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 A Virtual Roundtable

Providers in the spotlight hold a frank discussion on the state of the profession today.

 Contributing Editor


For this month’s issue, Provider posed a series of questions to long term care leaders from a number of backgrounds for their views on the state of the sector and how changes in reimbursement, government programs for accountable care organizations and bundled care, and other issues are impacting the way they operate.

In addition to long term care facility owners and operators, Provider talked to a manufacturer tied to long term care to get a unique perspective on its business prospects in providing goods and services to nursing homes, assisted living centers, and other seniors-centered businesses.

This “virtual” roundtable gives a snapshot of where the profession stands now and where it looks to be moving in the near term.

Participants include: Tom Coble—president and chief executive officer (CEO), Elmbrook Management Co.; Charles “Tripp” Francis—administrator, West Markham Sub Acute & Rehab; Robin Hillier—owner, Lake Pointe Rehab and Nursing Center; Shawn Scott—senior vice president for health care corporate sales, Medline HealthCare; and Chris Wright—president and CEO, iCare Management.

Provider—Have you made any changes to your operations since Medicare cuts went into effect last October?

Robin HillierHillier
—My facility is in Ohio, where we saw dramatic Medicaid cuts in the same fiscal year as the Medicare cuts, so we have had to make drastic changes to our operations.

We had to make the gut-wrenching decision to reduce staffing and employee benefits, we have delayed some investments in new equipment and facility improvements that we were hoping to make, and have tried to identify new revenue opportunities. We continue close monitoring of overtime and routine purchases.

Scott—As a manufacturer that distributes directly to our customers, we are well-positioned to help our customers in these uncertain economic times. Our mission—no matter what the economic climate—is to provide innovative ways to help our customers drive more efficiencies in their business and reduce costs with new, innovative programs and products. We’ve introduced new programs like abaqis that help facilities manage their risk with QA and readmission, as well as clinical programs to help facilities improve their outcomes, provide education to their staff, and ultimately reduce their costs.

Francis—I have put more emphasis on vendor relationships and pricing. When looking for vendors for service, we look for those who are associate members of our state and/or national associations because they also have a vested interest in our success as a profession.

Wright—Besides restructuring our management overhead and cost structures throughout our organization more efficiently, we have developed new clinical programs, focused on clinical staff development initiatives, and made significant capital improvements to several of our nursing facilities to meet the demands of providing care to higher-acuity short-term stay patients and residents.

Our new clinical program initiatives are partly due to the hospitals’ need to collaborate and work with post-acute care providers in reducing hospital readmissions.

Organizations, such as ours at iCare, that have the ability to service all aspects of the nursing home residents, including behavioral/chemical abuse, short term, dementia, and clinically complex, will sustain better outcomes overall provided the high-quality initiatives we have implemented are
successful.

Coble
—Yes. We restructured nursing administration and used resident assessment coordinator training to educate our nursing staff on minimum data set changes, proper assessment, and coding of activities of daily living.

Provider—What is your view on the general state of the long term care industry? Is it strong or extremely challenging, and what ways have you worked to make your business grow in the current climate?

Hillier—I have worked in long term care since 1986, and this is the most challenging environment that I have experienced. I feel that I am not able to operate my facility the way I want to due to reimbursement constraints and find myself frequently having to choose between options that I would have never considered in the past in order to keep my doors open.

It is very difficult to choose between providing care at a level that is not up to the standard of quality that I would prefer or closing my doors and depriving the community of the health care services they need. I think there is great opportunity in the future for those of us who can survive the current environment, which is what keeps me going each day.

Our facility has delved into providing a higher acuity level, focusing on pulmonary services and ventilator care in order to attract a new market and take advantage of the [resource utilization group] RUG IV categories that provide additional reimbursement over what has been available previously.

This is helping us strengthen our census and increase our average reimbursement rate. This has been especially successful since Ohio is a case-mix state for Medicaid reimbursement.

Francis—I think the state of long term care has been and will be forever changing, both in regulation oversight and funding. But the overwhelming need for the specialized services of long term care is steadily growing and changing as well.

