Mother-Daughter Team Makes Waves<p><img src="/Topics/Guest-Columns/PublishingImages/IMG_2217.jpg" alt="Kris Mastrangelo, Savannah James" class="ms-rtePosition-1" style="margin&#58;5px 20px;width&#58;295px;height&#58;429px;" />Kris Mastrangelo, OTR/L, LNHA, MBA, chief executive officer and president of Harmony Healthcare International (HHI), shares her journey of over 20 years in the long term health care industry. </p><p><strong><em>Provider</em>&#58; You have been quoted in the past saying, “I left what I thought was my dream job to start Harmony, and now this is the dream job.&quot; Why did you start Harmony? </strong></p><p><strong>Mastrangelo&#58;</strong> Initially, I began Harmony in 2001 to lessen my travel for work as I was on the road every week, and I had two young daughters—Savannah 2 ½ and Carissa nine months old. However, within two years of starting the company, the client base grew beyond the New England area, and it became apparent that travel would always be a part of my job.</p><p>As the company grew, so did the family, adding two more daughters, Alexandra the Great in 2003 and Mia in 2007. In addition to the travel, I noted that the work I was completing for nursing homes across the country was necessary and relevant as a third-party, unrelated vendor [versus being a department within the organization] to provide the client with unbiased, objective analysis and systems implementation.</p><p>Systems require oversight and refinement, and often companies are too close to the situation to see the necessary change or opportunity. Consulting to different organizations was vastly different from being a VP [vice president] in one organization. Consulting brought a deeper understanding and awareness of different ways to solve the same problem or opportunity. </p><p><strong><span><strong><em>Provider</em></strong></span>&#58; </strong><strong>&#160;</strong><strong>What did you see that was missing from the industry that Harmony could provide?</strong></p><p><strong>Mastrangelo&#58;</strong> HHI connects the dots between care and&#58;</p><ul><li><strong>C</strong>ompliance</li><li><strong>A</strong>uditing</li><li><strong>A</strong>nalysis</li><li><strong>R</strong>eimbursement</li><li><strong>R</strong>egulatory</li><li><strong>R</strong>ehabilitation</li><li><strong>E</strong>ducation </li><li><strong>E</strong>fficiency</li><li><strong>S</strong>urvey</li></ul><p>Back in 1998, the Medicare Part A reimbursement system transformed from a retrospective cost-based system to a prospective payment system (PPS). This was the first step in which the health care services rendered to the patient/resident directly impacted the rate of reimbursement.</p><p>Before 1998, clinicians virtually had zero fiscal responsibility. As an occupational therapist (OT), licensed nursing home administrator (LNHA), MBA, and, most importantly, the daughter of a mathematician/systems electrical engineer, I could translate the care [service delivery] into the numbers [reimbursement], a powerful combination back then. </p><p><strong><span><strong><em>Provider</em></strong></span>&#58; What do you wish you knew as a young entrepreneur that you know today?</strong></p><p><strong>Mastrangelo&#58; </strong>There is nothing that I wish I knew back then that I know today because every mistake is an educational experience on how not to do it next time. I am all about the journey. While I always have a sense of urgency to get the job done right, I know today that errors can make us better. </p><p>However, two concepts that do resonate&#58;</p><ol><li>If it isn't broke, do not fix it. Andy Turner, Sun Health Group, used to say that to us all the time. Yes, it is crucial to refine and improve, but don't blow up a system for a minor change. </li><li>Prioritization is a skill set. Knowing what requires your attention first is how you need to manage every day. Because, as an entrepreneur, there is always something on the to-do list. </li></ol><p><strong><em>Provider</em>&#58; How has your daughter becoming an entrepreneur in the health care industry changed your relationship? </strong></p><p><strong>Mastrangelo&#58;</strong> Savannah and I have always had a very close relationship and having her begin her career in the health care industry has only strengthened our bond. When Savannah was away for college, we talked every day. And this has not changed. Our conversations are endless, and we jump from subject matter to subject matter with excitement and curiosity. She retains complex, voluminous amounts of information while being able to distill and synthesize the subject matter…. with apparent ease. This affords everyone the benefit of her creations and ideas.</p><p><strong><em>Provider</em>&#58; Tuning in to your motherly intuition, is this the path you knew she would take, or did you imagine her in another field?</strong></p><p><strong>Mastrangelo&#58;</strong> I always knew that Savannah would be an entrepreneur. I didn't expect her to do it so quickly and so gracefully. She was on the path to be an OT during her freshman year of college. Two things happened.