A Fresh Look at Infection Prevention | https://www.providermagazine.com/Issues/Special-Features/Pages/A-Fresh-Look-at-Infection-Prevention.aspx | A Fresh Look at Infection Prevention | <p>Infection prevention and control has been a top priority in long term and post-acute care centers this past year and a half. However, much of it has understandably focused on COVID-19. Moving into flu season and the holidays, there is much to learn from COVID to help prevent and manage other common infections.</p><h2>While Focused on COVID . . .</h2><p>While everyone was busy managing the pandemic, a few developments regarding other infections have been made. <br></p><p>For instance, earlier this summer, the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America released new evidence-based guidelines on the management of Clostridioides difficile infection (CDI) in adults.<br></p><p>The guidelines include three recommendations on suggested treatments for patients with initial and recurring CDI episodes, based on new data for fidaxomicin and for bezlotoxumab, a monoclonal antibody targeting toxin B produced by C. difficile. Specifically, the revised guidelines say that patients with an initial C. diff infection should receive fidaxomicin instead of a standard course of vancomycin, though they say that implementing it depends on available resources. <br></p><p><img src="/Issues/2021/September/PublishingImages/GhinwaDumyati.jpg" alt="Ghinwa Dumyati, MD" class="ms-rtePosition-1" style="margin:5px;width:160px;height:204px;" />Elsewhere, Ghinwa Dumyati, MD, professor of medicine, infectious diseases, at the University of Rochester Medical Center, says, “In recent years there have been more studies showing that reducing inappropriate urine culture testing reduces the use of antibiotics, which is a positive step forward. At least one <a href="https://www.reliasmedia.com/articles/144326-avoid-antibiotics-by-reducing-unnecessary-urine-tests" target="_blank">study</a> found that inappropriate treatment of urinary tract infections with antibiotics raises the risk of C. diff.” <br></p><p>Influenza took a back seat during the pandemic. According to the Centers for Disease Control and Prevention (CDC), indicators of influenza began to decline by mid- to late-February 2020. In the 2020-2021 season, the United States saw approximately 700 deaths from influenza, compared with 22,000 in the previous season. These numbers are likely due to several contributing factors, including lockdowns and quarantines, mask-wearing, and hand hygiene.<br></p><p>“Our flu rates were fantastic this last year because everyone was taking precautions,” says Morgan Katz, MD, MHS, assistant professor of medicine at the Johns Hopkins University School of Medicine. “We did learn some things from COVID that will likely help us with flu prevention moving forward.”</p><h2>Putting Stewardship on the Front Burner</h2><p>Katz says that in recent years, clinicians have made advances on issues such as antibiotic stewardship. “That’s been put on the back burner [for now], but we need to get back on track with that,” she says.<br>Katz says that when COVID hit, staff were incredibly taxed, overwhelmed, and overworked, and they didn’t have time to prioritize stewardship.<br></p><p><img src="/Issues/2021/September/PublishingImages/MorganKatz.jpg" alt="Morgan Katz, MD" class="ms-rtePosition-2" style="margin:5px;width:160px;height:200px;" />At the same time, she says, “Prior to the pandemic, CDC had just come out with guidelines for enhanced barrier precaution for nursing homes, which prioritizes the use of PPE [personal protective equipment] for specific high-risk residents during high-risk activities to reduce the transmission of multi-drug-resistant organisms. Unfortunately, with the pandemic, we had to dedicate our PPE and our time and effort to caring for COVID patients.”</p><h2>IPs Need Attention ASAP</h2><p>“For nursing homes, I think one positive development is that everyone realizes we need more robust infection prevention programs,” Dumyati says. The federally mandated infection preventionist position may need to be expanded moving forward, she says. <br></p><p>“Being able to support someone working full-time on infection prevention and control is something we learned we need. We must figure out how to support this position and enable someone to have adequate time and resources to do the job well,” she says. “People are paying attention to [the issue], and that’s very positive. Looking ahead, we will need to look at the layout and design of facilities.” <br></p><p>One study showed that smaller units with fewer people such as the Green House model fared much better during the pandemic than facilities with multiple people sharing a room and a bathroom, Dumyati says. However, she adds, “Funding needs to be available.” In the meantime, she suggests, “We can look at things like updating ventilation and HVAC systems and replacing carpeting.”</p><h2>Lessons Learned</h2><p>Getting staff and others vaccinated for influenza and pneumococcal illnesses has always been a challenge. It’s too early to tell if the pandemic and the situation with the COVID vaccine will change how people view vaccinations in general, experts note.<br></p><p>“We mandated influenza vaccines for staff in the hospital and improved our numbers. In the nursing home, we never went above about 60 percent,” Dumyati says. “There is always distrust by some groups, and it’s clear from the response to the COVID vaccine that this hasn’t changed.<br></p><p>“But we need to be able to address these things. I have spent hours talking with people who didn’t want to get vaccinated. Some ultimately agreed to get vaccinated, and others didn’t.”<br></p><p>The recent groundswell for COVID vaccine mandates for staff may extend to influenza as well. “In general, based on the discussions I’ve had, facilities are considering mandating flu vaccines moving forward,” Katz says. “My hope is that this will happen, as it has proven to be the most effective way to increase staff vaccination rates.”<br></p><p>With flu season approaching, Dumyati says providers need to address all the issues and objections now. A blanket approach won’t work, she says. Instead, leaders need to talk to people one-on-one and have multiple conversations.<br></p><p>“We have learned that you can’t wait until the last minute to make decisions,” Katz says. “We need to have discussions about goals of care early. We found out during the pandemic how important that is.”</p><h2>Promising Future?</h2><p>COVID brought to light the continued need to improve infection prevention in long term care settings, Katz says. “We need to evaluate processes and regulations in this setting and dedicate the resources and research to improving practices. I do think things are going to change because of what has happened.”<br></p><p>Nonetheless, there may be some bumpy roads ahead. “I am prepared for fall to be a challenging time,” Katz says. “The flu is going to come back, as will other viruses. And the onset of the Delta variation of COVID makes it clear we’re not done with this virus either.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | Moving into flu season and the holidays, there is much to learn from COVID to help prevent and manage other common infections. | 2021-09-01T04:00:00Z | <img alt="" src="/Issues/2021/September/PublishingImages/0921_CF1.jpg" style="BORDER:0px solid;" /> | COVID-19;Infection Control | Cover Feature |
A Small World is a Big Solution for Workforce Woes | https://www.providermagazine.com/Issues/Special-Features/Pages/A-Small-World-Is-a-Big-Solution-for-Workforce-Woes.aspx | A Small World is a Big Solution for Workforce Woes | <p style="text-align:center;"><img src="/Issues/2022/JuneJuly/PublishingImages/060722_immigration_banner.jpg" alt="" style="margin:5px;" /> </p><p style="text-align:center;"><br></p><p>Sometimes we find ideas in our own backyard. Other times they come across the ocean or halfway around the world. Increasingly, post-acute and long term care leaders are finding physicians, nurses, frontline workers, and other staff in numerous countries. While immigration isn’t a panacea, it’s one promising solution to the workforce shortage. <br></p><p>Over several years, Jody Knox, chief executive officer of Lakeview Christian Home, Carlsbad, N.M., and her team have brought in nurses from nine different countries, most from the Philippines. “They are all RN-trained and have brought stability to our workforce. They are kind and caring and have made us a better community; they’ve become like family,” said Knox. <br></p><p>Access to these nurses always had a positive impact, but even more so when COVID hit. “During the pandemic, we didn’t have to bring in traveling nurses, but we struggled horribly with frontline staffing shortages. We decided to have some nurses handle care such as bathing and feeding.” That may sound like an expensive use of nursing staff, she said, but it would be more expensive to use agency certified nursing assistants (CNAs). Knox added, “We’re not sure how this will work down the road. But it has changed who we are.” She added, “Having bachelor-prepared nurses is a big deal. They provide quality skilled care.”<br></p><p>There definitely has been an increased interest in international staffing in the health care sector, particularly for registered nurses, partially due to the increasing need for nurses and a more long-term strategy of employers. Sherry Neal, an employment-based immigration attorney in Cincinnati, Ohio, says, “We have seen the ebb and flow of international nursing throughout the past two decades, but the demand has significantly increased since the pandemic. The nursing need is serious, and health care organizations know it’s not getting better any time soon. A decade ago, some hospitals and health care organizations shied away from international hiring because of the 12- to 18-month processing time for an immigrant visa. Now more and more organizations are realizing that although international hiring is not a quick fix; it’s part of the long-term strategy to help alleviate the shortage.” </p><h3>American Adjustment</h3><p>There needs to be a balance between giving immigrants the means and opportunities to celebrate their native cultures and helping them understand American ways of working and living. For instance, Knox said, “We have to teach them about American medicine and how we look at things like death and dying. This is different from what is believed in some countries.”<br></p><p>Providing help to get new workers acclimated is essential. This means efforts such as helping them find and retain affordable housing and transportation, arranging for cell phones, and securing services such as childcare. <br></p><p>Language barriers may exist, but this is typically not a problem for international registered nurses. Neal says, “As part of the immigration process for a registered nurse to obtain a green card to work in the U.S., a nurse has to pass an English proficiency exam as well as other credentialing requirements.” Usually, for instance, the only language adjustment for Filipino nurses is becoming familiar with American slang. </p><h3>All Together Now</h3><p>From the early days of this country, immigrants were sometimes demonized and ostracized instead of celebrated. So it is essential to help staff embrace their immigrant colleagues. The ease of this may be surprising. As Knox said, “We are a rural facility and have a large Hispanic population. We have long experienced people speaking multiple languages. At the same time, we try to teach people to be respectful and mindful.” She added, “We have nine different languages being spoken here, but we teach people to be courteous to others, for example, by not speaking another language in front of residents or staff who don’t understand it.”</p><h3>Policies that Promote Immigration</h3><p>American Health Care Association/National Center for Assisted Living (AHCA/NCAL) and other organizations are working to help ensure that organizations that want to bring in practitioners and workers from other countries have that opportunity. The processing of immigrant visa applications has been backlogged due to the pandemic and reduced staffing at U.S. embassies and consulates. Many international health care professionals with job offers from long term care facilities in the U.S. with approved immigrant petitions have been waiting a year or longer for visa interview appointments. Neal says, “There has been progress the last six months as consulate appointments have begun to increase, yet processing times have always been slower than desired. Even before the pandemic, employers had to expect a typical processing time of at least a year.” <br></p><p>Dana Ritchie, senior director of not-for-profit and constituent services at AHCA/NCAL, said, “We are pleased about the recent announcement from the U.S. Immigration and Citizenship Services regarding new actions to reduce the significant legal immigration backlogs and encourage further actions along these lines. We also have been working closely with national refugee organizations, noting our center doors are open to those new to our country who would like to pursue a career in long term care.” She stressed, “AHCA/NCAL strongly supports immigration reform.”<br></p><p>Elsewhere, Rajeev Kumar, MD, CMD, FACP, chief medical officer for Symbria in Warrenville, Ill., recently drafted two resolutions regarding immigration that passed the AMDA—The Society for Post-Acute and Long-Term Care Medicine House of Delegates in March 2022. He said, “These resolutions stemmed from a conversation our board had about struggling with the workforce issue. I also thought about my experiences when I first came to this country and did my training.” <br></p><p>In short, the resolutions are:<br></p><ul><li>Undocumented Noncitizens for Post-Acute and Long Term Care (PALTC). This calls for AMDA and like-minded organizations to advocate for legislative action to create a pathway to immigration for undocumented noncitizens in the U.S. who show their commitment to their intended homeland by working as Certified Nursing Assistants and/or nurses in PALTC settings for a minimum of five years.</li></ul><ul><li>Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) Designations for PALTC. This calls for AMDA and like-minded organizations to advocate for designation of all PALTC communities, irrespective of their geographic location, as HPSAs and/or MUAs to facilitate professional recruitment/retention.<br></li></ul><h3>It’s Complicated</h3><p>No doubt, immigration is complicated. Positions like professional nurses and physical therapists are U.S. Department of Labor Schedule A workers. This means that employers don’t need to get a foreign labor certificate when hiring these individuals. Instead, you must agree to sponsor the employee for permanent residence in the U.S. Schedule A nurse recruitment can be effective for helping to address nurse shortages. However, there are limitations and barriers. For instance, depending on the country of origin, it may take a year or more to process the petition.<br></p><p>Elsewhere, the TN Visa—for Mexican and Canadian Citizens—is a nonimmigrant visa, which is for temporary employment. However, it can be extended in three-year increments. <br></p><p>The most common temporary visa option in professional occupations is the H-1B. However, although registered nurses are “professionals,” they rarely meet the standard for H-1B. The H-1B is reserved only for occupations that require a bachelor’s degree. Even if a nurse has a bachelor’s degree, that’s not sufficient as the position/occupation itself must require a bachelor’s degree. Since most registered nurse positions in the U.S. can be filled by a nurse with an associate degree or diploma, it’s hard to overcome the U.S. </p><p>Citizenship and Immigration Service perception that registered nursing is not a specialty occupation for H-1B, unless the employer can show the nurse is filling a more specialized or complex nursing role where the employer does require its other nurses in that area to have at least a bachelor’s degree. <br></p><p>A pitfall, said Steve Flatt, chief executive officer of National HealthCare Corporation in Murfreesboro, Tenn., is that “this is a very slow process, and it’s tedious, especially the interview process at the embassy level. I’m hoping that the process will pick up speed, but right now it is slow and cumbersome.” However, facilities don’t have to go it alone or start from scratch. Flatt said, “It’s helpful to engage a third party that focuses on bringing international workers to the U.S. They’re adept at completing the paperwork and following through the process. They also know how to clear the hurdles that can make it cumbersome.” </p><p>He noted that this can cost money, and providers need to be prepared for that. He added that while bringing nurses from other countries can be pricey, it can be “a bargain” compared to the costs of hiring agency nurses. He said, “You get full-time staff who will be with you day-in and day-out and provide continuity of care, which always leads to better quality.” <br></p><p>Moving forward, immigration will likely continue to play a significant role in addressing long term care workforce shortages. President Biden has announced a commitment for the U.S. to take in 100,00 Ukrainian refugees, and AHCA/NCAL is already working with facilities across the country to offer thousands of jobs for these individuals. Of course, many will not have the ready credentials to work in some health care occupations, but some may be able to obtain the additional training or education in a fairly short time or can fill other positions within the sector. Participating facilities will also offer refugees training, relocation assistance, and support for their integration into local communities. Flatt said, “This is not the cure-all to our workforce issues, but it should be considered a major part of solving this challenge for the foreseeable future.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.</em></p> | Increasingly, post-acute and long term care leaders are finding physicians, nurses, frontline workers, and other staff in numerous countries. While immigration isn’t a panacea, it’s one promising solution to the workforce shortage. | 2022-06-01T04:00:00Z | <img alt="" src="/Issues/2022/JuneJuly/PublishingImages/060722_immigration.jpg" style="BORDER:0px solid;" /> | Workforce;COVID-19 | Cover Feature |