We have come to a time when those that we serve are looking for individualized care and services that meet their expectations. We have and will continue changing to meet our customers’ quality-of-life expectations on things such as wireless Internet, dietary fine dining, state-of-the-art rehab services, state-of-the-art nurse call system, and, in the case of our West Markham facility in Little Rock, Ark., we will be providing iPads at bedside for our residents to serve a variety of individual needs.

Wright—The need for 24-hour skilled nursing care will continue to be essential in the post-acute settings. The extreme challenge for the long term care industry is securing sustainable reimbursement levels in order to provide quality care and generate positive clinical outcomes. The operators of skilled nursing facilities will need to continue to increase their capability to care for the most fragile, medically complex patient.

The focus for all providers will be to deliver high-quality care that allows patients/residents to remain in the nursing home versus hospitalization. In order to achieve reduced hospital readmissions, we have enhanced our partnerships with APRNs [advanced practice registered nurses], physicians, and physician extender groups and purchased state-of-the-art therapy modalities to achieve better clinical and functional outcomes.

For instance, our new therapy modalities include a virtual rehab system and cardiac monitoring equipment. The critical need for us at iCare is to remain focused on the ongoing training and education of a workforce comprised of mostly licensed practical nurses, who are now entrusted to provide high-level medical care, with fewer registered nurses in the nursing home environment.

Our corporate director of education role is more necessary than ever, to ensure all nursing staff attains clinical competencies to provide the level of care that is—and once was—provided in the acute hospital setting.

Coble—The general state of the long term care industry is extremely challenging. The uncertainty of federal and state budgets, as well as the many new proposed demonstrations generated by the Affordable Care Act, make it very difficult to decide what is the right long term care business model for the future.

We have focused on post-acute care and have been proactively working with our local hospitals to reduce rehospitalizations.
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Provider—Can you describe your quality initiatives and how you are working on possible new goals, like, for instance, from the American Health Care Association’s (AHCA’s) new Quality Initiative* or your own independent efforts?

Hillier—Prior to the establishment of the AHCA quality agenda, our facility was mindful of trying to control hospital readmissions but did not formally track our rates nor have an actual plan in place to reduce them.

I appreciate the AHCA agenda for giving us firm goals to achieve, the mechanism to track our progress, and tools to help us be successful. It is exciting to be working toward improving our quality of care, even during these challenging financial times. AHCA has helped me realize that I need to be very specific in my quality goals. Up until now, we have had vague goals to improve quality, but we lacked specific targets and specific time frames to which we were going to hold ourselves accountable.

Tripp FrancisFrancis—Our quality initiatives include pain, consistency of care, falls, wounds, weight loss, and 14 other clinical metrics we track weekly to maintain a high quality of care. Unplanned hospital discharge is also a focus, and we utilize the Interact II** program for that. Our goal is to address these issues weekly and develop action plans as needed to maintain low percentages.

Scott—Yes, we are excited that AHCA is moving forward with an innovative quality program tied to the four goals released at AHCA’s Quality Symposium in February. We think it’s important our industry sets a high standard of care that is attainable to help improve our image among the general population.

It’s equally important to have our leaders at the table with CMS [the Centers for Medicare & Medicaid Services] to help set the benchmarks for these quality standards that will one day reflect our reimbursement levels. At Medline, we are working hard to develop programs based on the four quality goals.

As a vendor, we have an obligation to the long term care industry to help meet these challenges by developing programs to help staff become more efficient so they can spend more time at the bedside with the residents, help provide clinical support to help meet the oversight of their quality goals, and introduce new products to help improve the quality of life for those residents we care for.

Wright—Our facilities at iCare have focused on interdisciplinary continuous quality initiatives that have surfaced based on our customers’ feedback. The satisfaction surveys we obtain through My InnerView establish the framework for our ongoing CQI [continuous quality improvement] process. This enables our teams to evaluate all aspects of our care delivery and create opportunities for change and improvement.

The strong emphasis on homelike environments has given us the chance to take a hard look at the once very institutional environments that now need to service the baby boomer generation. Thus, the need for significant capital expenditures, including major facility face-lifts and renovations to our aging nursing homes, is also part of the efforts to improve quality. The enhancement of dining, activities, and treating each patient as an individual to meet their specific needs and expectations is more prevalent than ever in providing good customer satisfaction.

