Chelsea Senior Living is renovating one of its 15 assisted living communities to create a 20-bed short-stay unit equipped with hospital beds and 24-hour nursing care.
The unit, occupying one floor of an existing community in Bridgewater, N.J, will include an expanded therapy room, a nurses’ station, and private dining area. The completed project will be at the center of a pilot program to provide subacute-type care to patients from one or more of the area’s accountable care organizations (ACOs). “We have met with ACOs in New Jersey with the idea of providing short-term rehab stays, similar to a skilled nursing or subacute care facility,” says Roger Bernier, president and chief operations officer for Fanwood, N.J.-based Chelsea. “We believe we can do a good job and save the ACO money compared with a normal subacute setting.”

Starting The New Enterprise

In addition to hiring subacute care nurses, and possibly a medical director, Chelsea will rely on partnerships with therapy and home health care providers to bring a higher level of medical services into the short-stay unit.

Interviews are under way, too, with electronic health records companies for the development and implementation of a system that will track outcomes and rehospitalizations, as well as manage Chelsea’s financial and marketing functions. One thing that’s not yet settled is how payment for short-stay residents will be calculated, Bernier says.

The impetus for the short-stay pilot is a Medicare policy that takes effect Oct. 1—the same month that Chelsea’s new unit is slated to open—penalizing hospitals for certain readmissions. Under the Hospital Readmission Reduction Program, Medicare will withhold 1 percent of a hospital’s reimbursement rate for readmissions that take place within 30 days of a discharge and are deemed to be excessive.

The initiative, which will focus initially on three conditions—congestive heart failure, heart attack, and pneumonia—is spurring a shift toward more intensive management of patients who can be safely cared for in long term and post-acute care settings, rather than being transferred to a hospital.

Assisted living providers are meeting the challenge with a wide range of strategies and preparations, from the use of tools and protocols to help them better manage conditions associated with readmissions, to enhanced staffing, the adoption of electronic medical records systems, and, in some cases, renovations to accommodate new services and levels of care.

Some of the most dramatic efforts are emerging in states with regulations that allow high levels of medical care to be delivered in assisted living settings, enabling providers like Chelsea to ramp up their clinical capabilities for higher-acuity residents.

New Jersey, for example, where 11 of Chelsea’s 15 communities are located, allows assisted living providers to meet most post-acute care needs, short of ventilator care and conditions that require “true 24-hour” nursing, says Bernier. He describes Medicare’s initiative to reduce unnecessary hospital readmissions, coupled with the formation of ACOs that share the rehospitalization goal, as a “potential game-changer” for assisted living.

The ACO Connection

ACOs are groups of physicians, hospitals, insurers, and community-based organizations that come together to coordinate care for a defined population of patients.

The Accountable Care Act established a Medicare ACO program, launched by the Centers for Medicare & Medicaid Services (CMS) in January 2012, which is intended to hold down costs and meet an array of quality goals, including the reduction of preventable hospital readmissions. ACOs are rewarded for meeting cost and quality objectives by sharing in the Medicare savings they achieve. Those organizations that agree to take on risk share a larger portion of savings.

Medicare ACOs care for a minimum of 5,000 beneficiaries. Patients do not enroll as they would in a managed care organization. Instead, an ACO’s population is defined by CMS. Patients are not obligated to participate in an ACO and are free to choose non-ACO providers for any or all of their health care needs.
In July, 89 new ACOs began serving 1.2 million Medicare beneficiaries, Health and Human Services Secretary Kathleen Sebelius announced. With this latest growth spurt, there are now 154 ACOs participating in the Medicare Shared Savings Program (MSSP), providing care for more than 2.4 million beneficiaries. Sebelius said the MSSP could save as much as $940 million over four years.

A report on ACO growth and activity, released in June by the Salt Lake City, Utah-based Leavitt Partners, identified 221 ACOs in 45 states as of May 2012.

“By taking on risk for a defined population and being reimbursed, in part, for reaching quality benchmarks, ACOs seek to both improve health outcomes and decrease the growth of health care expenditures,” the report said.

Looking For Dependable Partners

Leavitt Partners, a consulting firm that looks at the future of health care, found that 118 of the ACOs it identified were sponsored by a hospital system, while 70 were sponsored by a physician group, 29 by insurers, and four were sponsored by community-based organizations.