</p><ul><li>She decided, “for fun,&quot; to take a computer class the summer of her Tufts University freshman year into her sophomore year, and she loved it.</li><li>The OT profession was discussing the need for doctorate degrees for the trade. Savannah attended a rigorous, academically intense high school and wanted to get into the workforce before graduating college.</li></ul><h2><span class="ms-rteForeColor-10 ms-rteFontSize-3">Savannah James</span></h2><p>Developing a calculator to determine the reimbursement rates for patients in a long term health care facility may not be what a young mind dreams of creating when imagining the future. For Savannah James, daughter of Kris Mastrangelo, reimbursement, patient advocacy, and the complexities of ever-changing regulations have always been standard dinner table talk. The mother-daughter team is rare in the health care industry, let alone the technology field, with two generations mirroring one another's journey through entrepreneurship. <strong><br></strong></p><p><strong><em>Provider</em>&#58; Please describe Hopforce.</strong></p><p><strong>James&#58;</strong> Hopforce's mission is to optimize processes (via technology) in the health care industry. Our primary focus is the PDPM [patient-driven payment model] calculator, i.e., pdpm-calc.com, specifically designed for the long term health care industry and specific Medicaid Case-Mix States. In just a couple of clicks, the user can obtain the Medicare Part A or Medicaid Case-Mix reimbursement level by day and for the entire patient stay. </p><p>Simplicity in the calculator functionality is paramount; it was important that we make<span style="text-decoration&#58;line-through;"> </span>pdpm-calc.com (The PDPM Calculator), user-friendly for those who are less enthusiastic<span style="text-decoration&#58;line-through;"> </span>about technology. More importantly, Hopforce provides accurate data, reliable results, that are readily and efficiently displayed despite the dense and often confusing, multifaceted regulations. There are approximately 60,000 potential combination of HIPPS [Health Insurance Prospective Payment System] Codes for every Medicare Part A patient. The opportunity for miscoding or missing an element of care can result in colossal mistakes that impact the facility and patient care.</p><p><strong></strong><strong><em>Provider</em>&#58; What was the inspiration behind Hopforce?</strong></p><p><strong>James&#58;</strong> I have a background in computer science, software development, and psychology. During my education, I became passionate about optimization and reducing human error. I grew up with a family engrossed in health care, so discussions about what worked and what didn't work in the industry were daily dialogue. The notion of removing the inefficiencies that exist in current processes that are ripe for human error and improving patient care truly spoke to me. </p><p><strong><em>Provider</em>&#58; What has the feedback been like since you launched Hopforce?</strong></p><p><strong>James&#58;</strong> The reaction has been outstanding! Users provide ongoing feedback and say it has “improved the lives of MDS coordinators, decreasing their stress and enhancing their jobs' efficiency.&quot; </p><p><strong><em>Provider</em>&#58; Many startups are concerned about setbacks due to COVID19, quarantining, social distancing, and the restrictive nature of hospitals and long term health care facilities. How has this time helped or hurt Hopforce?</strong></p><p><strong>James&#58;</strong> There has been a massive surge in usage due to COVID because no one knew how to code for this, let alone code correctly, to receive proper reimbursement and use a new payment model. It was rewarding to offer a level of ease and assistance in helping the long term care facilities generate the information they needed to activate the funds for the most vulnerable population. Using a haphazardly written spreadsheet that does not give accurate data paired with COVID is disastrous for the facility and the patient. </p><p><strong><em>Provider</em>&#58; What are your aspirations for Hopforce as it grows? If you could describe the dream, barring any setbacks, what do you envision?</strong></p><p><strong>James&#58;</strong> My biggest dream for Hopforce is expanding into other realms of health care that need optimization and improvement. I would like to be able to facilitate them while pioneering how to protect the data. Further down the line, I want to develop software to assist health care disparities toward women and people of color. </p><p><strong><em>Provider</em>&#58; What is it like directly working with your mother? How has it changed your relationship?</strong></p><p><strong>James&#58;</strong> I have always looked up to my mom. To be in the arena, side by side, it is exciting to run with her and watch her operate. She is a genius and inspiring to watch her problem-solve. I am excited to offer what I do well and be able to play in the same stratosphere, especially in tech, which is so male dominated. I do not think that you see too many mother-daughter duos in the health care and tech field. It's exciting to be pioneering this today in the climate of our country.