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 Providers Choose their own Technology Paths

Gauging present needs while mapping out future goals can set companies on course.

 

Technology is for many long term and post-acute care (LT/PAC) providers a driving force to improve quality, realize new efficiencies, and keep pace with the mandatory changes in how health care works. It also acts as an increasingly vital strategy to attract residents and to build a stable workforce.
 
Skilled nursing and assisted living operators tell Provider that while technology has been an influence for some time, the present and near term offer providers more critical choices than ever before. With the influx of new software for electronic health records (EHRs), case management, and administrative tools, there is ample opportunity for operators to build new systems for meeting financial and quality goals.
 
Is keeping up with this rapid change easy to do? Not by a long shot, sources say. Tight margins, limited capital resources, and intense competition in a consolidating business are roadblocks, especially for smaller providers.
 
Still, the stakeholders interviewed for this article say the stakes are high, and both large and small providers need to take action to at least be in step with the technology shifts, or eventually they will not have a business to run.
 
What follows is a snapshot covering how various tools are being used by providers to grow facility-based care, with quality and efficiency as top priorities.

Provider Sees Promise Ahead

Phil Fogg, Jr.Phil Fogg Jr., president and chief executive officer of Marquis Companies, Milwaukie, Ore., says he has reimbursement margins in mind when it comes to technology, as well as what his company needs and what it may want in terms of new tools for doing business. With margins on the decline, he says, it is imperative for a provider to consider what is a must-do technology and if it is not, how a new technology may fit within the company’s strategy.

“Some technology is now mandatory because there is a new way of doing what were traditionally manual things that are now going to become electronic,” he says. “For example, electronic medical records [EMRs]. They used to be paper, and now they are electronic. And if you don’t make the adjustment, you will no longer be able to be an effective partner along the care continuum.”

How to Evaluate Technology

Beyond the immediate needs of an EMR or EHR system, Fogg says he evaluates other technologies deliberatively to determine whether the goods or services being offered will actually create efficiencies.

“Cost savings may justify the investment in the technology,” he says. However, there are many technologies promising improved workflows or streamlined operations, but often they just don’t deliver. “All you are doing in those cases is creating a whole new cool little thing,” Fogg says.

Another part of the evaluative process for Marquis asks the question, can the technology enhance the customer experience? A recent example is an app Fogg says he is considering that works like Facebook for the LT/PAC environment, enabling family and friends in a resident’s inner circle to visually interact with one another.

“That is an example of something we measure on how it is going to enhance the consumer experience or help us get better patient care,” he says. “Pay-for-performance outcomes like hospital readmissions or quality measures are something that could justify a new technology as well.”

Fogg finds that providers that don’t go through a disciplined process to filter out what they want to do and when they want to do it suffer when it comes to planning around new technology.

Beyond these considerations is the practical matter of time. Fogg says this is the final piece of the decision-making process on whether to proceed with a technology change. “Can they even add one more thing into their day in trying to get it done right?” he asks.

Bridging the Interoperability Gap

Lynne Katzmann, president of Juniper Communities, says two things come to mind when technology is mentioned: interoperability and the corresponding ability to connect health records to providers along the care continuum. Her company offers care across the LT/PAC spectrum, operating 22 buildings in Colorado, Florida, New Jersey, and Pennsylvania with 1,650 beds and employing 1,800 people.

Juniper, she says, is adept at keeping pace and even ahead of technology trends. To date the company and its facilities work on an electronic operating system, covering quality, finance, care management, and risk management, and they are always striving to fit new technology into their business model and core mission.

Katzmann says the goal is to take the results of the technology, like clinical data, and open new avenues for growth, which is what the provider is doing currently in weighing new strategies for a push into managed care as both a provider partner and as a risk-taking insurer.

“Our goals for technology are broader; this is one opportunity. We use technology and the data it enables us to collect and analyze to drive our operations and inform management decisions,” she says.

But even with Juniper’s attention to technology, the interoperability problem remains. “Most EHRs are specific, as is ours, to their communities. The EHRs don’t allow you to easily integrate with other providers,” Katzmann says.

“After the Affordable Care Act was implemented in 2012, there was a lot of talk about something called care transitions, which really acknowledged that readmissions—and providers not talking to each other and not having a platform for sharing data—was a huge issue,” she says. “And so there was a bigger effort to move in that direction.”

Interoperability Elusive

That effort, however, has yet to bear much fruit in that sharing across the health care system is not really happening, Katzmann says.

“Having data of all varieties available from your own operations is akin to having a data aggregation pool,” she says.

However, “it is interoperability that brings together information from different sources, it normalizes that data, it arrays data so data can be analyzed and applied. From there you can ascertain algorithms and produce certain information in different ways to affect quality and care management, for example.”

But, even now in 2018, the general state of interoperability is bogged down for a number of reasons. One is the lack of interest by some vendors in giving up their share of the market, Katzmann says.

What could help move the ball down field is a government set of standards under the Fast Health Interoperability Resource Standard program, which is a draft proposal describing data formats and elements and an application programming interface for exchanging electronic health records. All players would utilize this open source platform, allowing for the honest flow of data. Even that effort is not moving fast enough and may be truncated by the lack of truly open information exchanges, Katzmann says.