Coble—We have adopted the AHCA Quality Initiative as our organization’s quality goals. We have used Interact II in our facilities for the past couple of years as a tool not only for avoiding rehospitalizations but also for avoidable hospitalizations. We have both nurse practitioners and physician assistants deployed in our facilities and will use them to assist in the reduction of the use of off-label antipsychotics.

Provider—Have you seen an impact on your business from new government programs under the health care reform act? Are you looking at taking part in an accountable care organization (ACO) or any other new initiative in the near future?

Francis—Health care services are continuing to evolve in both how they are delivered and how providers work together on the best outcomes for those who need a wide range of services from end-of-life care, to short-term rehab, to home or work.

So, as we continue to provide services in our communities, we are aligning ourselves with other health care providers so that we have the networking in place to meet the needs of our customers.

Chris WrightWright—The federal government has done a poor job of clearly demonstrating the steps nursing home providers must take to be successful. In my opinion, this is due to continued gridlock by Congress and the executive branch, which has done nothing but politicize issues. Therefore, this inaction and uncertainty have made it very complicated for nursing home providers to foster real change that will assure us sustainable reimbursement levels as we improve quality care for our residents and patients.

The government needs to set out clear, achievable steps that allow providers to better plan their business and have clear strategic objectives for success.

Regarding ACOs, yes, we are developing partnerships and alliances with our medical community, such as hospitals, physician groups, home care, etc., that are considering being an ACO. We have been working hard to ensure our facilities are part of any ACO networks in our market service areas.

Coble—The only impact we have currently seen from the new government programs is the large amount of time required to try to understand and evaluate them. We operate in a rural area. Most of the programs currently under development will happen in urban settings, but we understand the future payment models will change, and we look forward to participating.
 
Provider—What are your staff retention and hiring programs like? Have you had success in finding and keeping qualified nurses and other staff?

Hillier—This has been a real challenge for us in the past year due to the reductions we have had to make in staffing and benefits. But I am extremely grateful to the staff who have stayed with us and continue to be loyal to our residents. I look forward to the day when the environment improves and I can provide the staffing, benefits, and retention incentives that my staff deserve.

Francis—I think the key to retaining staff is to create a culture in the workplace that promotes positive outcomes for our residents and gives our staff a sense of pride in their work. Most all of the special and caring individuals that work in health care are called to do this work and really take pride in outcomes and patient and family satisfaction results.

Wright—We at iCare have very low staff turnover due to paying and providing better benefits to our employees than the national average for nursing home staff. Our new clinical program initiatives, staff development programs, and physical plant renovations have also made it more attractive to recruit quality staff.

Coble—Our staff is the most valuable asset of our organization. We face the same challenges other rural health care providers do but have been fortunate that we have been able to hire and retain not only qualified but also very caring and compassionate staff.
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Provider—What is the best part of running your company?

Hillier—The reason why I love working in long term care is that I have the opportunity to make a difference in someone’s life every single day.

Some days I can contribute to a positive outcome with a resident, some days I can provide emotional support or information to a distraught family member, some days I can help a staff member deal with a challenge in their life, and some days I can provide support or comfort to a fellow owner who is frustrated or overwhelmed. But every night when I go to bed, I know that in some small way I made a difference in someone’s life that day. I cannot imagine anything more rewarding.

Francis—Certainly, taking care of the elderly is our top priority. The rehabilitation aspect of the care is important, too, as it promotes independence and quality of life for any elderly person that is able to return home after an illness. Being able to meet or exceed our residents’ and families’ expectations is what drives me.

“Making every day of life count” is what my goal is each and every day for those that I have the pleasure of serving. I would focus a bit on people that work in this industry since they have to have a love or a “calling” to work in the long term care setting.

Wright—The best part is leading and being a part of a great team of senior management staff that is caring, creative, and knows how to implement change and make operational decisions, whether it is due to reimbursement constraints or meeting the needs and improving quality of care to our patients and residents. The balance between reimbursement reductions and quality outcomes is a delicate issue.