</p><p>Kris Mastrangelo, OTR/L, LNHA, MBA, is chief executive officer and president of Harmony Healthcare International. She can be reached at <a href="mailto&#58;Kmastrangelo@harmony-healthcare.com" target="_blank">Kmastrangelo@harmony-healthcare.com</a>. Her daughter, Savannah James, is founder of the PDPM calculator, Hopforce. Savannah James can be reached at <a href="mailto&#58;savannah.lee@hopforce.com" target="_blank">savannah.lee@hopforce.com</a>.</p><p>​</p>2020-10-01T04:00:00Z<img alt="" src="/Topics/Guest-Columns/PublishingImages/KrisSavannah.jpg" style="BORDER&#58;0px solid;" />ManagementMastrangelo and JamesKris Mastrangelo shares lessons learned from her first years as an entrepreneur and what it’s like cultivating a professional relationship with her daughter.
How Hands-on Nursing Home Ownership Works<div>At times, it seems appropriate to highlight the way in which nursing homes operate in the real world versus some of the misperceptions that can cloud the views of what we do in the long term and post-acute care profession.</div><div><br></div><div>A case in point is the idea that owners of skilled nursing centers are not involved or care about the residents who live in their buildings. Often, it seems, the larger the ownership group, the more talk there is of owners being focused on other things rather than the people who live in their communities.</div><br><p>I work for the Portopiccolo Group, and that idea could not be further from the truth,</p><p>Previously, I worked for several nursing home chains and when Portopiccolo/ClearView acquired Smith County Health and Rehabilitation in July 2019, I was unsure about what the changes would bring.&#160; <br></p><p>By that I mean, any previous acquisition I have been through as an administrator, the new owner overpromised when it came to lending support to meet the daily needs of the facility.</p><p>But, as I began to see the owner and the upper-level management in the building engaging the residents and staff, I gained some hope.&#160;Months later, I realized Portopiccolo Group had kept every promise they made.&#160;We did have everything we needed, and they did ensure the residents were our No. 1 priority.&#160; </p><p>Whether it be equipment, building renovations, supplies, operating cash, or good old moral support, we have it every day without fail.&#160; </p><p>There have been times in the past when I spent my own money on supplies that were needed. With this company, they are excellent at controlling waste, but not slashing.&#160;It doesn’t matter if it’s a resident wheelchair, or a kitchen fryer, or petty cash to buy the staff lunch, we always have it.&#160;</p><p>I see our owner and our executive operators quite frequently. For instance, just recently I witnessed our owner in a COVID-affected building talking to residents and staff to make certain they have everything they need, and that they were OK. He was doing the right thing when nobody was looking and putting his own health at risk to make certain his stakeholders know he cares for them. </p><p>I can’t put into words how proud I am to be a part of this company. I am grateful that even during this pandemic Portopiccolo Group is growing as a company because every building they buy is one more building full of residents and staff that will finally get the support and resources they need.&#160;They will be genuinely cared for by their owners and management team.</p><p><em>Alan A. Hall is administrator of Smith County Health and Rehabilitation, Carthage, Tenn.</em></p><p>​</p>2020-09-25T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/dr_staff.jpg" width="398" style="BORDER&#58;0px solid;" />Management;WorkforceAlan A. HallAt times, it seems appropriate to highlight the way in which nursing homes operate in the real world versus some of the misperceptions that can cloud the views of what we do in the long term and post-acute care profession.
What Drives PDPM<span style="background-color&#58;initial;">​Like most people, there are days when it is tempting to kick back and reminisce about all the fun during long lost childhood days. Fond memories of long, and fun-filled, driving vacations—each and every summer—are still gleefully etched in memory. Those trips took weeks of planning and incorporated a variety of opinions from the entire family. However, when the dust settled, there was just one driver—the author’s father.&#160;</span><div><div>&#160;</div> <div><span style="background-color&#58;initial;"></span></div> <div>After nearly two years of planning, the long term and post-acute care profession has embarked on its Patient-Driven Payment Model (PDPM) journey. Now that therapy is not the primary driver of reimbursement for skilled nursing facilities (SNFs) anymore, before one could say Interim Payment Assessment (IPA), thousands of therapists have job uncertainty. To come to grips with this somewhat expected, yet sobering reality, the burning question—what drives PDPM—needs to be answered first.