“To be truly interoperable, you have to allow data to live in the public domain. It needs to be accessible and not held hostage,” she says.

For the short term, she expects providers to build data integration platforms for tapping into other population health resources with their vendor partners. This includes data on behavioral health, Medicare claims, and genetic information. Once the data are pulled together from outside sources, they can be matched with data from a provider’s EHR into a platform. Katzmann says the purpose of all of this effort is to be able to manage residents’ health.
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Making Technology Pay

So, does a provider stand on the sidelines until the interoperability revolution actually occurs?
Katzmann says no. In the case of Juniper, management realized early on that much of the talk about care transitions dovetailed into the way the company was already operating, so they used that understanding to build up their intra-company capabilities.

“We already did [successful transitions] through care plans, care conferences, consistent assignments, and through the use of the nationally recognized INTERACT program many years ago,” she says. INTERACT stands for Interventions to Reduce Acute Care Transfers.

And with data at its fingertips, Juniper can print out a medication administration record for appropriate sharing with a hospital or another provider with a click of a button or two.

“So, since 2013 we’ve been doing that, and after 2013 we started to persuade people who provided ancillary services in our communities to utilize our digital platform so that we could integrate within our community,” Katzmann says.

The company has also added a primary care practice to the group of ancillary service providers that serve residents and enter data in Juniper’s electronic platform, joining pharmacy, labs, home care, and hospice segments to coordinate clinical data on residents.

“We have onsite primary care, and we have integrated all of those through a common digital platform and common communication protocols. We’ve called the program, Connect for Life,” she says.

The results? Connect for Life has helped cut readmissions by 80 percent and hospitalizations by 50 percent, Katzmann says.

“If a program like this was utilized for all Medicare beneficiaries with a similar profile as our Juniper assisted living residents, we would save the government between $10 billion and $15 billion a year,” she says.

The Next Step

Juniper’s use of technology as a way to increase referrals and improve length of stay by fostering and saving money for payers is leading to the company’s next big move. “We are looking at it as a managed care vehicle, so that is our next step. This would be a combination of dealing with existing managed care organizations or starting our own,” Katzmann says.

Juniper will probably work with established insurers in some markets, and in others, they may venture out on their own or with another provider.

“Seniors housing provides service-enriched housing,” she says. “The people who utilize most of the Medicare dollars are the 5 percent of the population who use 50 percent of the resources,” she says, citing government data.

“And who are those people? They are the people with functional limitations and typically two to four or
more ADLs [activities of daily living]. And these are the people who live with us.”

Thus, the thinking goes, if Juniper can manage people in assisted living better than the competition, it can save money for an insurance company, which would allow it to share in the profits, too.

“It makes you a very attractive referral source as well,” Katzmann says.

Boosting Smaller Providers

For Steven Chies, president of North Cities Health Care, New Brighton, Minn., technology is a priority since he is chair of the American Health Care Association’s (AHCA’s) Clinical & Performance Data Management Technology Committee, which is focused on how the organization can provide the best possible information to smaller operators who may be struggling to keep pace.

Steven ChiesChies’ family operates two skilled nursing facilities (SNFs) and one assisted living community, so he knows the ropes when it comes to being a smaller provider. He is no longer active in the day-to-day operation of the business, with his main focus now on directing an online program offering long term care administration classes for St. Joseph’s College in Maine.

Through his experience, Chies knows how important it is to give smaller operators information that the larger providers have staff to handle through a chief information officer.

“The dichotomy within AHCA’s membership is we have highly sophisticated users, a middle group of users doing the best with what they have, and a third group struggling to find the manpower and resources to operate,” he says.

The Interoperability Failure

Like Katzmann, Chies says interoperability among all providers in the care continuum is a focal point. “That is the holy grail of health information technology right now, and it is not just us, but everybody in the health care world is struggling with this. There are a lot of proprietary systems out there, and there is no universal standard,” he says.

While people can go anywhere in the world and take money out of an ATM, there is no way to access a health information record in any easy manner, he says.

“We have basically observed that information transfer is probably going to end up being a very localized decision based on what other providers in that market are doing,” he says.

Chies uses his state of Minnesota and neighboring North Dakota as an example. North Dakota spent a lot of money to put everybody on the same health information exchange platform, Chies says, while
Minnesota tried a statewide platform several times, but failed.

“This is because the program wanted to charge people on a flat-fee basis plus utilization fees, and the large hospitals decided that they were not going to do that,” he says. Instead, hospitals are allowing people to access health records on a read-only basis.

While Chies calls it “great” to be able to look at info, that read-only mode still prevents a SNF from creating a record in advance of the patient walking in the door and allowing the provider to prepare medications and get the right medical protocol, or care planning process, in place.

“Without being able to populate the record on the skilled side, the ability to read a record is not much better than a paper-based record,” he says.

Time Saved as Paper Disappears

Interoperability remains the goal, but even without it, Chies says, EHRs have spurred much process and productivity improvement across the LT/PAC sector.