ACO growth is concentrated in large metropolitan areas, and the organizations are testing “multiple, varied models for sharing risk,” the report said. By the end of May, 59 of the organizations had become Medicare ACOs.

Accountable care organizations are expected to seek out long term and post-acute care providers that can demonstrate the ability to safely prevent readmissions. Those that do so will become favored partners for Medicare discharges and gain a competitive edge in the markets where ACOs are active, providers say.
As subcontractors to ACOs, assisted living providers may, for the first time, become part of the Medicare revenue stream.

“It’s a huge opportunity for assisted living,” Bernier says. “Medicare dollars that were never available to us are going to be available to us. If we do it right, if we do it safely, it may be the advent of a new assisted living.”

Acuity Rising

Whether an assisted living provider engages in the effort to reduce avoidable hospitalizations as part of an ACO agreement, or through closer alliance with local hospitals, the emphasis on preventable readmissions is expected to launch an evolution along the long term care continuum and drive up acuity in assisted living settings.

“There’s no question assisted living is moving toward higher acuity,” a trend that has been ongoing for some time, says David Kyllo, executive director of the National Center for Assisted Living (NCAL). Last year, 16 states modified their assisted living regulations, often making changes “designed to recognize that residents are staying longer” and need more medical care, he says.

Assisted living communities care for about 750,000 Medicare beneficiaries nationwide, according to NCAL. Though assisted living providers cannot participate directly in the program, they must be able to “demonstrate to Medicare providers that they can deliver good care and be actively involved in trying to reduce unnecessary hospital readmissions,” Kyllo says.

One organization moving rapidly in that direction is Avamere Health Services in Wilsonville, Ore., which operates a total of 12 assisted living and independent living communities in Oregon and Washington state.

Avamere started adding certified nurse assistants (CNAs) last year at its Oregon communities, in anticipation of the need for higher-qualified staff to meet the clinical expectations of ACOs and to help contain hospital readmissions, says Nicolette Merino, regional director of operations and a former NCAL chair. Rather than hire new staff, Avamere is putting existing staff through CNA training.

Oregon allows assisted living communities to care for a “medically advanced population,” she says. Residents with bowel and bladder incontinence, those who need a two-person transfer or require sliding scale insulin, can have their needs met in assisted living under Oregon rules, Merino says.

As Avamere aligns with ACOs and engages in the readmission effort, Merino expects to see heightened acuity, with residents requiring such services as wound management and rehabilitation.

Meeting ACO Expectations

To accommodate rising medical needs, Avamere plans to hire on-site home health care providers and has converted one apartment in each of its assisted living communities to a “mini rehab room,” which will be staffed by local rehabilitation providers, she says.

The company has also started measuring its hospital readmission and unplanned hospitalization rate and is tracking associated diagnoses, such as urinary tract infections, falls, and COPD, Merino says.

“We know we will have to have that data to give to hospitals and ACOs to stand out as quality providers.” Avamere is also in the process of converting its properties to a standardized electronic medical record system. As residents move from “home care to hospice and all options in between, we will have the continuity of the same medical record up and down the continuum,” Merino says.

The company is reaching out to hospitals and to ACOs that are forming in the marketplace, designating the marketing director as its chief liaison.

“We want to make sure they’re seeing the steps we’re taking to be prepared,” Merino says. Though it may take time for ACOs to roll out completely, Avamere wants to establish relationships early on and develop the data capabilities it will need to demonstrate performance.

“The more work we can do for ACOs, the more likely they are to refer to us,” Merino says.

Assisted Living Interacts With Readmissions

To help providers manage unnecessary hospital transfers, including emergency room visits, observation stays, inpatient admissions, and readmissions safely, NCAL is working with the American Assisted Living Nurses Association (AALNA) on adapting a set of tools for use in assisted living settings.

The average assisted living resident is 87 years old and vulnerable to the risks of an unnecessary hospital stay, such as trauma from the disruption caused by the event, or complications like a urinary tract infection, Kyllo says. Reducing unnecessary hospitalizations lowers these risks and “contributes to quality of life,” he says.