Building Relationships to Rejuvenate the Market | https://www.providermagazine.com/Issues/Special-Features/Pages/Building-Relationships-to-Rejuvenate-the-Market.aspx | Building Relationships to Rejuvenate the Market | <p>Long term/post-acute care is a “relationship” business, says Stacy Hejda, vice president of regulatory compliance for Assisted Living Partners. “The pandemic took away what we were used to—the handshakes, hugs, and visits—and how we thought about marketing,” she says. “We were stunned for a minute, but we embraced a virtual means to reach people.” <br></p><p>Marketing in the post-pandemic may get back some of the hugs and handshakes and a lot of the visits, but virtual connection and other innovations embraced in the past year are here to stay. The result will be stronger, more flexible, and more creative ways to attract new residents and referrals.<br></p><p><img src="/Issues/2021/June/PublishingImages/JamesHarvey.jpg" alt="James Harvey" class="ms-rtePosition-1" style="margin:5px;width:113px;height:144px;" />“The human element that we always sold ourselves on and took pride in was suddenly on hold,” agrees James Harvey, vice president of marketing and communication at ALG Senior in Hickory, N.C. Fortunately, he says, “Before COVID, we had started to build digital platforms and train and educate our teams to utilize them effectively.”</p><h2>Occupancy Drops, Creativity Soars</h2><p>There is no question that occupancy in nursing homes and assisted living facilities took a hit during the pandemic. According to one source (<a href="https://skillednursingnews.com/2021/01/48-states-saw-nursing-home-occupancy-of-80-or-worse-as-2021-dawned-with-census-as-low-as-56/">https://skillednursingnews.com/2021/01/48-states-saw-nursing-home-occupancy-of-80-or-worse-as-2021-dawned-with-census-as-low-as-56/</a>), of the 48 continental U.S. states, none reported occupancy higher than 80 percent in the past year, with some as low as 56 percent. Assisted living didn’t fare much better. Average assisted living occupancy dropped 1.2 percent to 77.7 percent in the fourth quarter of 2020.<br></p><h2>Communication is King</h2><p>“During the pandemic, communication became king as our industry was thrust into the spotlight. We needed a way to maintain contact with the outside world,” says Harvey. Skype, FaceTime, Zoom, and other video conferencing took center stage and became a lifeline for facilities to communicate with residents’ family members, as well as prospects and others. <br></p><p>“We also took to social media to make the general public aware of what was happening so that they could have a trusted source of information,” Harvey says. “We embraced virtual means quickly to get and keep people engaged.”<br></p><p>ALG Senior published infection rates and communicated virtually with residents, families, staff, and others about the facility’s infection control processes and other updates.<br></p><p>“This helped create feelings of trust and comfort in our communities,” Harvey says. “Facebook has been incredible. We saw a big uptick in engagement. Consumers have come to expect to see this used for education but also to see what is happening in the community day to day.”<br></p><p><img src="/Issues/2021/June/PublishingImages/Andrews.jpg" alt="CC Andrews" class="ms-rtePosition-2" style="margin:5px;width:113px;height:141px;" />“The pandemic has accelerated the adoption of multi-channel, open communication in our sector,” observes CC Andrews, president and chief strategist of Quantum Age Collaborative. “We’re using new platforms and old ones in new ways. Virtual meeting platforms like Zoom and FaceTime have been a lifeline to keep our residents connected with their families, physicians, and other supports,” she says.<br></p><p>“Our use of social media blossomed, as we found it extremely useful in keeping families in touch with what was happening within our communities and how we were adapting to keep residents happy, healthy, and engaged.”<br></p><p>Quantum Age’s websites offered educational information, status updates, and virtual visit signup—often in near real time.<br></p><p>“This level of open communication over multiple channels will remain with us,” Andrews predicts. “Moving forward, it will continue to be about personalized, open communication—answering every question with authenticity so that we give every stakeholder—referrer, patient, family member, team member—the information they need to feel confident about their care decisions.”<br></p><h2>Virtual Tours, Real-Time Interactions</h2><p>Virtual tours became the norm in the sector quickly, but to be effective, they had to include the personal element that made in-person visits such a powerful marketing tool. <br></p><p>“For us, we used virtual tours to bring back that human element during the pandemic,” Harvey says. “We had department directors conduct these tours and introduce and engage other team members along the way.”<br></p><p>At the same time, some communities produced videos showing resident activities and introducing teams, and they posted them online. “We made sure our tours and videos were robust and team-centered. They have been a valuable way to show who we are and what we do,” he says.<br></p><p>While communities were able to embrace virtual tours and visits and make the most of these opportunities, Harvey says, “Nothing can take the place of face-to-face interactions, but digital is here to stay. Our rebound has been strong because of the digital process.”<br>Looking forward, expect to see more hybrid efforts and ongoing and innovative ways to engage prospects and families both in person and digitally.</p><h2>Media Issues</h2><p>While media coverage of the pandemic in long term/post-acute care (LT/PAC) admittedly often took a negative tone, avoiding or ignoring reporters isn’t the answer moving forward. Harvey explains that his team has taken a positive approach to media relations.<br></p><p>“We took advantage of any media opportunities that came our way. We saw this as a chance to educate people about assisted living, what kind of care we provide, and how we work to protect our residents and maximize their quality of life,” he says. As a result, ALG Senior saw an “evolution” in reporters’ perspectives. “We were able to change people’s minds,” he says.<br></p><p>It’s important to understand where reporters are coming from, Harvey says. <br></p><p>“It’s challenging to have to navigate an industry or issue you’re not familiar with. We welcomed questions and the opportunity to provide education and insights. We were able to work with journalists and bring them virtually into our communities,” he says. <br></p><p>“We always want to share our perspective with the public. We need to be part of this conversation.”<br></p><p>The relationships established during the pandemic are now paying dividends. As Harvey says, “We have reporters reaching out to us for stories about vaccines, family reunions, and other positive events. COVID has provided us with more opportunities than ever to be taken seriously and to be seen as health care leaders.”<br></p><h2>Moving Past COVID</h2><p>Moving into the post-pandemic world, it may be tempting to put COVID-19 and everything related to it in the past. However, issues such as safety, cleanliness, and infection prevention remain on everyone’s minds.<br></p><p>“We’d be kidding ourselves to think COVID will be in the rearview any time soon, to the extent that it won’t be an important topic for referral sources, prospective residents, and families,” says Andrews. “As a daughter of an assisted living resident, I want to know about precautions being taken, the percentage of vaccinated staff and residents, and what the plan is should there be another outbreak.” <br></p><p>It’s definitely not too early to talk about what the facility did during the pandemic to protect residents, such as implementing separate wings with separate HVAC systems, touchless faucets and other technology, and cleaning systems and processes that are safe and effective. <br></p><p>Hejda of Assisted Living Partners suggests that different audiences may want different information. “When you look at demographics, people in the 80-plus group want ‘safety-first’ knowledge. They’re still conscious of it because it hit them the hardest. Younger people, on the other hand, are more likely to want to move past it.” <br></p><p>She adds, “We tackled it head-on.” This means providing information about vaccines, illnesses, and what is being done to maximize safety. “Potential residents want to know what will happen to them if they move in. Will they be quarantined? Will they be able to visit with family members? What will their <a href="/Issues/Special-Features/Pages/Building-Relationships-to-Rejuvenate-the-Market.aspx" target="_blank" title="Marketing to the New Normal">‘new normal’</a> look like? We need to create a picture of what this new normal will look like, but we also need to address what will happen if the COVID positivity rate goes up.”<br></p><p>In the end, Hejda says, “No matter what age you are, people want to go back to being with family. A lot of seniors feel like they’ve been robbed of a year of their life. The buildings I work with recognize that and are trying to give residents back that year.”<br></p><h2>Engaging Ambassadors</h2><p>During the pandemic, walls were broken down. Existing relationships were strengthened, and new ones were forged in the community. These can be important marketing partners moving forward, says Hejda. “This is a matter of small steps and making sure all parties are comfortable getting back into the community.” <br></p><p>For example, she says, one building is talking with local schools about arranging music or sporting events that residents can enjoy in smaller, more physically distanced audiences. “Staff have done a great job of rolling up their sleeves, and we need to recognize this and continue to present opportunities for them to be involved.”<br></p><p>Elsewhere, Hejda adds, “We were able to utilize everyone in the community to be part of the communication process. All of a sudden, everyone in the community became ambassadors, reaching out to the broader community and engaging people in different ways.”<br></p><p>When asking teams to advocate for the community, management has to invest in them. “Make sure teams have the opportunity to tell their stories,” Hejda says. “We have office hours every week so people can share their ideas, ask questions, etc. We invest in our people so they can represent themselves the best they can with support from us.”</p><p>It also will be important to focus efforts on referring physicians, Andrews says. “Spend time ensuring that they know your clinical expertise, capabilities and services, and what you’re doing to keep residents safe and prevent avoidable readmissions.”</p><p><img src="/Issues/2021/June/PublishingImages/Hedja.jpg" alt="Stacy Hejda" class="ms-rtePosition-1" style="margin:5px;width:113px;height:141px;" />Of course, Hejda says, don’t forget that the buildings themselves are ambassadors of sorts.</p><p>“Look around for opportunities to do some ‘spring cleaning.’ We are so used to not having people come in, and we have to make sure that our buildings not only are clean and safe but also welcoming and warm.”<br></p><p>For instance, she notes that furniture may not be displayed in an appealing manner or in a way that is conducive to socialization and engagements. At the same time, staff may have been wearing jeans and other more casual clothes during the pandemic instead of uniforms, work attire, and name badges or IDs. “Let’s look around and do some cleaning and start preparing for more visits,” Hejda says.<br></p><h2>Skilled Care at Home: What’s the Strategy?</h2><p>During the pandemic, elective procedures such as hip and knee replacements were cancelled or postponed. As a result, assisted living communities and nursing homes saw a significant drop in short-term admissions. In recent months, as the procedures resumed, there’s been a trend of sending patients directly home—the least intensive setting for care—after a hospital stay for surgery or illness. <br></p><p><img src="/Issues/2021/June/PublishingImages/Easter%20Bunny.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:276px;height:367px;" />To this, Andrews suggests that referral patterns established during the past year are unlikely to revert to pre-COVID conditions. This means there is an important role for marketing to play. Remind hospital discharge planners, referring physicians, and patients alike of the benefits of rehabilitating in the post-acute care setting, she says. <br></p><p>It doesn’t have to be expensive to reach out to patients and families in the community. “Many buildings I work with did things like inviting people from the community in for meals, when that was safe and possible, or taking meals out to them,” says Hejda. “We’re seeing more of an effort to get out for more face-to-face interactions with people in the community at large.” <br></p><p>For instance, she says, one building delivered May Day baskets to people. As vaccinations are more widespread and infection rates reach new lows, there likely will be more of such efforts, particularly aimed at people who are doing all right in their homes but would flourish in an assisted living or other LT/PAC setting.</p><p>At the same time, some organizations are promoting in-home skilled care services, competing with home care agencies. Andrews suggests that this may be a practical move for those that have the business model, resources, and staffing to provide such care and services. <br></p><p>After all, about one in four home health patients is over age 85, and many have acuity that matches skilled nursing and assisted living residents. Nearly half have five or more chronic conditions, including asthma, arthritis, diabetes, and/or heart disease (<a href="https://homehealthcarenews.com/2021/01/top-home-health-trends-for-2021/" target="_blank">https://homehealthcarenews.com/2021/01/top-home-health-trends-for-2021/</a>).<br></p><h2>The Significance of a Smile</h2><p>“The biggest thing we learned about marketing this past year is that regular, robust communication and transparency are essential. We learned that we can’t sugarcoat or spin things,” says Harvey. “You have to keep the curtain pulled back. It sounds simple, but it is the greatest thing you can do.”<br></p><p>Like so many who work in and love LT/PAC communities, Hejda is optimistic about the future. “I think the past year has helped us be grateful for the little things. We all have come to appreciate the value of something as simple as a smile, because we haven’t seen smiles for so long.” <br><br><strong>Joanne Kaldy</strong> <em>is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | Marketing in the post-pandemic may get back some of the hugs and handshakes and a lot of the visits, but virtual connection and other innovations embraced in the past year are here to stay. | 2021-06-01T04:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/0621CF_AssistedLiving.jpg" style="BORDER:0px solid;" /> | COVID-19 | Cover Feature |