For example, nurses no longer have to initial every box for scores of patients when ordering medication. That process can be done much faster with the use of an electronic medical administration record and a barcode, which allows a nurse to electronically sign the necessary document for processing.

One issue that has challenged the makers of EHR systems is a medical knowledge gap, Chies says, but even that is changing for the better.

“EHRs are often designed by programmers who don’t understand what a nurse or doctor or pharmacist does on a day-to-day basis. The best health records out there are the ones in which the users have had substantial input on the programming and how they are functioning,” he says.

This input can aid in how seemingly basic concepts work better. Simple things like drop-down menus are a great time saver for the user but often don’t cover all patient conditions. If the conditions are not there, then text has to be entered, which eliminates the time saved. So having more conditions to click versus conversations with clinicians can speed up this function, Chies says.
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Costs Often Get Repaid

When the subject of technology arises, one of the first words out of anyone’s mouth pertain to the cost of making a move to something new. Chies says that of course what something costs to implement is always a major factor. But, when looking at up-front expenses, it is important to stretch the definition of cost to include savings that will likely occur as time passes.

“If the systems are designed properly and the workflow is arranged around an EHR, not only can you save time, money, and energy, but you can improve outcomes, which pays off in many ways,” he says.

When Chies worked for Benedictine Health System, the provider deployed a kiosk that allowed nurse assistants to input information directly into the health record, which improved the Minimum Data Set (MDS) scores of individuals in a case-mix system.

The case-mix systems used for Minnesota Medicaid and most other systems, including the Medicare Resource Utilization Groups, start with an assessment of the activities of daily living, he says. “If the performance of the individual patient is not captured to accurately reflect their condition, it does not get into the MDS and thus is not recognized for payment,” Chies says.

Giving staff direct access to the assessment input allows for the collection of data on a 24/7 basis, including weekends and holidays. The broader the array of information inputting, the better the opportunity to capture the full and complete needs of the patient in the health record, he says.

“For one building, if you assume the average case-mix is operating at 1, this building was operating at .95, which obviously is less than 1. But after 18 months with the kiosk they were able to document and raise their case-mix score to a 1.10. And for that facility, that was a more than $100,000 swing in revenue for doing this improvement to documentation, without any increase in care needs,” Chies says.

Brookdale Builds on the Fundamentals

Brookdale Senior Living’s technology initiative starts with the basics, like making sure the infrastructure is in place to have high-speed Internet everywhere in its buildings, according to Andrew Smith, senior director of innovation and growth strategy for Brookdale, which operates around 1,000 communities across the nation.

Andrew Smith“When it comes to fancy gadgets, we are still in the experimental stage to gauge which ones are really going to make a difference for our residents,” he says.

“The high-priority items in the area of technology are making sure we get the basics right in connecting our existing digital systems so that we have better information about our residents and their families and are able to better communicate with them.”

Smith says getting these all-important groups access to education about some of the core technologies that they can use to enhance their lives is also an immediate goal. “An example of that is we have iPads in every community, plus we have iPad education classes for residents, and we are teaching them about how to use it, and we recommend various apps,” he says.

There is talk in the profession about how the change in demographics to the baby boomer generation
aging into community care may shift demand for more technology.

But for Smith, that’s not the case right now. “I think we are not yet seeing that demand from the resident perspective; certainly, it has grown over the last five years but it has not yet started to have every resident coming in with a smart device and requesting electronic bill pay,” he says.

Family, Staff Needs Matter

There is, however, a marked increase for the latest technology from family members of residents expecting easier access to information and from Brookdale staff who are trained in nursing school, for example, on high-tech devices.

The families, Smith says, are accustomed to getting answers quickly, and this often comes from residents’
family members who are from the baby boom age cohort.

Technology is even more of an important aspect of life in a community for staff, though, he says. “We are competing for talent against other industries that have digital schedules and digital collaboration tools for their employees and on and on, and so we really have to improve the employee focus on digital tools,” he says.

Engagement a Winning Strategy

While it may take some time to see if many technology upgrades pay off in terms of efficiencies or in quality results, Brookdale sees one technology to explore more deeply in the area of customer engagement. This area covers items like two-way communication with a family or resident and the ability to pay a bill online or submit maintenance requests.

“Seniors housing is such a combination of hospitality and health care, and too often we get stuck on the health care side,” Smith says. “There are a lot of data out there and a lot of ability to improve clinical outcomes, but at times we forget how meaningful some of those hospitality experiences can be and how important they are to people’s lives.”

How to achieve success can be as complex as family engagement strategies or as simple as making it easier for residents or families to view dinner menus, designate what to eat, or order it to go. “It is about adopting customer experiences people are having outside of senior living and bringing those into senior living,” Smith says.

“We have a 65-year-old talking to us about their mother who needs dementia care, and the expectations that this person brings may go way beyond what we can deliver. They have expectations from their last luxury resort or a cruise.”

And, it is here, he says, that technology can fill in the gaps and make living in a senior living community part of the solution, not part of the problem.
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