&#160;</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">The Right Amount</h2> <div> </div> <div>When introducing RCS-1, and then PDPM, the Centers for Medicare &amp; Medicaid Services (CMS) realized that the therapy-centric, resource utilization groups (RUGs) based prospective payment system (PPS) was flawed and obsolete. Now, the main goal of PDPM has been to reimburse SNFs based on patient characteristics and complexity of care.</div> <div> </div> <div><br></div> <div> </div> <div>Since therapy would cease to be the prime driver of SNF reimbursement under PDPM, most expected the therapy utilization to drop. However, CMS has declared that it reserves the option to audit providers when therapy is underutilized. So, what does all of this mean? How much therapy is the right amount? And who decides what is right?</div> <div> </div> <div><br></div> <div> </div> <div>Firstly, PDPM means just that. It is a payment model driven by patient characteristics and complexity of care. It goes without saying that the care of patients in SNFs, in general, ought to include therapy. The goal for patient stays in SNFs is to optimize their functional status while providing all the necessary clinical and nursing care, so that they may transition to their homes or to other care settings at an opportune time.</div> <div> </div> <div>Granted, there will be patients who do not benefit from therapy as they may be too weak or too sick, but even they need to be reevaluated periodically to assess their candidacy for therapy.</div> <h2 class="ms-rteElement-H2"> </h2> <h2 class="ms-rteElement-H2">Don’t Forget Therapy</h2> <div> </div> <div>If providers do not do a good job in recognizing patients’ needs and stint therapy, one thing is bound to happen. CMS will audit and recover payments from those who are not providing adequate therapy to their residents. CMS has ready access to resident characteristics and therapy minutes provided through minimum data set (MDS) assessments. A quick audit could be accomplished by taking the various payments for physical, occupational, and speech therapy categories under PDPM—for individuals or a group of patients—and comparing them to the prevailing cost of actual therapy minutes provided, and/or prior utilization patterns under RUGs.&#160;</div> <div> </div> <div><br></div> <div> </div> <div>If patients are demonstrating a high potential for improvement through their characteristics and functional scores, but are receiving suboptimal therapy, one may expect claim audits and survey citations. Under PDPM, CMS pays SNFs to provide therapy based on the anticipated need, as calculated by clinical characteristics and functional scores documented on MDS assessments, and not any longer by therapy minutes.&#160;</div> <div> </div> <div><br></div> <div> </div> <div>In the absence of a published formula, how does one determine what is the “right” amount of therapy for each patient? Obviously, that has to be a collaborative determination by the clinical team and therapists, based on the patient’s characteristics and medical necessity. The clinical documentation should always be supportive of such a decision, and of any subsequent changes to utilization of therapy services.&#160;</div> <div> </div> <div><br></div> <div> </div> <div>Adhering to the 25 percent cap on group and concurrent therapy may not be sufficient to prevent audits if patients are provided group or concurrent therapy while not meeting inclusion criteria for such options. If a patient truly does not need much active therapist engagement, consideration should be given to the use of Restorative Nursing Programs, which should enable quicker improvement in functional scores and perhaps a shorter length of stay, while providing an audit defense against stinting—if documented clearly along with medical necessity.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Look to the Future</h2> <div> </div> <div>Will there be a shrinkage of the therapy workforce in SNFs? Yes, there likely will be, but it should not be a knee jerk response to a change in payment models, rather based on determination of need and utilization patterns. Since those standards are still being established in the industry under PDPM, across the board workforce reductions are premature and are bound to raise red flags for audit from regulators.</div> <div> </div> <div><br></div> <div> </div> <div>Until a decision to reduce the workforce is obvious and unavoidable, perhaps asking the therapists to focus on the patient rather than the minutes every week is the right thing to do. Therapists could collaborate with nursing staff to revamp the Medicare Part B therapy program for long term care residents, while training SNF nursing staff to be effective partners in Restorative Nursing Programs.</div> <div> </div> <div><br></div> <div> </div> <div>So, what drives PDPM? Is it the patient, or the payment? While initial reactions, such as changing therapy staffing in some centers, appear to suggest that payment is driving the change, the patient is the driver of the PDPM bus. Payment, no doubt, fuels the PDPM bus.