Creating Seamless Transitions in Challenging Tımes | https://www.providermagazine.com/Issues/Special-Features/Pages/Creating-Seamless-Transitions-in-Challenging-Tımes.aspx | Creating Seamless Transitions in Challenging Tımes | <p>“The best transition of care is when there is no transition at all.” James Lett, MD, coined this maxim many years ago, and it’s still the mantra of post-acute and long term care providers.<br></p><p><img src="/PublishingImages/Headshots/RajeevKumar.jpg" alt="Rajeev Kumar, MD" class="ms-rtePosition-1" style="margin:5px;width:145px;height:186px;" />“Of course, sometimes transitions are necessary, so we need to focus on doing this as seamlessly as possible,” says Rajeev Kumar, MD, CMD, FACP, chief medical officer of Symbria in Warrenville, Ill. “Even though we are well into the third decade of meaningful EHR [electronic health record] use, we still have discordant records, and what happens in the hospital doesn’t always filter back to the nursing home, and vice versa.”</p><h2>Working Toward the Ideal Transition</h2><p>The Centers for Medicare and Medicaid Services (CMS) defines transitions of care as the movement of a patient from one setting of care to another. This setting may include hospitals, ambulatory care practices, ambulatory specialty care practices, long term care facilities, home health, and rehabilitation facilities. It involves care coordination that ensures accurate clinical information is available to support medical decisions by both patients and providers.<br></p><p>“An ideal transition is grounded in knowing who the patient is—their goals, wishes, needs, and support systems,” says Kathleen McCauley, PhD, RN, FAAN, FAHA, professor of cardiovascular nursing at the University of Pennsylvania School of Nursing. “And there have to be partnerships that happen between the person and their network and where they’re going in the continuum.”<br></p><p>McCauley refers to a study she was part of—a qualitative analysis of what patients and families feel on discharge: “One thing that stood out was they often felt like they were out in the wilderness,” she says. “Good transitions anticipate what will be needed and help the patient and family prepare. You can’t do this in a 30-minute interview at the bedside. Everyone needs to work together, starting with identifying what’s important to the person and knowing what their goals are.” </p><h2>From Miscommunication to Connection</h2><p>Transitions have always been a challenge, plagued by miscommunication, lack of communication, and delays in communication. Value-based care initiatives have helped, suggests Kumar, “because no one wants to be penalized for high readmission rates or wasteful utilization.” This has motivated better communication between settings, but gaps still exist, he says, and while it may seem obvious that better communication is the answer, it’s easier said than done. <br></p><p>While EHRs have evolved over the years to improve communication, Kumar says, “Even today, we are facing challenges getting hospitals to understand what is happening in nursing homes. The hospitals and hospitalists are looking after their facilities’ interests and want to move COVID patients out sooner, but we need to protect our vulnerable residents, so we want patients tested first before they can enter our facilities.”<br></p><p>Nonetheless, some good has come out of the pandemic. Robert Choi, chief executive officer of Caraday Healthcare in Austin, Texas, says, “The pandemic revealed that hospital and skilled nursing facility partnerships are strong, and that nursing homes are seen as an essential part of the health care continuum. It also exposed opportunities for greater innovation, integration, and <a href="/Issues/Special-Features/Pages/Interoperability-Where-Do-We-Stand.aspx" target="_blank">interoperability</a>.”<br></p><p>Having a care management company or dedicated team to follow up on and track patients throughout the continuum can help promote seamless movement. “We formed our own home health and home-based care program to navigate patients from the hospital to the skilled nursing facility to home,” Choi says. “We also have strong partnerships with physician groups through the continuum of care who are essential across these transitions.” <br></p><p>Choi says his company has focused its internal analysis, research, and development of systems and processes with the goal of facilitating a safe discharge home. “We are building integrations and working with our health care partners and physicians to ensure we aren’t beholden to 17-plus different communication platforms and software subscriptions,” he says.<br></p><p>Despite these kinds of advances, data exchange continues to be a challenge. “We always strive to keep open lines of communication and provide real-time information,” Kumar says. “And we continue to highlight the challenges related to EHRs and the importance of nursing homes having access to real-time data. In particular, real-time medication reconciliation is crucial.”</p><h2>Warm Handoffs Are Hot</h2><p>Warm handoffs have always been shown to be effective, Kumar notes. Communication is important, but sometimes a lack of time gets in the way. “However, a quick text or a two-minute phone call can be a tremendous help when a patient is being transferred,” he says. “In fact, it goes a long way to help the physician and care team understand what is happening with that patient. It’s important to put some time and effort into it.” <br></p><p>Kumar says that it is also essential to have a protocol for “mandatory warm handoffs.” One option is to have a dedicated liaison who can talk to families, patients, and providers when patients leave or come back to the facility. That can go a long way toward ensuring patient safety, he says.<br></p><p>“It would be helpful to have nurse practitioners onsite who are trained in transitions of care and who can be contacted if a patient experiences an acute change,” McCauley adds. “They can focus on putting the pieces together and keeping patients out of trouble and, whenever possible, out of the hospital.”<br></p><p>It helps to have a good rapport with hospitalists so that patient transfers aren’t the only time providers initiate communication. “Periodically I go to their meetings, and sometimes they ask me to do educational presentations,” Kumar says. “For instance, I’ve talked about the Beers list and medications that should be prescribed carefully, particularly in frail, older patients.”<br></p><p>It also can help, McCauley suggests, to have tip sheets or checklists to address problems the patient is likely to experience, such as constipation or ambulation challenges. This can help prevent surprises and issues that can fall through the cracks after a transition. <br></p><p>Telemedicine helped enable virtual communication during the pandemic. However, Choi notes, “As a veteran of telemedicine and virtual care, I am the largest supporter of digital health. However, a telemedicine visit doesn’t solve the need for more information sharing and care coordination. There is a lot of communication and interactions among multiple parties that need to happen. There also are processes that need to be designed and implemented between health care ecosystem partners.”</p><h2>Education Makes a Difference</h2><p>“The tool I’ve found to be most useful is education,” Kumar says. “People want to do the right thing, but there is a lot of misinformation, doubts, and questions. Having something like a one-on-one dialogue or a webinar to ensure everyone has consistent, up-to-date information helps.” <br></p><p>The need for education isn’t limited to providers and staff. “Sometimes families or patients misunderstand what they are told, and by the time they come to us, they can have a lot of misconceptions,” he says. “First we need to sit down and find out where they’re coming from and what happened. It’s all about transparency, honesty, and humility.”<br></p><p>Family communication and education also need to involve what the patient will need on returning home and what that involves, McCauley says. “We don’t have a system designed to meet the needs of elders when they go home. We expect family members to deliver care that would be challenging for a trained nurse, and the patient is stuck in the middle.”<br></p><p>Strong partnerships and consistent, ongoing communication between nursing homes and their primary care provider are key to ensuring no one feels that they’re in the wilderness or being asked to provide care that is beyond their skill and knowledge levels.<br></p><p>Most people are open to communication “if you take a blame-free approach and not point fingers,” Kumar says. “If there is a problem at the other end, we need to be able to talk about it, and we expect them to tell us if we could have done something better or different.” It is essential to espouse patient-safety culture with a focus on brainstorming for success instead of placing blame or making excuses. “We need to prioritize patient-safety culture to enable everyone to perform at their best,” he says. </p><h2>The Road Home</h2><p>“In our research, the most common goal patients have is to go home, live and function in their house, and not be a burden,” McCauley says. “That’s a phenomenal goal, but first you have to be safe, be able to make or get meals, take medications safely, and so on. You have to participate in physical therapy to get stronger and have the stamina to care for yourself and not deteriorate.<br></p><p>“Using goals as a driver is a way to get people motivated and help them appreciate small successes in physical therapy. “ <br></p><p>To identify these goals, it is essential to give patients and families, including family members who know the patients and their history, a place at the table and really listen to their goals and expectations. It’s important to realize they may have unrealistic expectations.<br></p><p>To help them focus on what they can do and to set realistic expectations, “We need to find out what gives them joy and what quality of life means to them,” McCauley says. “Start with what’s important to the patient, and then you can put a plan into place that includes good symptom management.”</p><h2>When Readmissions Happen</h2><p>It’s imperative to look at each readmission and understand what happened, Kumar says. “We do a root-cause analysis of every hospitalization—what happened, what caused it, and if/how it was avoidable.”<br>McCauley says that while it’s essential to prevent avoidable readmission, there are times when it’s appropriate to send a patient out.<br></p><p>“An urgent visit with the physician is better than an ER [emergency room] visit, and an ER visit is better than a hospitalization. But we need partnerships between nursing homes and the hospital to plan, communicate, and determine when a transfer is essential and what it will take to ensure a smooth transition.”<br></p><p>Putting all the pieces in place to ensure smooth transitions of care is easier than it used to be because value-based care principles and technology are available. However, transitions aren’t yet as smooth as they can be. Everyone has been stretched, but there will be greater opportunities to improve care transitions as the entire health care industry gains bandwidth. Then, all the lessons learned will present ways and means to re-evaluate and re-engineer gaps in care and communication. <br></p><p>Read More: <a href="/Issues/Special-Features/Pages/Make-Advance-Directives-Mobile.aspx">Make Advance Directives Mobile</a></p><p><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | Care coordination between nursing homes and hospitals is critical to ensure a timely exchange
of clinical information. | 2021-10-01T04:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/1021/1021_CF1.jpg" style="BORDER:0px solid;" /> | Culture Change;Quality | Cover Feature |
Customizing Screening for Accuracy and Convenience | https://www.providermagazine.com/Issues/Special-Features/Pages/Customizing-Screening-for-Accuracy-and-Convenience.aspx | Customizing Screening for Accuracy and Convenience | <p><img src="/Issues/Special-Features/PublishingImages/2021/1121/NateSchema.jpg" alt="Nate Schema" class="ms-rtePosition-1" style="margin:5px;width:210px;height:210px;" />When the COVID-19 pandemic hit in early 2020, providers needed all hands on deck, all the time. When the Centers for Medicare and Medicaid Services (CMS) issued new requirements on visitor restrictions, The Evangelical Lutheran Good Samaritan Society—the largest not-for-profit provider of senior housing and services in the United States—was ready with a customized solution that has helped streamline visitor screenings and saved staff time. </p><p>Nate Schema, vice president of operations at Good Samaritan Society, oversees 300 locations across 22 states. “When the pandemic broke out, we realized quickly that we would have to hardwire a system for visitation,” he says. “So we custom-built a platform to integrate with our system.”</p><h2>Reasons For Change</h2><p>A key reason for the change was Schema and his team wanted to have automated information to share with CMS and with surveyors. </p><p>“We didn’t want to be reliant on bundles and reams of paper and have to go through that when checking information at all our sites,” he says. “We are able to flag any symptoms that people might be having and then integrate that into how we communicate our results to CMS. We wanted to broadly hardwire all we were doing.” </p><p>For example, if a surveyor were to come in and ask for a record of those who have checked into the facility, Schema and his team wanted to have information ready to share on demand. “We would have all kinds of automated background that we could run reports on and demonstrate all that we were doing to keep our residents safe,” he says.</p><h2>How The Program Developed<br></h2><p>To start, Schema and his team purchased a number of iPads, and then the company’s developers wrote a new program. “We incorporated all of the screening questions that we were required to ask of visitors and employees upon coming into our locations, and then we deployed that to all 300 sites,” he says. “So whether you were going to one of our senior living communities or to one of our skilled nursing facilities, we have that iPad technology in place when people come in our doors.”</p><p>The new screening process was launched in April 2020, at all 300 locations. “We wanted to make sure we had visibility of this process of all our locations,” says Schema. </p><h2>How It Works <br></h2><p>Walking into the front entrance at a Good Samaritan facility, a visitor or employee will arrive to a kiosk that includes an iPad. The visitor selects their options on the touch screen and will have their temperature taken, most often by an automated temperature screening hung on the wall next to the iPad. If any symptoms are detected, the visitor is asked to leave. Repeat visitors have information on file. “We prepopulated our employee data, and the visitor information accumulates over time,” Schema says. </p><p>If anything is flagged or if people are having symptoms, an email notification is automatically sent to that facility’s site leader. That individual then communicates the issue to family members and staff as appropriate. “While we built some communication templates out, we encourage all of our leaders to put their personal touch and style on the message, because no one knows their family members like they do,” says Schema.