportunities for skilled care providers, especially those who can demonstrate prowess with cardiac, pulmonary, renal failure, sepsis and neurologically impaired patients. 

Health systems and insurers are “going to have to start looking at these specialty providers not just as another vendor, but as partners,” says Justin Border, OTR/L, who helps facilitate SNF-hospital partnerships as founder and president of Titan Healthcare Solutions. “They are helping them achieve operational outcomes that they never really give them credit for.”

Andrea Rizik is vice president of clinical integration and clinical operations for Integrated Care Solutions and formerly worked with nursing home operator National Health Care Associates. NHCA launched clinical pathways during the early days of value-based care. Those models led to a Passport Program covering more than a dozen conditions, and Integrated Care now uses similar models to help skilled nursing clients build out specialties of their own.

“Preferred networks (need) to make sure patients are appropriately referred to skilled nursing facilities that can manage their care,” Rizik says. “If a patient has CHF, for example, they should be going to a facility that can push Lasix. … We also look at the complement of coverage. Do they have mid-level provider coverage gaps? If a patient starts to have health concerns at 7 p.m. on Friday, do they have somebody who can start IV hydration?”

Choosing a specialty

Today’s providers are tackling a wide range of specialties.

In Vermont, Berlin Health and Rehab reported a 75% reduction in facility-acquired pressure ulcers after adding weekly rounds with a board certified wound ARPN and extra coverage from a third-party wound care specialist. The facility also is part of the Sepsis Alliance, which provides additional training and certifications to help improve detection and trigger earlier treatment of infection.

Those factors, the site’s managers said, contributed to a 41% drop in hospital readmissions over the last year.

Symphony Care Network this summer announced its new Serenata Geropsychiatric Care program to address behavioral concerns related to dementia or other neurological issues in seniors. It will include a multidisciplinary team of geriatric psychiatrists, social workers, therapists and nurses; provide additional neuropsychological cognitive assessments and screenings; and train staff in crisis prevention and de-escalation strategies.

Building out a program can be a lengthy process that includes collaboration with local health systems; data sharing; goal setting; best practices that span settings; and investments in personnel, equipment and physical plant. One thing it shouldn’t include: any kind of guesswork as to what the market will support. 

“With skilled nursing facilities, you’ll now see them reaching out, saying, ‘I feel like we have all this clinical capability but yet our census still hovers around 60 or 70%, and I feel like there’s so much more we can do,’ ” Border says.

He suggests facilities start by assessing what they’re doing, what they can provide and what they can further develop. It isn’t just consideration of personnel, but physical requirements, too. Renal programs may need dedicated space for bedside dialysis, as well as the capacity to handle biowaste. Respiratory units will require supplemental oxygen delivery, either pumped through in-wall piping or through concentrators.

“The worst thing you can do is say you want to go gung-ho, full-on specialty service but not be prepared to provide it,” Border says. “The payer sources and the referral sources tend to have long memories. When they think you weren’t as prepared as you maybe you presented yourself to be, it’s a long time before you’ll get another chance.”

Tech and teamwork

Understanding what partners truly need starts with opening a dialog with a hospital’s service line leaders before any additional investments are made, Hertzog says.

“Then our first step is to recruit and align specialists,” she says. “We look for a partner that is aligned with our primary hospitals and the goals that we have overall. But it’s speciality programming that is more than just a specialist at the bedside.”

Each building’s team reviews monthly metrics including length of stay and readmissions; clinical outcomes; and how well patients move through the continuum of care. To that end, management is implementing technology that can help smooth care transitions and put patients, as well as provider partners, at ease.

One recent investment is in HillRom’s Life2000, a one-pound, portable ventilator for patients who prefer to be mobile. They can begin using it in the skilled nursing facility, then program coordinators ensure similar durable medical equipment is delivered to home.

Marquis has a readmission rate of 8% for patients in their cardiopulmonary program, which helps attract more resources. In some locations, service line hospital staff come to the SNFs to further educate staff “because they see value in the outcomes we’ve been able to produce collaboratively,” Hertzog says.

Letting the heart guide

At Connecticut-based iCare Health Network, dedicated specialty programs grew out of a longstanding focus on complex patients, ranging from those with substance use disorders to those in need of memory or HIV care. A congestive heart failure program was a logical extension of the organization’s model blending social support with advanced nursing services, such as medication-assisted therapy.

When several local hospitals were having a hard time placing residents who needed inotropic drips, iCare built a program to accommodate them, according to David Skoczulek, vice president of business development.

More recently, the organization added pulmonary specialists to round in the same four buildings, each operating as a Touchpoints Rehab facility. ACOs have made service requests on top, including the latest addition in June.

“It sort of layered on itself until (the Touchpoints buildings) became really specialized,” Skoczulek says. “Once we built the program, the rest of it continued to follow.”

Two corporate LPNs and a registered nurse director track CHF patients and others who need a readmission prevention protocol. They work with APRNs, cardiologists and discharge planners to coordinate, which has led to several quarters without hospital readmissions, Skoczulek says. Transitional care nurses also work with patients who need advanced therapies, such as the inotropic drip milrinone.

“We obviously want all these patients to follow a very specific clinical pathway, and we do that by trying to be the experts on it,” says Skoczulek, noting that includes guiding patients into home care arrangements known to successfully handle infusion or other advanced treatments. 

The logistics planning and investments iCare has put into its specialty programs are now coming full circle: Hospitals “frequently identify iCare as the ones that will create a program from scratch to meet their needs,” Skoczulek says.

“The level of integration just continues to build, and we love that,” he adds. “We don’t find that the networks feel like they’re being squeezed out of centers. That really is the future.”