&#160;</div> <div> </div> <div><br></div> <div> </div> <div>If the journey is planned well—by charting a good path with accurate initial MDS assessments, there should be enough fuel to arrive at the destination. CMS acts as the gas station, and if providers encounter unexpected detours due to changes in patients’ conditions, IPAs will provide the additional fuel needed to get home. But it behooves providers to remember that gas stations can top off fuel, but not change drivers. The driver, for PDPM, is definitely the patient, and anyone who does not agree will be asked to get off the bus.</div> <div> </div> <div><br></div> <div> </div> <div><em>Rajeev Kumar, MD, is chief medical officer at Symbria and secretary at AMDA—The Society for Post-Acute and Long-Term Care Medicine.&#160;</em></div> <div> </div> <div><br></div> <div> </div></div>2020-02-11T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/150x150/RK.JPG" style="BORDER&#58;0px solid;" />PolicyRajeev Kumar, MDA medical doctor highlights the various issues driving PDPM.
Meeting Challenges Head-on in Today’s Revenue Environment<div>​&#160;</div> <p class="MsoNormal">The past few years have seen a record level of health care facility bankruptcy filings, and if the first half of the year has shown anything, it is that this trend is far from over. Ever-evolving challenges around demographics, reimbursement, staffing, and operating costs present enormous challenges for nursing centers and assisted living communities. </p> <div> </div> <p class="MsoNormal">With pressures mounting, both distressed and currently operational facilities need to consider tactics to improve revenue and efficiency. Having worked with dozens of health care businesses facing these common pressures, there are clear avenues for facilities big and small. </p> <div> </div> <h2 class="ms-rteElement-H2B">Renegotiate Real Estate and Operational Costs</h2> <p class="MsoNormal">Rent is a significant cost for many nursing facility operators, and it is often set at a point in time when the organization enjoyed a higher valuation. This makes it ripe for renegotiation and represents what is perhaps the most immediate way to relieve financial stress on a nursing center.&#160;</p> <div> </div> <p class="MsoNormal">While it is true that no landlord will want to lower costs off the bat, often times <span>&#160;</span>most are amenable, understanding that reduced rent is still income. Even within the larger operating company/property company financial structures, most of the time rental or property leasing costs can be amended relatively quickly. </p> <div> </div> <p class="MsoNormal">Besides property costs, it is important to seek out other areas where savings can be realized without compromising quality, such as food vendor, pharmacy, or service contracts. This effort can positively impact the bottom line. Perform assessments of the business to identify areas of operations that could be improved, evaluate the return on overhead expenses, and collect overdue accounts receivable in a disciplined way. </p> <div> </div> <h2 class="ms-rteElement-H2B">Code for Revenue Enhancement</h2> <div> </div> <p class="MsoNormal">Regulatory scrutiny of nursing centers has increased dramatically both to ensure proper billing as well as satisfactory patient care. Facilities are exposed to multiple audits of their patient care techniques and billing procedures, and when issues are uncovered, the penalties and required remedies can be taxing and expensive to implement.</p> <div> </div> <p class="MsoNormal">Staffing levels and direct patient care hours are among the most highly scrutinized details, so some nursing center operators who cut corners here do so at their peril—it is an expense that must be borne.</p> <div> </div> <p class="MsoNormal">Regulation around the minimum direct hours for patient care, including certified nurse assistant (CNA) hours, places additional pressure on the cost model by removing some of the decision-making autonomy management staff would otherwise have on labor costs. This aspect is particularly challenging because clinical staff in nursing centers—and in particular CNAs—typically have high turnover due to low pay for the performance of a very difficult job, both mentally and physically. </p> <div> </div> <p class="MsoNormal">One way to alleviate these pressures is to place emphasis on recording and billing for all services rendered, and to implement best practices in doing so. Develop proper coding protocols to maximize realizable reimbursement rates so that that the facility is paid for all provided services, even when operating in a reduced rate environment. </p> <div> </div> <p class="MsoNormal">When rising labor costs are already a concern, it might seem counterintuitive to add extra coders to drill down into the details of recording and billing. However, in the long run, effectively managing the nitty-gritty details will make audits a much less stressful time for all involved. </p> <div> </div> <h2 class="ms-rteElement-H2B">Market to the Right Audiences</h2> <div> </div> <p class="MsoNormal">Compared to residents that previously entered nursing centers in moderate to good health, the average entrant today is older and sicker. At the same time, hospital systems are increasingly referring patients within their own networks, and preferred provider networks are referring to fewer nursing centers. This all adds up to higher cost of care per resident.