<br></p><h2>Adoption Among Staff</h2><p>Every week Schema and his team take two actions to help keep everyone aligned. The first is a weekly 500-person teleconference with all of Good Samaritan’s department leaders, location leaders, and executive team. The second is every Thursday the team sends out a leader link message that includes updates of the screening program and what the team has observed in terms of adoption. “Right now we have conducted over 3.5 million check-ins between family members and employees,” says Schema. “Those are screenings we’ve done through this automated process. So we know it’s working, and it continues to be a vital resource for our people so they can focus on what they do best, and that’s taking care of the residents.”</p><h2>Regular Updates</h2><p>Updates occur periodically with questions that are asked on the kiosk. Early on during the pandemic, everything had to be actively screened. “So, regardless of the technology being right there, we [employees] actively had to ask people questions and take their temperature,” Schema says.</p><p>“Now where states allow, we are able to move toward a passive process. A family member or visitor comes in, they type in their own info, and in many locations their temperature is taken by the automated system.”</p><p>The technology, which has brought multiple benefits to Good Samaritan Society, is here to stay, says Schema. “This technology has allowed us to communicate with not only our employees at a different level but also with our family members,” he says. </p><p>As a result, Schema and his staff are proud to be more visible and more transparent in real time. “What we learned early on in the pandemic is that we wanted to make sure that all of our family members are reassured on a daily and a weekly basis that they knew what was happening in our buildings,” he says. “Whether we have one positive case or one person with symptoms, we wanted to be able to share that.”</p><h2>Future Plans <br></h2><p>A recent update includes a visitor check-in reservation process. While it has not received the same kind of adoption as the screening process, Schema sees potential. “I really envision that as we continue to move forward, we will see more people schedule times to come visit,” he says. “We can’t have 50 family members in our buildings like we once could. We need to know who’s coming to our building at all times because of the nature of this virus.”</p><p>Capacity tracking, which would be unique site to site, is something that the team will continue to monitor as a future enhancement.</p><p>The best advice from Schema to fellow providers is to leverage technology and not be afraid to dive in. “Whether you are a stand-alone operation or a member of a multifacility chain, we need to continue to leverage technology in new and creative ways if we are going to truly be able to meet the demand that’s out there,” he says.</p><p>“There’s no question that we are working through some unprecedented shortfalls with staff. So saving even a couple of minutes—whether it’s screening in or scheduling visitation—those all add up. I would encourage all providers to jump in feet first on this one.” <br></p><p></p> | Good Samaritan keeps everyone in the loop with weekly updates to each of its 300 skilled nursing and senior living centers. | 2021-11-01T04:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/1121/CF1.jpg" style="BORDER:0px solid;" /> | Management;Quality | Cover Feature |
Cyber Security Alert! | https://www.providermagazine.com/Issues/Special-Features/Pages/Cyber-Security-Alert.aspx | Cyber Security Alert! | <p><img src="/Issues/2021/January/PublishingImages/cybersecurity-0121.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 20px;width:190px;height:190px;" />Mega guru Steven Chies fills Senior Editor and Writer Patrick Connole in on all the ways criminals can worm their way into sensitive company data via phony emails. Chies also offers tips for how employees can spot them. <a href="https://pagepro.mydigitalpublication.com/publication/?m=63330&i=687740&p=10"><strong>See Page 8.</strong></a></p> | Steven Chies says there is no let-up in the need for owners and operators to be on alert for attempts by criminal elements to hack into their computer systems.
| 2021-01-01T05:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/cybersecurity-0121.jpg" style="BORDER:0px solid;" /> | Technology;Cyber Security | Special Feature |
Designing Spaces for Memory Care | https://www.providermagazine.com/Issues/Special-Features/Pages/Designing-Spaces-for-Memory-Care.aspx | Designing Spaces for Memory Care | <p>COVID-19 has affected people and health care systems in multiple ways. Previous flu seasons and outbreaks have demonstrated the challenges of infection control and prevention for vulnerable populations living within the parameters of a closed community.<br></p><p>Meg Sutton, director of interior design at Direct Supply, says that while isolation was also felt during previous flu seasons, it has been a larger issue during COVID, which has led to more client focus on safely visiting family.<br>In her role within the design and construction arm of the company, Sutton works on technical and creative development, professional development of her team, business development and quality control, and memory care interior design.<br></p><p>“What we have seen come out of COVID in terms of design has to do with this idea of dividing\conquering, or creating smaller environments from larger environments,” says Sutton. <br></p><p>Generally speaking, memory care design has always been about limiting exit points and limiting the risk of elopement. “Here that’s still a concern, and it’s still something we incorporate into the designs we do, but now it’s also about how do you get people safely in and out of the building,” says Sutton. </p><h2>Changing Dynamics</h2><p>A priority nowadays for Direct Supply design clients has been how to enter spaces without traveling through other parts of the building, which is something that was not seen before. “Our challenge was how do you create an environment that allows you to see your family regardless of what’s going on in the outside world rather than having this locked-down mode,” says Sutton. <br></p><p>For memory care specifically, having separate entrances available for not only staff but also for families and visitors when allowed to enter into those sections of the building has been critical. “It’s been really important, and one of the ideas that we’ve come up with and that we’ve seen implemented in some areas is this idea of a transition space for memory care,” says Sutton. “This space should be adjacent to the exterior of the building, so again you’re not traveling through other areas of the building to get there.”<br></p><p>Think of a space where a resident, family member, an art teacher, or a visiting physician can enter the memory care space from the outside. “Your exterior space in general and outside space is your first line of defense,” says Sutton. “How you enter this transition space has become really critical to maintaining relationships outside the building.”<br></p><p>In an assisted living community, one may see a discovery room, a closing room, or even a hospitality suite. “Any of these could potentially be converted or otherwise adapted to that transition space,” says Sutton. “It doesn’t have to be large, and it needs to be occupied by only a few people, but it needs to be accessible from inside and outside.”<br></p><p>Another example is a community that has a transition lobby between the assisted living portion and the memory care portion. “Again, that was originally focused on elopement, but that type of space can also be converted into a receiving lobby where people are coming in directly from the outside, depending on where those places are located,” says Sutton.</p><h2>The Great Outdoors</h2><p>When thinking of spaces where there is a low risk of spreading illness, an outdoor space like a courtyard comes to mind, but there are caveats. While outdoor dining has been a trend for some time, often, seniors don’t use outdoor space because it’s uncomfortable—either too hot, cold, or windy for a fragile population. <br></p><p>“You can’t just take an outdoor patio and throw some chairs on it and call it a rest in space and expect residents to take advantage of it,” says Sutton. “You really need to make sure that it is well-shaded and well-protected from the elements as the best way to encourage people to use it, especially when you are dealing with a fragile population in assisted living or memory care,” she says. Then comes programming—activities that draw people to the space and help everyone understand how it’s being used. </p><h2>Staying Ahead</h2><p>In a challenging year of COVID, collaboration and coordination have taken a different tone for Sutton and her team, which is spread all over the country. The team meets weekly to talk about what’s going on, what the trends are, and how to stay creative. One of the ways is offering a review to help clients stay safe and ahead of the curve.<br></p><p>“We offer our clients a COVID review,” says Sutton. “We take a look at their floor plan—either an existing one that needs refreshing or floor plan upcoming. We talk about how we can divide and conquer the population given their issues with COVID.” Indoor air quality is a large component to the health and wellness of a building, and it is frequently discussed among clients. </p><h2>Future Focus</h2><p>Expect to see a big uptick in renovation and repositioning in the future, such as adding additional beds or adding memory care into assisted living or independent living, says Sutton. This pertains most to providers that were doing well before the pandemic and are continuing to do well, picking up failing communities or aging assets and adding them to their portfolios.<br></p><p>Changes in ownership play into that shift and will lead to marketing communities in a different way, such as marketing separate entrances for staff and visitors. <br></p> | Memory care design has always been about limiting exit points and limiting the risk of elopement. | 2021-05-01T04:00:00Z | | Design | Cover Feature |
Diving into Dining with Sparkling Innovations | https://www.providermagazine.com/Issues/Special-Features/Pages/Diving-into-Dining-with-Sparkling-Innovations.aspx | Diving into Dining with Sparkling Innovations | <p>Like so many aspects of everyday life, dining will take on new dimensions post-pandemic. To ensure that residents stay safe and can again enjoy the social aspects of dining, nursing homes, assisted living communities, and other long term care settings are embracing creative ideas, thinking in fresh new ways, breaking some norms, and making meals a source of health, fun, and celebration.</p><h2>Creating Dining Options</h2><p>During the pandemic, many communities devised creative ways to make dining fun for residents. Some took mobile margarita or mimosa carts (often nonalcoholic) around to rooms, while some had restaurant-style dessert carts with an array of tempting sweets. <br></p><p>Some places had live chef demonstrations where residents could enjoy the fresh food they watched being prepared. <br></p><p><img src="/Issues/Special-Features/PublishingImages/2021/0721/Dining_LauriWright.jpg" alt="Lauri Wright, PhD" class="ms-rtePosition-1" style="margin:5px;width:145px;height:186px;" />“When you’re shut in your room, time gets away from you, and people sometimes forget to eat,” says Lauri Wright, PhD, RDN, LD, national spokesperson for the Academy of Nutrition and Dietetics. “It’s useful to have more touchpoints and opportunities to eat and intake fluids,” she says. Staff have gotten creative in this regard.<br></p><p>For instance, afternoon snacks have taken on a new dimension. Some communities celebrated special events such as National Peanut Butter Day or National Pretzel Month with themed treats. “During the summer, we brought in a snow cone truck,” says Ashley Langley, LBSW, director of social services at Hearthstone Nursing and Rehabilitation in Round Rock, Texas. “We took a few residents at a time out to get snow cones, and we brought in treats for those we couldn’t take outside. It was lots of fun, and everyone loved it.”<br></p><p>Especially where such innovations became popular with residents, they can be continued in some capacity even as the pandemic winds down and buildings open up. For example, in many buildings, activities staff got involved with helping residents to eat.<br></p><p>“For example, our activity team will have late morning activities, such as baking cinnamon rolls, to stimulate appetite,” says Phyllis Famularo, DCN, RD, CSG, LDN, CDP, CADDCT, senior manager of nutrition services for Sodexo. “Having food cooked right on the unit triggers hunger. This is one of the biggest things we can do.”</p><h2>Safety and Socialization</h2><p>Dining is back, Wright says. “Slowly we are starting to do small group meals with sparser seating in the dining rooms,” she says. “We also are finding some of those vacant spaces, such as sunrooms, to bring people together in a social but safe way.”<br></p><p>In locations and climates where outside dining is viable, it has become an increasingly popular option. “This can be challenging for residents with memory issues or dementia, but you can monitor people in small groups for a barbeque or picnic,” says Famularo.<br></p><p><img src="/Issues/Special-Features/PublishingImages/2021/0721/Dining_GregHunteman.jpg" alt="Greg Hunteman" class="ms-rtePosition-2" style="margin:5px;width:145px;height:181px;" />Greg Hunteman, AIA, president of Pi Architects in Austin, Texas, agrees. “There will be a lot more opportunities for external dining, including the use of covered patios and enclosed sun porches,” he says. “Inside, there will be a need for cutting-edge air filtration. Ensuring safe, controlled air circulation in buildings will be essential.”<br></p><p>However, he says, residents shouldn’t feel claustrophobic in indoor dining spaces. There should be windows and lots of natural light. At the same time, it will be important to have indoor areas that open onto patios, courtyards, balconies, and decks that enable access to fresh air and sunshine.<br></p><p>Hunteman says color can impact appetite, so splashes of reds and yellows will help trigger hunger as well as create bright, cheerful dining spaces. Ultimately, he suggests, facilities will offer multiple and more varied dining venues—from bistros and coffee shops to takeout windows, food trucks, and pop-up cafes.</p><h2>Innovations in Fun</h2><p><img src="/Issues/Special-Features/PublishingImages/2021/0721/Dining_AshleyLangley.jpg" alt="Ashley Langley" class="ms-rtePosition-1" style="margin:5px;width:145px;height:181px;" />As more residents and staff are vaccinated, watch for the return (or the start) of happy hours. “We enjoy going home or out with friends for a glass of wine and a little conversation,” Langley says. </p><p>“Residents should be able to do that, too. We limit the amount of alcohol, but residents can have a drink and a snack, and we play music that they grew up with. It has a great impact on mental well-being and mood,” she says. <br></p><p>At least for the time being, gone are the plates of cookies and bowls of fruit in dining halls and common areas. To maximize safety and sanitation, expect to see more prepackaged snacks, including healthy items such as dried fruit and cheese. Shared condiments and items such as cream and sugar likely will be replaced by individual servings in sealed packaging. <br></p><p>The farm-to-table concept has become popular in the dining world, and it is making its way into senior living as well, says Hunteman. “Onsite gardens and orchards are huge. People like to eat fresh foods that are grown in their own backyard and that they have had a hand in producing.”</p><h2>Opening Doors Is Not Enough</h2><p>As much as isolation was problematic during the pandemic, the truth is that many people got used to eating in their rooms and are hesitant to come out again. As Famularo says, “Some residents need enticement to get out of their rooms. Things like a happy hour with snacks or someone playing the piano during meals can be helpful.” She suggests that when nursing and other staff are engaged, they can help get residents out and enable them to embrace new routines. <br></p><p>It is important to realize why residents may prefer to stay in their rooms, providers say. After all, they’ve been told for a year that it was necessary to keep them safe. Now managers are telling them it’s safe to come out. This may be confusing for some.