The tools, created for skilled nursing facilities (SNFs), are a component of Interventions to Reduce Acute Care Transfers (INTERACT), a quality improvement program created to help nursing staff manage conditions before they become serious enough to require a hospital transfer.

The program’s clinical practice tools are “not unique to the nursing home setting,” says Joseph Ouslander, MD, project director for INTERACT and senior associate dean of geriatric programs at Florida Atlantic University’s Charles E. Schmidt College of Medicine in Boca Raton, Fla.

“If a frail older person has symptoms of a lower respiratory infection, it doesn’t matter whether she is in a nursing home or assisted living facility,” he says. “While the capacity of an assisted living facility to manage acute illness may be more limited than in a SNF, the clinical evaluation, management principles, communication protocols, and quality improvement tools are the same.”

NCAL and AALNA have started the effort with a tool designed to help reduce the off-label use of antipsychotic medications. Ultimately, the changes to INTERACT tools will be “really minor,” in some cases changing “nursing home” to “assisted living,” Kyllo says. The final products will be reviewed by the INTERACT team before being released.

Not Lost In Translation

Ouslander developed the first INTERACT tools in 2007 for the Georgia Medical Care Foundation, a Medicare quality improvement organization that contracted with CMS to look at the issue of avoidable hospitalizations and strategies to reduce them, he says.

The program was piloted in three Georgia facilities and subsequently tested in a larger project supported by The Commonwealth Fund, in which hospital admissions fell 17 percent over a six-month period among 25 nursing facilities in Florida, Massachusetts, and New York.

The tools are “translatable” across care settings, Ouslander says. “They are just good clinical practice put into formats people can use.”

An array of INTERACT tools (see box, below) have been created for early identification and timely assessment, documentation, and communication of changes in the status of residents. Central to the effort to reduce preventable hospitalizations is the SBAR, which stands for Situation, Background, Assessment, and Request, a two-page form used by nurses to gather resident information before calling a physician.
The SBAR documents changes in condition, vital signs, and symptoms to help determine whether a person needs to be transferred to the hospital or can be treated in place. There is also a separate SBAR for reducing antipsychotic medications under development.

“The goal is to have communication tools so that when nurses make the call to physicians, they have all the information needed for doctors to make a decision and take appropriate action,” Kyllo says.

An assisted living resident who is dehydrated, for example, may be treated by a home health nurse who can start intravenous fluids, rather than transferring the resident to a hospital, he says.

Among the newest tools being created is a template that addresses family expectations for hospitalization, Ouslander says. Ruth Tappen, MD, a scholar in the Florida Atlantic University Christine E. Lynn College of Nursing and partner in the INTERACT projects, has received a grant from the Patient-Centered Outcomes Institute to develop “ethnically sensitive decision support for patients and families around the issue of hospitalization,” Ouslander says. “This is a very difficult issue,” one that is different for each group, he says.

In conjunction with the tools, it’s important that providers have “a really good relationship with patients and families so they trust you,” Ouslander says. “If they know you and think you know what you are doing, they will trust you and listen to you,” he adds. “We can provide tools, but unless you have a good relationship and communicate well, a piece of paper won’t help.”

Readmissions: The Competitive Edge

At Tealwood Care Centers in Bloomington, Minn., where INTERACT tools have been implemented in skilled nursing facilities with funding from a state grant for that purpose, President Howard Groff plans to use the same tools in the company’s 32 assisted living communities. Though the organization is still in the process of reviewing its SNF experience with INTERACT and rolling out the tools to assisted living, the initiative appears to already be giving Tealwood a competitive edge when it comes to developing relationships with hospitals and ACOs.

One of Tealwood’s assisted living properties is across from a hospital, in a community of about 15,000, says Groff, a former NCAL chair. “When I told them about using the INTERACT tools in our nursing facilities and applying them to assisted living, they really listened,” he says.

“We’re going to meetings with hospitals and saying, ‘Here’s where our readmission rates are, and here’s what we’re doing about it,’” Groff adds. He believes that providers at the forefront of these efforts will make early inroads in reducing avoidable readmissions, strengthening their appeal as subcontractors to ACOs.

Three ACOs are forming in the Minneapolis area, and Tealwood is reaching out to all of them, Groff says.
“ACOs really want to have a connection to assisted living” as a less costly option for chronic illness, he says.