<span>&#160; </span></p> <div> </div> <p class="MsoNormal">As the center faces these increased costs, it can be tempting to focus all energy on private payers, who are attractive admissions due to their higher reimbursement rates. However, today’s high deductibles and heavy patient responsibility have decreased the market presence of private payers. The Centers for Medicare &amp; Medicaid Services (CMS), on the other hand, may have lower rates of reimbursement but offer a growing pool of potential patients backed by a payer that is guaranteed to pay its bills. As long as a reasonable payer mix among residents can be maintained, accepting more Medicaid patients can be a sustainable way to fill beds.</p> <p class="MsoNormal">With both types of patients in mind, operators need to focus proactively on referrals from hospital systems, assisted living facilities, and preferred provider networks. Mandates vary from state to state, but most assisted living facilities are required to discharge patients when their care requires more than a one to one patient to professional ratio. </p> <div> </div> <p class="MsoNormal">At the same time, it is important to examine how to cost-effectively reach and educate discharge planners at other health care facilities and agencies, as well as families and other decision influencers. It can be hard to consider investments in marketing when facing financial strains, but spending smartly on radio, newspaper, or digital advertising can pay dividends in driving new inquiries. Examine the competition’s pain points and market the facility as an alternative solution. </p> <div> </div> <p class="MsoNormal">In addition to referral-focused outreach, it is important to reach the wider community to raise awareness of services with a positive message about the facility. Patients today have access to extensive research and reviews when making choices about long term care, so it is imperative to improve the facility’s CMS Five-Star Rating. The evaluation process is a bit long—one year—but investing in care levels to enhance quality of care and quality of life for all patients and residents will also help ensure a good Five-Star Rating, which is a must to secure future organic inbound traction. <span>&#160;</span></p> <div> </div> <p class="MsoNormal">Some of these tactics can be led by operations, marketing, finance, or legal teams. Those providers that are more complex and are further along in the distress cycle may require outside expertise to lay out options and viable paths forward. In the end, doing what is best for the health and well-being of residents and patients often proves to be the most beneficial for the facility in the long run as well. </p> <div> </div> <div> </div> <p class="ms-rteElement-P"><a href="https&#58;//www.carlmarksadvisors.com/team/marc-pfefferle/" target="_blank"><img src="/Topics/Guest-Columns/PublishingImages/MarcPfefferle.jpg" alt="Marc Pfefferle" class="ms-rtePosition-1" style="margin&#58;5px 10px;width&#58;70px;height&#58;70px;" />Marc Pfefferle</a>, partner at Carl Marks Advisors, has more than 30 years of financial and operational restructuring experience. He serves in roles as senior advisor or interim executive to companies in transition or in need of substantial performance improvement or debt restructuring. He has served as CEO, CRO, or equivalent leadership positions at 15+ companies, competing in a variety of industrial, service, consumer, health care, and retail market segmen<span><span>ts. He can be reached at </span></span><a href="mailto&#58;mpfefferle@carlmarks.com" target="_blank">mpfefferle@carlmarks.com</a>. <a href="https&#58;//www.carlmarksadvisors.com/team/jeffrey-pielusko/" target="_blank"><img src="/Topics/Guest-Columns/PublishingImages/JeffPielusko.jpg" alt="Jeff Pielusko" class="ms-rtePosition-1" style="margin&#58;35px 10px;width&#58;70px;height&#58;70px;" /><br><br>Jeffrey Pielusko</a>, director at Carl Marks Advisors, has over 10 years of financial and operational restructuring and investment banking experience. He serves as both company and lender advisor in evaluating and executing financial and operational restructurings. He can be reached at <a href="mailto&#58;jpielusko@carlmarks.com" target="_blank">jpielusko@carlmarks.com</a>.</p> <div> </div>2019-07-29T04:00:00Z<img alt="" src="/Topics/Guest-Columns/PublishingImages/carlmarks.jpg" style="BORDER&#58;0px solid;" />Management;FinanceMarc Pfefferle and Jeffrey PieluskoEver-evolving challenges around demographics, reimbursement, staffing, and operating costs present enormous challenges for nursing centers and assisted living communities.