<br></p><p><img src="/Issues/Special-Features/PublishingImages/2021/0721/Nutrition_PhyllisFamularo.jpg" alt="Phyllis Famularo" class="ms-rtePosition-2" style="margin:5px;width:145px;height:181px;" />At the same time, Famularo observes, “Many residents are really enjoying going back to group dining; some never really did like it. We need to realize that our outgoing, social residents were impacted the most by having to eat in their rooms.”<br></p><p>Sherry Perry, a long-time nursing home and home care certified nurse assistant, says, “Some residents don’t want to come out because they’re scared. A lot of them know that they got the vaccination, but they don’t necessarily understand it means that they can safely be more social. This needs to be explained to them.” <br></p><p>“Start slow,” she says. “Bring them out a little at a time. Be encouraging and supportive.” <br></p><p>Although many residents may see their room as their safe zone, the warm weather and sunshine could be enticing. “We always see a big change in residents when the seasons change. When the sun is shining and it’s pretty outside, residents are happier to go and sit outside, dig in the garden, and make sure the bird feeders are filled,” Perry says. “If we can get them out now, we can help readjust them to spending time outside of their rooms.”<br></p><p>Of course, if people want to eat in their rooms, that is their right. However, says Wright, “we can make it more homey, with a separate space designated for eating, fewer distractions (turn off the TV), and provide soft music.”<br></p><p>With some residents staying in their rooms to eat, it can be helpful to position small portable ovens in different areas throughout the facility to bake cookies and stimulate appetites with tempting aromas, she says.<br></p><h2>Eating Assistance Through Devices</h2><p>Dining is particularly challenging for residents who have trouble feeding themselves. Assistive devices may help, says Famularo. “The best thing we can do as a team is to identify those who are just beginning to need help and address the issue before they start losing weight.” Devices such as weighted utensils and plates and bowls with lips that making scooping food easier can enable some residents to feed themselves in spite of physical disabilities or limitations, she says.<br></p><p>Anne Royer, president of The Meal Lifter and a family member of a resident in an assisted living community, says that such assistive devices not only can help residents feed themselves but also can help give them dignity.<br></p><p>“My mother-in-law was a lovely, elegant woman who always took pride in her appearance. We had dinner with her after she moved into assisted living, and because of her Parkinson’s tremors, she was spilling food on herself. She didn’t want to wear her meal, and she was embarrassed,” Royer says. “Once we made it easier for her to get food from the plate to her mouth, she was much happier and able to enjoy her meals. She gained back some of the weight she had lost.”<br></p><p>There are many “wonderful assistive devices available,” Royer notes. “It is useful to discuss them with staff and families and try to identify who might benefit from which ones. Then it is essential to train people on their use.”<br></p><p>During the pandemic when family members and volunteers were unable to come into the buildings, teams had to be more creative. Devices helped in some cases. However, Famularo stresses, “What works best is when we have all hands on deck—housekeeping, administrative, and other staff—all trained to help feed residents.”</p><h2>Putting Back the Fun in Food</h2><p><img src="/Issues/Special-Features/PublishingImages/2021/0721/Dining_MargaretRoche.jpg" class="ms-rtePosition-1" alt="Margaret Roche, MS" style="margin:5px;width:145px;height:181px;" />“We need to bring back the celebration of food and the joy food can bring in these settings,” says Margaret Roche, MS, RD, CDCES, CSG, FAND, founder of Illinois-based Roche Dietitians. “People will bounce back and fairly quickly if we focus on these things and get them engaged again in eating. <br></p><p>“When we bring back joy—the parties and the celebrations—we create an opportunity to connect with others on a human level, and with that comes the added benefit of improved nutrition,” she says. <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em><br></p> | To ensure that residents stay safe and can again enjoy the social aspects of dining, long term care settings are embracing creative ideas, thinking in fresh new ways, breaking some norms, and making meals a source of health, fun, and celebration. | 2021-07-01T04:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/0721/0721_Dining.jpg" style="BORDER:0px solid;" /> | Quality | Cover Feature |
HUD Program Offers New Options for Providers | https://www.providermagazine.com/Issues/Special-Features/Pages/HUD-Program-Offers-New-Options-for-Providers.aspx | HUD Program Offers New Options for Providers | <div></div>
<div>Amid growing concerns that interest rates are on an upward trajectory, a leading voice in the seniors housing funding space says skilled nursing and assisted living providers should be aware of the many benefits of the HUD (Department of Housing and Urban Development) Section 232 program, which has made positive changes to its policies that could benefit owners and operators by giving more access to refinancing tools.</div>
<h2 class="ms-rteElement-H2">Good Tool to Begin With</h2>
<div>Even before the changes, Erik Howard, managing director, real estate finance, Capital Funding Group (CFG) in Baltimore, tells <em>Provider</em> the HUD 232/233(f) funding option has been a mainstay for skilled nursing and assisted living market segments for years. So much so that the fundamental business for Capital Funding is bridge-to-HUD loans. These involve providing relatively short-term acquisition financing for a borrower, and eventually taking that out to permanent financing via the HUD 232/233(f) program. The HUD program permits refinancing of existing indebtedness with a Federal Housing Administration-insured loan.</div>
<div><br>But, what makes the program even more attractive now is the new policy that provides for “a shortened seasoning period for deals that have low leverage, relatively consistent performance, and where there has been an equity recapture for a bridge loan,” he says.</div>
<div><br>What that means in plainer terms is owners and operators who have little to no debt on their assets now can recapture some of that equity at a lower leverage point, and not have to wait for a prolonged period to refinance that debt through HUD 232/233(f). </div>
<div><br>“Let’s say that a building has no debt on it, and an owner/operator has had this facility for 20 years so they paid down the mortgage,” Howard says. “Historically, if you recaptured some of that equity and put some of those funds in your pocket, you would have to wait two years before you could go to refinance that debt through HUD.”</div>
<div><br>Now, with the changes, HUD looks at loan-to-value ratios on the asset as opposed to just the fact there was an equity recapture. “So, again, in that example, if you had no debt (and stable cash flow) you could cash out to up to 60 percent of the loan to value and could go immediately to HUD without having to wait.”</div>
<div><br>This gives providers an efficient option to redeploy money for capital improvements to a facility, or utilize in any number of ways. “It is really a great opportunity for owners who may want to put capital back into their buildings or use the cash for any number of things and really take advantage of still relatively low interest rates,” he says.</div>
<h2 class="ms-rteElement-H2">Why Did HUD Make the Change?</h2>
<div>“HUD has continued to grow their expertise in terms of overall industry knowledge and underwriting since the LEAN inception in 2008,” Howard says. “So, I think they recognized that the characteristics for these buildings and these owner/operators who have little to no debt have proven them to be strong borrowers thus good candidates for HUD-insured mortgages.” </div>
<div><br>This positive view of the risk, reward, and changing of HUD’s policies won out in the end. But, have providers and others really taken advantage of the new policy?</div>
<div><br>Howard doesn’t think so. “It was relatively slow out of the gate” with the components of the plan being worked out, but that seems to be shifting as the months go by, he says. “I would say it is continuing to gain more momentum, but there is definitely an opportunity for further education in the industry to let them know the program exists.”</div>
<h2 class="ms-rteElement-H2">HUD Has Improved Financing Options for Borrowers</h2>
<div>Pulling back a bit, Howard says historically, owners/operators may not have elected to take equity out in refinancing their facilities, in particular if they had no immediate use for the funds. “In the past, if you recapitalized a loan with your bank, you would have been required to wait two years until refinancing the loan with HUD; with that, a borrower would have some level of interest rate risk,”he says.
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<div><br>“In contrast, with the new low-leverage program, a borrower now has relatively good visibility with respect to its refinancing timeline and rates. A bank like CFG can provide a bridge loan to a borrower, and to the extent that the underwriting and debt criteria meet HUD requirements, CFG can submit the application for HUD refinancing almost immediately after that bridge loan has closed. That provides comfort to borrowers that they are able to obtain a fixed-rate HUD-insured mortgage within a reasonable time period.”</div>
<div><br>HUD and the new policy changes provide a much clearer execution strategy for borrowers and lenders and a clearer path to refinancing, he says.</div>
<h2 class="ms-rteElement-H2">Marketplace Working Through Issues</h2>
<div>In looking at the general marketplace for capital funding in the skilled nursing/assisted living industry, Howard says there is continued talk about potential reimbursement challenges to the Medicare and Medicaid programs, as seen in the recent federal budget and spending talks in Washington, with the financing world trying to gauge the direction of such trends. </div>
<div><br>As the skilled nursing sector deals with shorter lengths of stay and an ongoing battle with staffing, Howard says owners/operators are working through a number of strategies to mitigate immediate challenges.</div>
<div><br>“We think that many of the larger operators have worked through their issues with their various landlords or lenders to come up with solutions that hopefully will provide for long-term growth and stability in those operations,” he says.</div>
<div><br>Beyond the near-term headwinds, there are optimistic expectations in the offing. “We do believe and hope to see the occupancy gains that have been long predicted with baby boomers and are in a cycle where we really expect that to accelerate occupancy within the next handful of years,” he says. </div>
<div><br>“While there has been some pressure lately as it relates to both revenue and expenses, we are hopeful that those trends will start to turn and create overall positive results for owners and operators around the country.” </div>
| Amid growing concerns that interest rates are on an upward trajectory, a leading voice in the seniors housing funding space says skilled nursing and assisted living providers should be aware of the many benefits of the HUD Section 232 program. | 2018-04-01T04:00:00Z | <img alt="" src="/Issues/2018/April/PublishingImages/finance_t.jpg" style="BORDER:0px solid;" /> | Finance;Management | Special Feature |
Keeping an Eye on Oral Health | https://www.providermagazine.com/Issues/Special-Features/Pages/Keeping-an-Eye-on-Oral-Health.aspx | Keeping an Eye on Oral Health | <div>
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<p class="ms-rteElement-P"><span style="background-color:initial;">O</span><span style="background-color:initial;">ne of the very first skills taught to children in the early years of life is how to brush their teeth. Small children, who are often sensitive to the physical sensation of it, don’t always take it in stride. However, it soon becomes routine in childhood and automatic in adulthood, with the daily ritual of brushing and flossing done twice or more continuing into the future. In later years of life, they may be brushing fewer of their original teeth, or none at all.</span><span style="background-color:initial;"> </span><br></p>
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<p class="ms-rteElement-P">For the elderly entering long term and post-acute care (LT/PAC) facilities, the charge of brushing and flossing carries on, usually with the help of a certified nurse assistant (CNA).</p>
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<p class="ms-rteElement-P">While moving into an LT/PAC center may mark a new beginning, there is hardly anything new about a resident’s teeth. They may reflect the resident’s physical abilities, medications, and undiagnosed oral or other medical conditions. Taking oral hygiene a step further, to knowing the hidden signs of these conditions and how they appear, can make a difference to the resident’s oral and overall health.</p>
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<h2 class="ms-rteElement-H2">Undiagnosed Outcomes</h2>
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<p class="ms-rteElement-P">Often, oral conditions in the elderly are largely unknown. “Some of the most common oral health issues in the elderly population include undiagnosed and untreated periodontal disease, undiagnosed and untreated dental caries, difficulty with swallowing due to dry mouth, and undiagnosed and untreated dental infections,” says Sal Selvaggio, DDS, who had a private practice in general dentistry for 36 years in the District of Columbia.<span> </span></p>
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<p class="ms-rteElement-P">During his tenure as a dentist, Selvaggio treated a number of long-term patients who also became long term care (LTC) patients. Undiagnosed periodontal disease, many times unseen, can lead to a large number of problems, he says.</p>
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<p class="ms-rteElement-P">“It has sometimes been called an intra oral bedsore,” he says. “For example, if a patient in an LTC center has a bedsore, it is considered a real problem that can lead to many bad outcomes. Because periodontal disease is not readily visible, a large area of undiagnosed inflammation can cause multiple problems.”</p>
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<p class="ms-rteElement-P">Those problems include oral infections and the increase in circulating inflammatory factors that can have an effect on multiple organs and pre-existing diseases.</p>
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<h2 class="ms-rteElement-H2">Oral Trouble Triggers Body Trouble</h2>
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<p class="ms-rteElement-P">Poor oral health can also affect other health conditions in the body, says Selvaggio. These include an exacerbation of diabetes; aspiration pneumonia; possible contributing factors to stroke, heart disease, and dementia; and poor nutrition causing weight loss.</p>
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<p class="ms-rteElement-P">According to the Centers for Disease Control and Prevention (CDC), oral diseases and conditions are common among older Americans who grew up without the community water fluoridation and other fluoride products. Those with the poorest oral health are those who have economic disadvantages, lack insurance, and are members of racial and ethnic minorities. Individuals with disabilities also have an increased risk of poor oral health, CDC says.<span> </span></p>