Tealwood is in preliminary discussions with one of the area’s ACOs about a potential payment model and may even dedicate sections of its assisted living communities to residents that come from ACOs, creating smaller units with separate dining areas designed to meet the needs of shorter-stay residents with more intensive medical needs, Groff says.

Concentrating On Services

Like other assisted living providers that anticipate higher acuity, Tealwood is broadening its clinical capabilities, implementing 24-hour nurse staffing and CNA hiring at six communities.

Tealwood has an established relationship with a certified home health agency and is developing an association with a physician group that specializes in assisted living, which, like Tealwood, is reaching out to the area’s emerging ACOs, Groff says.

Physicians and nurse practitioners from the group make visits to assisted living communities, giving frail residents the option of onsite primary care, Groff says.

Among the many benefits of the arrangement, physicians and nurse practitioners review the panoply of medications that residents are taking, discontinuing those that are no longer needed or pose a risk of unwanted interactions or side effects, he adds.

Over time, Groff envisions a long term care continuum in which the site of care is not as important as the services provided. “We are going to see services become more critical than the actual location” where services are delivered, Groff says. “It may be that the lines will become blurred between what takes place in a SNF and assisted living community.”

Managed Care Compounds Marketplace Challenge

Assisted living providers in New Jersey are readying for a transformation of the state’s Medicaid program, in which all long term and post-acute care benefits will be administered through a managed care organization (MCO). Effective Jan. 1, 2013, the massive overhaul compounds the changes assisted living providers face in the marketplace, observers say.

Paul Langevin, president of the Health Care Association of New Jersey, expects managed care organizations to overshadow the impact of ACOs.

“On Jan. 1, 28,000 nursing home and 3,500 assisted living residents will move into Medicaid managed care,” Langevin says.

State regulations allow assisted living communities that have been operating for at least three years to have 20 percent of their census comprised of residents who are eligible for nursing facility care.

While other states might require residents needing that level of care to leave assisted living, New Jersey allows those services to be brought into the residences, Langevin says. With assisted living providers capable of managing higher-acuity residents, Langevin speculates that the four Medicaid MCOs that will serve the state may try to reduce long term care costs by “loading up on assisted living providers.”

The state’s Medicaid managed care revolution is expected to usher in many of the same performance expectations that ACOs bring to the marketplace, including pressure to reduce unnecessary hospitalizations as well as ever-increasing acuity along the long term care continuum.

Data Delivery Critical

Christian Health Care Center (CHCC) in Wyckoff, N.J., is prepared to meet the new competitive challenges with a diverse array of services and data—loads of data.

“We were one of the first in New Jersey to implement a complete electronic medical records (EMR) system in 2008,” says Kevin Stagg, chief financial officer.

Located on a campus with skilled nursing, assisted living, and rehabilitation care, CHCC has developed a sophisticated information system, capable of generating detailed performance data on rehospitalization, Stagg says.

“We have the ability to identify the specific codes and diseases to track individuals who are readmitted to the hospital” from assisted living as well as the nursing facility,” he says. By reviewing quality indicators, implementing clinical protocols, and monitoring diseases associated with readmissions, CHCC has driven down its rate of avoidable hospitalizations, Stagg says.

Data are entered into the system from medication and treatment carts, hand-held devices, and laptops. The pocket-sized devices used by staff in assisted living “get smaller and smaller,” so the system doesn’t intrude on the residential environment, Stagg says.

CHCC also uses its EMR system to track the various levels of care in assisted living, which include basic care, wound care, and assistance with several functions. The EMR measures and tracks care and outcomes for each of those levels. Ultimately, Stagg says, he expects MCOs to drive the development of a case-mix index for assisted living, which would allow measurements among and within states. “I see that coming about as managed care organizations want to get a handle on how sick a patient in assisted living is,” he says.

Stagg predicts that as managed care organizations come to understand what assisted living providers can do, there will be a push to care for more Medicaid beneficiaries in those settings, accelerating a shift that has been occurring all along the long term care continuum.

“What we’ve seen in the past five years is residents who previously would have been in a nursing home are still in assisted living,” Stagg says. Care that was once provided in the hospital is moving to nursing facilities, “and from nursing homes to assisted living.”
Lynn Wagner is a freelance writer based in Shepherdstown, W.V.