Therefore, iCare’s 2012 company motto is “Great people deliver great quality, which results in great sustainability and great financial performance.” So building and being a part of a group of great people is very rewarding to me.

Coble—The best part of running our company is the interaction with our staff, residents, and their families. Our base of operations is the community where I was born, raised, and have lived all my life. I have the honor and privileged to help take care of those who helped me grow into who I am.

Provider—Name one thing that you would change, be it a reimbursement program cut or a regulation, that would improve your ability to take care of residents and run your operations.

Hillier—I would love to see the introduction of Boren-type language back into the federal regulations that would require the Medicaid program to cover the costs of efficiently run facilities, with a reasonable definition of who is efficient. Many Medicaid reimbursement programs throughout the country have been either constrained or cut for so many years in a row that it has become almost impossible to provide care at any reasonable level of quality.

If CMS is going to continue to consider the profit margin being earned on the skilled nursing facility PPS [prospective payment system] as a reason to restrict or reduce Medicare rates, there needs to be some requirement on the other hand for Medicaid to pay its fair share.

Francis—We continue to work closely with our associations to carry the torch, if you will, on getting the word out to our legislators and our communities on the value of our services to the country’s most frail and elderly and those that got us where we are today.

Wright—Stop the constant bureaucratic review. Change the regulatory system to one that assumes compliance and innovation rather than one that checks providers every step of the way. There is far too much overhead at both the Medicaid and Medicare offices. Resizing these two areas of government will save money to taxpayers and allow these agencies to properly reimburse providers. A possible solution is that these agencies should regulate in an IRS-style method—very few providers audited and reviewed—with severe penalties for egregious offenses.

Coble—Remove the three-day stay requirement for a qualifying skilled nursing stay.
 
Provider—How have new technologies affected your care programs?

Hillier—New technology has been beneficial in helping us be more efficient in the assessment process, as well as monitoring and creating efficiencies in our purchases. I think there is tremendous opportunity for technology to improve our operations, but often this requires a significant investment, which is getting harder and harder to find.

Francis—Moving toward an EMR [electronic medical record] allows the nursing staff more time with the resident. It also enhances communication to internal caregivers and external health care providers that work with us in providing continuity of care. I think technology is the tipping point in service provided by any provider. Our ability to meet the customers’ demands and expectation in a setting that they require, and on their time schedule, is crucial.

As an example, how many of our families communicate through the Internet? For a family who has to place a loved one in a skilled facility, how nice would it be to Face Time them at any time during the day or night? This will not only give the family a sense of peace but also give our residents the security and confidence they need to focus their attention on what they need to do for recovery.

Wright—New technologies are great! However, as of yet, the federal government has not provided clear programming and file formatting criteria to allow these technologies to integrate well.

Coble—Telemedicine in rural areas has had many false starts over the years. We look forward to embracing any opportunity to improve the quality of care we can provide.
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Shawn ScottProvider—How would you describe the business climate for long term care heading into the summer of 2012?

Scott—Between now and the end of the election, I don’t think we’ll see any major changes in the business climate. But we are seeing our customers adapting to the reimbursement changes that occurred in the fall of last year and the beginning of this year.
 
Provider—How do you think long term care can become a more prominent issue for the upcoming election season?

Scott—With health care being such a significant part of the federal and state budgets, and health care reform so top of mind, health care will remain a prominent issue before, during, and after the election.

Also, with thousands of baby boomers entering our marketplace every day, health care, and especially long term care, will become a priority with our elected officials, if it hasn’t already. It is imperative for the leadership of AHCA to bring CMS creative ways to look at reducing these deficits without financially hurting our segment. By working alongside CMS as a partner to attain common goals, we can help assure ourselves of a sound financial future.

These five stakeholders in the business of caring for, and providing goods and services to, the country’s elderly and frail and those with disabilities have given their views during what is not only a crucial time for the long term care sector, but also for the country as the nation ages and people seek new ways to live in their later years.

The numbers of Americans becoming senior citizens and much older is staggering, and from the opinions expressed above there is a cautious optimism, a steadfastness offered by the providers and vendor Provider talked to about being able to get the job done, and done right.

Patrick Connole is a Provider contributing editor.
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