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<p class="ms-rteElement-P">Medications also add to the complexity. Selvaggio says a number of commonly taken medications can affect the oral health of older adults. “These include blood pressure medications and antianxiety medications,” he says. “A big problem is the side effect of causing dry mouth, or xerostomia, for people taking these medications. This can cause an alarming increase in caries, swallowing difficulties (dysphagia), aspiration pneumonia, bad breath, and discomfort.”</p>
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<h2 class="ms-rteElement-H2">Education on the Frontlines</h2>
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<p class="ms-rteElement-P">So what does it take for caregivers, particularly CNAs on the frontline who are helping residents brush their teeth, to recognize the signs of a potential breakdown in oral health? The answer is education.<span> </span></p>
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<p class="ms-rteElement-P">The Carlos Rosario Training Center in the District of Columbia trains about 50 students per year for CNA certification. The center also helps with job placement, with about half of graduates going into hospitals and the other half working in care centers, including LT/PAC centers.<span> </span></p>
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<p class="ms-rteElement-P">Thanks to a partnership with the District of Columbia Dental Society Foundation, oral health care is a big part of the curriculum, says Laurel Anderson, coordinator of the program.<span> </span></p>
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<p class="ms-rteElement-P">While oral care is taught along with other activities of daily living in the curriculum, students take a deeper dive into it. “In the curriculum, we typically don’t get into the challenges of oral care in the elderly, and that’s where Dr. Selvaggio comes in,” says Anderson.</p>
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<p class="ms-rteElement-P">The goal of the in-depth portion of the program, taught by Selvaggio, is to educate the students in the biology of oral health, the relationship of microbes to infection, and the relationship of poor oral health to general health.<span> </span></p>
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<p class="ms-rteElement-P">After touching on these key areas, students are shown examples of healthy and unhealthy mouths so that they can understand what is normal and what is not when attending their patients.</p>
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<p class="ms-rteElement-P">The last two parts of the training include an overview of dental appliances students may come across as CNAs and how to provide oral care to patients with various abilities to self care.</p>
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<h2 class="ms-rteElement-H2">Seeing the Difference</h2>
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<p class="ms-rteElement-P">“Someone who’s not had that deeper dive is able to perform oral care, but they’re not able to recognize issues when they arise,” says Anderson, “and be able to report them.”<span> </span></p>
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<p class="ms-rteElement-P">The students in their curriculum are taught how to clean dentures, for example, and that’s where the curriculum leaves it. “But recognizing any issues with the dentures—like if they are chipped, cracked, or not fitting correctly, if those things come up, the deeper dive helps the students recognize that,” she says.</p>
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<p class="ms-rteElement-P">The in-depth training is given to the students to not only recognize the red flags of failing oral health, but to help them to act on it when needed. “The aim is to empower the students to be able to alert the medical staff when needed on dental issues,” says Selvaggio.</p>
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<h2 class="ms-rteElement-H2">Ongoing Education Plays a Role</h2>
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<p class="ms-rteElement-P">CNAs receive oral care training on the job twice a year and as needed at Forest Hills of D.C., a private, nonprofit, full-service retirement community. Creative and compassionate care techniques are the focus, says Janice Johnson, RN, nurse educator/infection preventionist at Forest Hills.<span> </span></p>
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<p class="ms-rteElement-P">Johnson says the idea for the onsite training began two years ago when she conducted a dining class in which the importance of oral hygiene was emphasized. “Research shows that if you provide oral hygiene prior to the meal, it will stimulate their appetite,” she says. “This also helps prevent weight loss.”</p>
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<p class="ms-rteElement-P">Partnering with a local dentist to gather research, Johnson incorporates it into the training. “Some techniques include approach [residents] from the front, make eye contact, and use verbal cueing and a hand over hand approach, where you’re putting your hand over their hand to demonstrate,” she says. She tells staff that if they use these approaches, they will get better outcomes and the resident will not be as resistant.</p>
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<p class="ms-rteElement-P">Medications also play a role in the state of residents’ oral health. “They have reduced salivary glands so their mouths are dryer,” Johnson says. “They take a lot of medications that affect their taste buds.”</p>
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<h2 class="ms-rteElement-H2">The Right Approach</h2>
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<p class="ms-rteElement-P">At Forest Side, the provider’s assisted living location providing care to people with Alzheimer’s or other dementia, Johnson says the key to proper oral care is knowing which residents have what type and stage of dementia so that staff use the right approaches. “Those residents exhibit very specific behaviors with the type of dementia they have,” she says. “Staff have to know all that so that they know how to approach them.”</p>
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<p class="ms-rteElement-P">Residents with Alzheimer’s disease, for example, may have hallucinations. Another resident with a different type of dementia may not hallucinate but may be combative.<span> </span></p>
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<p class="ms-rteElement-P">“The staff have a good baseline knowledge of dementia and the specifics of it,” she says.</p>
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<p class="ms-rteElement-P">Johnson says if residents are experiencing issues with eating or weight loss, she will review their medications to find the cause and then will do individualized training that is specific for each resident.</p>
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<h2 class="ms-rteElement-H2">Keeping Up Routine</h2>
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<p class="ms-rteElement-P">All residents receive routine dental care in the center’s dental suite, says Johnson. The dentist comes at least once a month and provides routine dental care for all residents there and whatever is needed—extractions or dentures, for example. A former director of nursing, Johnson says it has been a few years since more dentists started to accept Medicaid, and that has helped.<span> </span></p>
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<p class="ms-rteElement-P">What also helps, she says, is the center’s restorative nursing program, which aims to keep residents from declining functionally. “We have some residents that are on bathing and grooming—restorative nursing,” says Johnson. “Twice a day, six days a week, they are instructed on how to bathe or how to groom, which includes brushing your teeth, combing your hair, and so on.”</p>
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<p class="ms-rteElement-P">The regular training helps keep oral care at the top of mind for staff. “They are trained to look for anything abnormal in the mouth, or pain or bleeding or any type of discharge,” she says. “Immediately they will notify the charge nurse, who will call the dentist and get a dental consult. And that resident will see the dentist on their next visit.”<span><br></span></p> | For the elderly entering long term and post-acute care (LT/PAC) facilities, the charge of brushing and flossing carries on, usually with the help of a certified nurse assistant (CNA).
| 2018-07-01T04:00:00Z | <img alt="" src="/Issues/2018/July/PublishingImages/dental_t.jpg" style="BORDER:0px solid;" /> | Caregiving;Oral Care | Special Feature |
Landscape for Financing Remains on Firm Ground, Demand Robust | https://www.providermagazine.com/Issues/Special-Features/Pages/Landscape-for-Financing-Remains-on-Firm-Ground-Demand-Robust.aspx | Landscape for Financing Remains on Firm Ground, Demand Robust | <div></div>
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<img src="/Issues/2019/September/PublishingImages/finance.jpg" class="ms-rtePosition-4" alt="" style="margin:5px;width:490px;height:216px;" /> </div>
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<div>A leading player serving the financing and capital market needs of long term and post-acute care (LT/PAC) providers and investors tells Provider that financing programs and the markets remain robust in the broader LT/PAC industry and in the seniors housing market. </div></div>
<div> </div>
<div>Large, national provider brands and REITs (real estate investment trusts) have driven mergers and acquisitions (M&A) volume in recent months as both entities have looked to restructure their portfolios, divest non-core assets and non-strategic tenants, and rebalance their holdings through diversification into other parts of the continuum of care, according to Erik Howard, executive managing director, healthcare finance, Capital Funding Group (CFG).</div>
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<div>He says the increase in M&A activity over the past couple of years, which has continued into this year, has created highly liquid debt markets and driven competition among lenders, making financing solutions readily available to potential borrowers. </div>
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<div>Baltimore-based CFG, which bills itself as a one-stop shop dedicated to providing “full-service” financing and advisory solutions to the health care and multi-family industries, expects demand for LT/PAC to continue to grow as the broader industry sees increasing demand in the coming years from the influx of residents hailing from the baby boom generation.</div>
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<h2 class="ms-rteElement-H2">Popular Loan Programs</h2>
<div>When asked which of the many financing tools available to LT/PAC stakeholders and those in seniors housing is most popular these days, Howard says the answer largely depends on the specific needs of the borrower. But, Howard notes that one program typically popular for most borrowers is so-called “Bridge-to-HUD (Department of Housing and Urban Development)” financing. </div>
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<div>By definition, such Bridge-to-HUD loans are for borrowers who require a more timely and rapid financing option for acquisition; refinancing of existing loans; and/or repairs, renovations, additions, or conversions to properties. CFG provides bridge loans starting at $3 million, with no dollar limit on financings of larger transactions.</div>
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<div>“A bridge loan allows for flexible, timely financing and is a good alternative for straight-to-HUD loans,” Howard says. “Bridge loans allow for creative structuring solutions tailored to each unique situation and provide the ability to execute turnaround acquisitions, short-fuse transactions, and cash-out deals while arranging for an ultimate exit through HUD refinancing,” he says.</div>
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<div>HUD financing in general, either through a refinancing event following a successful end to the terms of a bridge loan, or a straight-to-HUD financing event, remains in favor for many borrowers because of the attractive terms HUD provides that endure in all interest rate environments. </div>
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<div>“Owners with portfolios of any size find the non-recourse, long-term, fully amortizing, and fixed-rate terms very attractive,” Howard says.</div>
<h2 class="ms-rteElement-H2">All Care Settings Active</h2>
<div>Within LT/PAC and seniors housing, he says M&A activity across the assisted living, independent living, and skilled nursing sectors has remained strong.</div>
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<div>Looking at what pressures there are on the capital markets and financing worlds, Howard says there are several macro issues that will continue to influence debt and equity markets. </div>
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<div>Clearly global financial market participants and borrowers alike are focused on the Federal Reserve, as well as the overall health of the economy. The Fed’s decision to reduce short-term interest rates, coupled with recent events in the currency market, have created a flight to quality for investors seeking stability in <br></div>
<div>U.S. Treasuries. </div>
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<div>This has been, at least temporarily, a great opportunity for borrowers to lock in long-term rates and has helped to keep cost of debt capital relatively cheap, with rates for HUD-insured mortgages approaching 3 percent. </div>
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<div>The yield curve is suggesting there is minimal inflation expected on the horizon, which could provide a near-term window to take advantage of historically low HUD rates for those companies that have traditionally utilized bank financing.</div>
<h2 class="ms-rteElement-H2">Consolidation Continues</h2>
<div>Much talk has occurred of late on bankruptcy developments among some providers, but Howard sees the worst as being nearing its end even as the topic continues to attract attention.</div>
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<div>“I feel the industry is moving in a direction that will reduce the number of these bankruptcies going forward,” he says. </div>
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<div>“As the industry becomes more complex, we are seeing a trend of regional companies acquiring assets from smaller operators while large, nationally focused operators also look to concentrate efforts in specific markets.” </div>
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<div>The operational nuances within the LT/PAC industry have become more complex as a result of changes to reimbursement models and local and state regulations, which has left the smaller operators in a lurch. </div>
<div>“We are seeing a trend of regional companies acquiring more of these assets within their geographic footprint,” Howard says. </div>
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<div>“These operators are large enough to have the economies of scale and organizational backing to run these facilities efficiently, while still being small enough to focus on the micro-operational aspects that can oftentimes be overlooked at some of the larger operators—health care is a local business.”</div>
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<div>At the same time, larger and nationally prolific operators have in many cases become overleveraged and may have met capital financing and lease payment challenges by breaking up their portfolios through sales of properties. </div>
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<div>“The acquiring operators have predominantly been more geographically hyper-focused [on staying within a certain region] and can be more nimble than larger operators,” Howard says.</div>
<h2 class="ms-rteElement-H2">PDPM Lurks This Autumn</h2>
<div>There is another priority issue lurking in the LT/PAC community and its interested investors, and that is the new payment model for skilled nursing centers coming online in October, Howard says. </div>
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<div>“I would say one of the primary subjects on everyone’s radar right now is PDPM, Patient-Driven Payment Model reimbursement,” he says. “We believe that PDPM represents an opportunity for the well-established operators to outperform their peers.”</div>
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<div>Howard says CFG also expects PDPM to enable market opportunities whereby operators that will not be able to successfully adapt to the changing reimbursement environment will divest assets, increasing the M&A activity.</div>
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<div>As for CFG and its results of late, he says the company has continued to be a top competitor in the market, resulting in closing nearly three-quarters of a billion dollars in combined bridge and HUD loans in 2018, a number that should be surpassed in 2019. “We have already closed over half a billion of combined bridge and HUD loans through July [2019],” Howard says. </div>
| Large, national provider brands and REITs have driven mergers and acquisitions volume in recent months as both entities have looked to restructure their portfolios, divest non-core assets and non-strategic tenants, and rebalance their holdings through diversification into other parts of the continuum of care. | 2019-09-01T04:00:00Z | <img alt="" src="/Issues/2019/September/PublishingImages/finance_t.jpg" style="BORDER:0px solid;" /> | Finance | Special Feature |
Making a New Life, One Step at a Time | https://www.providermagazine.com/Issues/Special-Features/Pages/Making-a-New-Life-One-Step-at-a-Time.aspx | Making a New Life, One Step at a Time | <div></div>
<div>
Ellen Tadese is not a typical certified nurse assistant (CNA). With a year-long tenure at Manchester Manor, a post-hospital rehabilitation and long term nursing care center in Manchester, Conn., Tadese is among the newest members of the team, but she brings with her years of life experience in difficult and challenging situations. </div>
<h2 class="ms-rteElement-H2">Fleeing Persecution</h2>
<div>Tadese fled as a refugee on March 25, 2006, from Eritrea, a country with about 5 million people located in the Horn of Africa. There, Tadese and her family faced religious persecution. According to Human Rights Watch, the Eritrean government’s human rights record is among the worst in the world. </div>
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<div>“I grew up with a beautiful family, and my country was good, but there was a lot of persecution for Christians,” says Tadese. To continue to practice her Christian faith without fear, she decided to leave. Her first stop was Sudan. She then trekked through the Sahara Desert where she remained for three months before journeying through the Mediterranean Sea for five days. Finally, she arrived in Malta. </div>
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<div>She would stay for three years in Malta working, and it wasn’t easy. “Over there it’s very difficult,” she says. “It’s a small island, and there are too many refugees.” But after three years, things changed for Tadese when she was given the opportunity to come to the United States. “The U.S. came in, heard my case, and upheld it,” she says. “They paid for my flight, and the flights of my husband and two children.” </div>
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<div>Tadese’s seven sisters and one brother are all out of Eritrea. One sister who just left the country is currently living in a refugee camp.</div>
<h2 class="ms-rteElement-H2">Taking Charge</h2>
<div>The next stop for Tadese was Springfield, Mass. She was pregnant at the time, and her third child was born there. A stranger in a new country, Tadese’s personal challenges came to a head when she took action to leave her then abusive husband. “I had no language, no family to help me,” she says. </div>
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<div>Tadese took to Google to figure out what to do next. She searched for information on domestic violence and how one should protect oneself. “I looked up what you’re supposed to do if you cannot live with an abusive person,” she says. And so Tadese left to live at a women’s shelter in Hartford, Conn., with her three young children at ages six months, one year, and five years. She stayed there for nine months. </div>
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<div>At the women’s shelter, Tadese met more challenges, but this time she found help. “I was working housekeeping at the time, and it was not easy for me to work or do anything because I needed to provide for my kids,” she says. But after securing housing with the shelter, Tadese was able to earn her certificate to be a CNA. She worked in home care for a year before her supervisor suggested she apply at Manchester Manor.</div>
<h2 class="ms-rteElement-H2">New Support</h2>
<div>Working at Manchester Manor has been a game changer for Tadese. “I am not just lucky but blessed to be at Manchester Manor,” says Tadese. “When I started this job it wasn’t really easy, it was very difficult, and they walked me through it, to be what I am now.” In the beginning she was under extreme emotional stress, and management supported her, she says. “I started with time management. I was saying, ‘Maybe I cannot do it,’ but they told me, ‘You can do it. You’re doing good.’ And I said, ‘I’m doing good? I’m so slow,’ and they told me, ‘No, you are a good aide.’” The staff stood by Tadese and were patient with her, she says. This gave her room to grow. </div>
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<div>The support from the staff at Manchester Manor continued, says Tadese, especially when it came to day care for her three children. </div>
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<div>“My schedule started out being from nine to four,” says Tadese. “Now it starts at seven. I had no family, no friends, and it was difficult. But they have been there for me like a family and a friend.” Tadese recalls coming in almost 20 minutes late during her first month. “They worked with me to get together my baby sitter and day care, and I am just blessed and thank God for this favor from them.”</div>
<h1>A Typical Day</h1>
<div>On a typical day, Tadese helps eight residents. Like every other CNA, she runs a normal routine of helping residents get up in the morning, getting them dressed, supporting personal hygiene, and helping them start their day. “The best part of my job is to help people in need,” she says. “Everything that they need I do all with my heart.”</div>
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<div>Most residents at Manchester Manor would describe her as patient, she says. “People give me compliments, they say, ‘You’re too kind.’ Love is patient so I love people the way that God loves me so I give that to people. And that gives me joy.”</div>
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<div>It’s the kind of joy that comes with giving with a full heart, she says. “I ask them, ‘How was your night, did you sleep good? How are you feeling?’ They tell me thank you for asking them. And suddenly we talk, they share with me their life and I share with them mine. They are so grateful that I am just doing my job. And that really makes it a pleasure to be part of their life, and I’m blessed to be a part of theirs.”</div>
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<div>Fellow staff have been especially supportive, which has gone a long way toward Tadese’s success, she says. “All staff are very good and kind to me. And with the language barrier, they understand me and are very understanding. They make it very easy for me to fit in.”</div>
<h2 class="ms-rteElement-H2">What’s Changed</h2>
<div>When asked what has changed about her since she fled Eritrea, Tadese doesn’t miss a beat to give an answer. “My view of life,” she says. “I’ve gone through so much, and life is very important to me. I feel different. In every minute there is an opportunity, and I don’t take it for granted.</div>
<div><br></div>
<div>“Working with older people has helped me to strengthen myself and gain wisdom to know that life is short and live the best of it every moment,” she says. </div>
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<div>Seeing life in a different way is based on many things, she says. One of which has to do with facing challenges differently. </div>
<div><br></div>
<div>“I have to be patient with whatever is around me or comes my way,” she says. “Life is not perfect but it helps to be strong in one’s mind and thinking, to not to give up and not to complain. You make it worse <br></div>
<div>when you complain in life.”</div>
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<div>And for when life brings challenges front and center, dealing with them takes not only patience and a strong mind, but a refocusing on what is really important, she says. </div>
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<div>“I am a spiritual person. I distract myself to not focus on the bad and not put my mind on the bad. I deal with what’s in front of me and refocus to start working toward the good,” she says.</div>
<h2 class="ms-rteElement-H2">A Special Lesson</h2>
<div>Tadese has several favorite memories during her year at Manchester Manor, but one stands out in her mind. Two male residents are friends who frequent the common areas of the center together. One day one resident wanted to sit in his preferred chair but didn’t see it behind him. So when his fellow resident sat in the chair he wanted, he noticed it and said, “Don’t touch it, it’s mine.”</div>
<div><br></div>
<div>“I said, ‘It’s OK, I’ll take care of it,’” says Tadese. “But the resident was insistent about sitting in his preferred chair.”</div>
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<div>Soon after, the other resident asked Tadese to help him walk over to the first resident. “And he said, ‘We are buddies. I apologize. We are not going to argue over the chair. We are better than that.’</div>
<div><br></div>
<div>“And that stayed in my heart,” Tadese says. “The love that they have for each other. He took the time to go there to not hold anything in his heart. It taught me that forgiveness is medicine and healing.” </div>
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<div><p class="ms-rteElement-P">Operated by the same family for two generations, Manchester Manor is nationally recognized for its first-rate reputation in delivering outstanding post-hospital rehabilitation and long term nursing care. Manchester Manor is the recipient of the prestigious American Health Care Association/National Center for Assisted Living National Quality Award—Gold and has been recognized as one of the country’s Best Nursing Homes by <em>U.S. News & World Report.</em></p>
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<p class="ms-rteElement-P">These reflect Manchester Manor’s dedication to quality and a nurturing environment for staff, residents, and their families. Manchester Manor and Arbors of Hop Brook make up Connecticut’s only family-owned Life Plan Retirement Community.</p>
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<div> </div></div> | With a year-long tenure at Manchester Manor, a post-hospital rehabilitation and long term nursing care center in Manchester, Conn., Tadese is among the newest members of the team. | 2019-08-01T04:00:00Z | <img alt="" src="/Issues/2019/August/PublishingImages/EllenTadese_t.jpg" style="BORDER:0px solid;" /> | Caregiving;Workforce | Special Feature |
Making the Right Connections | https://www.providermagazine.com/Issues/Special-Features/Pages/Making-the-Right-Connections.aspx | Making the Right Connections | <p><img src="/Issues/2021/August/PublishingImages/0821_Connections.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:100px;height:100px;" />Charles Turner is one of the founders of an innovative new company that markets an app aimed at helping long term and post-acute care facilities solve their staffing challenges. He will explain how innovation is coming to bear in caring for the nation’s elderly and people with disabilities. <a href="https://pagepro.mydigitalpublication.com/publication/?m=63330&i=716028&p=6&ver=html5" target="_blank">Read more.</a></p> | Charles Turner is one of the founders of an innovative new company that markets an app aimed at helping long term and post-acute care facilities solve their staffing challenges. | 2021-08-01T04:00:00Z | <img alt="" src="/Issues/2021/August/PublishingImages/0821_Connections.jpg" style="BORDER:0px solid;" /> | Management;Workforce | Cover Feature |
Parkinson Sees Bright Decade Ahead for Skilled Nursing, Assisted Living Providers | https://www.providermagazine.com/Issues/Special-Features/Pages/Parkinson-Sees-Bright-Decade-Ahead--for-Skilled-Nursing-Assisted-Living-Providers.aspx | Parkinson Sees Bright Decade Ahead for Skilled Nursing, Assisted Living Providers | <div></div>
<div>In an exclusive interview with <em>Provider,</em> Mark Parkinson, president and chief executive officer (CEO) of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), reveals the organization’s priorities for the coming months and beyond on the legislative and regulatory fronts.</div>
<br>At the same time, he notes how 2020 is a special year with both congressional elections and a presidential vote in November. And, on a more personal level, Parkinson discusses the factors that motivate him to start anew every January in the battle to promote the interests of the residents who reside in long term and post-acute care (LT/PAC) facilities and the providers who serve them every day.<br><br><strong class="ms-rteThemeForeColor-6-4" style=""><em><span></span>Provider:</em></strong> What are AHCA/NCAL’s priorities for 2020, and how does the association formulate these issues each year?<br><div><strong class="ms-rteThemeForeColor-9-4" style=""><span></span><span></span><span></span>Parkinson</strong><span class="ms-rteThemeForeColor-9-4" style="">:</span> The process is that the issues are driven by members. In the fall of every year we survey our board and our key constituency groups and ask them what issues they want to focus on for the following year. We hold a strategic planning meeting in November to review input and then make decisions on what to work on.</div>
<br>For 2020, the board decided that the principal issues will be first to protect any gains we achieve through the new PDPM [Patient-Driven Payment Model] to make sure that our benefits from PDPM continue. Second, to defeat the CMS [Centers for Medicare & Medicaid Services] rule that would restrict provider assessments and intergovernmental transfers. And, then thirdly to work to ensure that assisted living continues to be regulated at the state level and not at the federal level.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> PDPM was such a huge transition last year. Is there much more work to be done in this area for AHCA/NCAL in 2020?<br><div><span></span><span></span><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> PDPM and what happens with PDPM is one of our top issues. We are pleased with the success CMS had in rolling out PDPM. A thousand things could have gone wrong, but CMS got them all right, and the new payment model was successfully rolled out. Our members also pretty seamlessly implemented the changes, and while there aren’t data out yet it sounds like they are getting good results with patients, and of course that is the most important thing.</div>
<br>We continue to monitor PDPM and the impact it has on patients, and the issues of budget neutrality and expenses are high on our priority list. We will be following all of those things, and if adjustments are needed, we want to be involved with CMS to make sure the best interests of our residents and our members are first and foremost.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> This is an election year. Can you talk about how important it is to be active in the political and policy process as an association, and why grassroots interactions with members of Congress matter?<br><div><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> The reality is that in order to have a seat at the table in Washington, D.C., you have to be strong politically with your lobbying mechanism and you also have to be really strong on policy. So, we work quite hard on both the political side and policy side because ultimately policymakers are not influenced without strong, sound policies.</div>
<br>For grassroots, it is incredibly important as the most effective form of lobbying is not having people like me or outside consultants go into congressional offices to lobby, but instead the most effective lobbying is when members get active. And, really the best way to do this is for members to talk to members of Congress and get them into our buildings to see the work providers are actually doing and the challenges providers face in doing that work.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> When January rolls around every year, how do you stay motivated to start fresh?<br><div><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> It is really easy since one of the things I get to do with my job is to run around the country and meet with members in the locations where they are taking care of residents. When I am out doing that and see the work they are doing and hear the passion in the voices of their teams, it really becomes clear how important our work is in D.C., to have that work continue.</div>
<br>I was just in Iowa with Ted LeNeave [president and CEO] and his team at Accura HealthCare and was able to meet with all 40 of his administrators and directors of nursing, and meeting them made it easy to get excited to fight on behalf of people like that as they are all completely aligned with taking care of the residents in their charge.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> Is there a new focus on how AHCA/NCAL relays the successes of the profession in 2020?<br><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> We launched the Why I Care Campaign where members tell individual stories of success with residents and also tell why they are involved in the profession. I am convinced that showing data and percentage improvement in quality will not change public perceptions of our profession. It is the individual stories that are needed.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> Industry data seem to point to a bottoming out and possibly a modest strengthening of occupancy levels in segments of the LT/PAC space, like for skilled nursing centers. What is your view on occupancy levels moving forward?<br><div><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> We hope that we have made progress on occupancy, with data pointing to a possible bottoming out a year-and-a-half ago. And, at the same time occupancy may have bottomed out, the demographics started to help. This is because starting in 2018 and for the next 40 to 50 years, the 80- to 85-year-old group grew significantly. This of course will help occupancy.</div>
<br>Hopefully, the last 18 months are a period of stabilization and not a blip but a start of a long-term improvement.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> Another key issue for providers is workforce, specifically the ability to attract and retain staff. What is your take on where the association and profession stand on this significant concern?<br><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> With national unemployment so low [around 3.5 percent] there are going to be workforce challenges all over the country. We need Congress to pass our bill that will allow CNA [certified nurse assistant] training schools to operate easier, we need immigration reform to attract more workers to the country, and we are providing relief to our members by offering a new program on best practices for attracting and retaining workers. But, any scenario will be a challenge as long as unemployment is so low.<br><br><span><strong class="ms-rteThemeForeColor-6-4"><em>Provider:</em></strong><span style="display:inline-block;"></span></span> In a general sense, what is the business outlook for skilled nursing and assisted living?<br><div><span><strong class="ms-rteThemeForeColor-9-4">Parkinson</strong><span class="ms-rteThemeForeColor-9-4">:<span style="display:inline-block;"></span></span></span> I think the outlook for both is as positive as it has been in many years, particularly on the skilled nursing side. It was not long ago that skilled nursing was viewed as an uninvestable space, but the last few years with stable occupancy and gradual improvement in Medicare and Medicaid rates, the sector has stabilized with fewer bankruptcies and other problems. This, however, comes at a time the sector is still operating with nearly 0 percent margins nationwide.</div>
<br><div>Assisted living has been strong for the past 30 years as a sector to invest in, and though it is market-driven and there are some places where there is overbuilding, it remains so.</div>
<br>Taken as a whole, with the aging of the population and other factors, both skilled nursing and assisted living are poised to do quite well in the 2020s. <br><span></span><span></span><span></span><span></span><span></span><span></span><span class="ms-rteThemeForeColor-9-4"></span><span></span><span></span><span></span><span></span><span></span><span></span><span class="ms-rteThemeForeColor-9-4"></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span class="ms-rteThemeForeColor-9-4"></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span class="ms-rteThemeForeColor-9-4"></span><span></span><span></span><span></span><span></span><span></span><span></span><span class="ms-rteThemeForeColor-9-4"></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span><span></span> | In an exclusive interview with Provider, Mark Parkinson, president and CEO of AHCA/NCAL, reveals the organization’s priorities for the coming months and beyond on the legislative and regulatory fronts. | 2020-03-01T05:00:00Z | <img alt="" src="/Issues/2020/March/PublishingImages/MParkinson.png" style="BORDER:0px solid;" /> | | Column |
Picking Up the Pieces Post-Trauma | https://www.providermagazine.com/Issues/Special-Features/Pages/Picking-Up-the-Pieces-Post-Trauma.aspx | Picking Up the Pieces Post-Trauma | <p>In many ways, trauma is like snowflakes. It looks different for each person, and everyone experiences it in their own unique way. How someone responds to a traumatic event—such as a pandemic—depends on their history, beliefs, values, and other factors. Addressing trauma may seem like reconstructing a shattered vase, but putting the pieces together, even when it doesn’t look perfect, can result in something strong and beautiful.<br></p><p>The American Psychological Association (APA) defines trauma as an emotional response to an accident or natural disaster. Immediately after the event, APA says, shock and denial are typical. Longer-term reactions include “unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea.”</p><h2>Identify, Acknowledge Trauma</h2><p>While trauma and grief are different, they are intertwined. As Trish Childress, LCSW-S, ACHP-SW, a long term care social worker and director of supportive services, says, “Grief is a natural emotional process we go through after a loss, whereas trauma is an emotional response after a horrific event. But grief can be impacted by trauma, and trauma can be complicated by grief.”<br></p><p>Identifying trauma can be challenging, as people can respond in different ways. But there are signs to watch for, such as someone who was always a pleasant, cheerful person is now angry and short-tempered, or someone becomes preoccupied with death. <br></p><p>As with grief, ignoring signs of trauma isn’t healthy. Instead, Childress suggests, “Try to identify where the person is. Acknowledge that their mood, attitude, approach, etc. has changed, and support them through it.” She stresses that a person can’t receive information about someone’s trauma and just do nothing.<br></p><p>“If you open the box, you have a responsibility to help, and that can be challenging; knowing your boundaries and professional limits with co-workers is important,” she says. An option could be referring them to the Employee Assistance Program. “We don’t want to be passive, but we don’t want to be intrusive either,” she says.</p><h2>Check in With Co-workers</h2><p>After a situation such as a pandemic, natural disaster, or violent event, Childress says, “It is important to check in with team members and co-workers. HR [Human Resources] or other leaders can meet with team members and talk to staff. They can watch for shifts in attitudes, behaviors, or company culture and simply ask people if there is anything they need to do their jobs.” </p><h2>The Role of Control</h2><p>“Two of the greatest predictors of trauma are whether we feel like we had adequate support and how well we were able to take action on our own behalf after the traumatic experience,” says Carla Cheatham, MA, PhD, founder of the Carla Cheatham Consulting Group.<br></p><p>“I know of nurse leaders who when the pandemic began had team members who were terrified, and understandably so,” she says. “They were struggling with lack of information, understanding, and support. I suggested: Go be present with them; walk them through it.” <br></p><p>These leaders were concerned about their teams and took actions such as providing detailed written instruction on how to put on, take off, and dispose of Personal Protective Equipment, how to wash up, and how to protect their families when they went home. However, Cheatham observes, “Their presence gave their teams comfort that written memos and training programs couldn’t. This took time, but the impact was tremendous. It bonded teams and reassured frontline workers that they were cared for.<br></p><p>“Leaders who turn off their phones and listen to their people will build brand loyalty and connections and, ultimately, save much time, money, and energy in the long run.”</p><h2>Offer Options, Be There</h2><p>Giving people the option of initiating outreach for help is important as well. “We set up a call line where residents and employees could talk about their losses and their feelings,” says Jasmine Wadkins, LCSW, CDP, BF-CMT, CCTP, CEA, director of behavioral health services operations and education at Signature HealthCARE.<br></p><p>At the same time, it is important to realize that some people may not be willing or able to take that first step, she says. “If someone acknowledges feelings of trauma, you can say, ‘Would you like me to help you get assistance?’ or, ‘Can I make a call for you?’”<br></p><p>The personal touch is essential. For instance, instead of having corporate HR handle everything, Signature has HR people who deal with just a few buildings so they can get to know staff and communicate with them one-on-one. “We promote the Employee Assistance Program and do many referrals. We connect with area clergy and form other partnerships. As a result, we are able to make sure that employees get what they need.”<br></p><p>Encouraging self-care is important, especially after people have experienced a trauma or crisis. However, Cheatham stresses the need to realize that this isn’t a panacea. “We can’t tell people to exercise, eat right, take a vacation, or something else and expect everything to be okay. We need to look at what aspects of the workplace contribute to or trigger trauma and address them head on,” she says.</p><h2>Trauma Beyond Disease and Death</h2><p>There is no doubt that COVID has been responsible for much trauma, but there are issues beyond the illness that have negatively impacted many in long term care. The battles and controversies about vaccinations and masking, as well as conspiracy theories about the virus itself, have affected many people at all levels.<br></p><p>“When what we believe about the world gets smacked by reality, we hit an existential crisis,” Cheatham says. To let go of the belief that people will stop doing something that will hurt others when you find that this isn’t necessarily true, you first have to grieve, she says. “Once you do that, you can find a new place to come to. You can accept the reality of the world while understanding that when people are afraid, they’re not always their best selves.” </p><h2>Post-Trauma: PTSD</h2><p>With post-traumatic stress disorder (PTSD), which is not uncommon for people who have experienced traumas, specific triggers (such as loud noises) take them back to the event and make them feel fear, terror, or helplessness. Symptoms may include flashbacks, recurring dreams or nightmares, feelings of detachment, problems sleeping, and/or an exaggerated startle response.<br></p><p>Researchers have found that PTSD affects many COVID survivors, as well as those who have been impacted by the virus in some way. One contributor to this is economic stress, something that many people—including a number of frontline workers—experienced during the pandemic. <br></p><p>COVID-related PTSD can be challenging to treat. In “COVID-Related Post Traumatic Stress Disorder: What It Is and What To Do About It,” William Haseltine, PhD, said, “Building resilience is an important part of overcoming trauma, yet the ambiguity surrounding it makes it more difficult to build resilience. People can’t always resort to typical methods such as goal setting and shifting the focus away from the trauma and toward the future.”</p><h2>So Many Starfish</h2><p>It may be tempting to assume that once the worst of COVID is over, trauma will ease. However, this isn’t likely to be the case.<br></p><p>“When people have time to come up for air and reflect on what they’ve been through, we can anticipate that burnout and trauma rates will go up,” Cheatham cautions. In addition to trauma, there may be widespread compassion fatigue, the physical and emotional exhaustion that leads to diminished ability to empathize or feel compassion, and moral distress, which results when people are prevented from taking or are unable to take the correct response to a situation.<br></p><p>Even the best, most caring, and conscientious of leaders and organizations are likely to see these kinds of issues arise. In addition to dealing with the Delta variant and new outbreaks and infections, says Cheatham, many staff members are confronted by pushback on vaccinations and masking, as well denials of COVID’s existence or severity. <br></p><p>“When there are that many starfish on the beach, you can only pick up so many,” she says. “It will take time, effort, and patience to deal with the traumas resulting from the pandemic and other crises we’ve faced in the past few years.”</p><h2>Person-Centered Care for Staff, Too</h2><p>“We pride ourselves as an industry for doing person-centered care, but it’s not enough to do it for residents. We need to take what we do for our residents, like trauma-informed care, and do it for our staff as well,” says Cheatham, adding, “The best leaders I’ve seen understand this.”<br></p><p>Paige Hector, LMSW, national speaker and clinical educator, suggests encouraging staff to have an “empathy buddy.” An empathy buddy can be a colleague or co-worker or someone outside of the work setting. Engaging with an empathy buddy is an intentional practice that is different from usual conversation, one in which the individuals can share their feelings and explore underlying needs.<br></p><p>“This doesn’t have to be a formal arrangement or involve structured meetings,” Hector says. It could mean a "check-in," where each person has the opportunity to share while the other person listens deeply instead of typical back-and-forth talking or problem solving. It can be helpful to agree upon a set time, for example, five minutes each (or longer if the situation allows). <br></p><p>“It lays a foundation to help people understand and practice empathy, and it encourages mutually supportive relationships,” Hector says. Of course, she notes, “Participating in this type of practice is voluntary, and some staff may choose to not participate.”<br></p><p>It’s important for leaders to create a culture where everyone understands that trauma is an injury, and not a weakness, illness, or character flaw, says Hector.<br></p><p>“Few of us will get though life without being traumatized by something at some point," she says. “Infusing trauma-informed care in the facility fabric of daily interactions is the beautiful opportunity we all have to support each other in healing.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | Identifying trauma can be challenging, as people can respond in different ways. But there are signs to watch for. | 2021-12-01T05:00:00Z | <img alt="" src="/Issues/Special-Features/PublishingImages/2021/1221/CF1-Truama.jpg" style="BORDER:0px solid;" /> | Caregiving;Behavioral Health | Cover Feature |