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The Difference Makers<p>​There’s a reason why some skilled nursing facilities have one star and others have five, or why some struggle to maintain census and others are nearly full and selective about which patients they admit. Some are just better than others.</p><p>In several decades of providing care in skilled nursing facilities, I’ve learned a lot about balancing the need for better care with the need to earn a profit. Most important, I’ve learned that improved care and improved profits are not concepts that are at odds with each other. On the contrary, they are essential and totally complementary. Facilities that accomplish this are the ones with all the stars, the full census, the selective admissions counselors, and yes, the most impressive profits.</p><p>When I pioneered telemedicine in nursing homes, the goal was to reduce hospitalizations. If a doctor could see the patient at 1 AM and determine if they could be safely stabilized at the facility until morning, then the patient would be kept safe, the facility would save on staff and transportation costs, census would be maintained, and a lower hospitalization rate would help improve their reputation. That service continues today, and is expanding to other levels of post-acute care and even into private practices.</p><p>The big change in telemedicine is the extent to which providers have embraced technology, how aggressive they have been about innovation, and how well they balance profitability and care. Most don’t. They continue to provide a valuable but limited service. Let’s start with this premise&#58; Patients that are treated regularly by their own primary care physician will fare better than those who are not.</p><p>No one really disputes that, but the cost is prohibitive. Enter innovation. At TapestryHealth, we started with this premise and then figured out how to accomplish it through technology, business savvy, a deep understanding of all aspects of the skilled nursing environment, and a desire to see our patients get what they need. What we realized, is that technology actually lets us take a step back to a time when doctors still made house calls. </p><h2>Build Around the Clinician, NOT Around the Technology</h2><p>There is no better alternative to a patient seeing their own clinician, which is why we build our services around the clinician. Technology is a tool; a very valuable one, but it is not the care provider. That is still the domain of doctors, nurses and nurse practitioners. The shortcoming of traditional telemedicine is that it is built around the technology. At TapestryHealth, each facility is assigned its own trained clinician with geriatric and behavioral care experience. That clinician gets to know and build a relationship with each patient. They work closely with the facility staff, helping to train them on examination, evaluation and treatment techniques, and even meet with family members. The result is the kind of trusting doctor/patient relationship that is missing for so many nursing home residents. <br></p><p>Now, enter technology. In some cases, the most efficient delivery is for our clinician to work on-site in the facility, but typically, especially in smaller, rural facilities the clinician works remotely. And it’s common for facilities to utilize a combination of both to provide complete 24/7 coverage. <br></p><p><img src="/Topics/Special-Features/PublishingImages/2022/Rosie%20art.jpg" alt="Rosie" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;280px;height&#58;280px;" />Technologically, we’ve come a long way from the early years of telemedicine. Our clinicians have access to multiple hi-def cameras to closely examine wounds down to the smallest skin tear. An integrated digital stethoscope provides crystal clear transmission of blood flow, breathing and an integrated otoscope allows for examinations of the ears, nose and throat. Digitally recorded vital signs are guaranteed accurate and uploaded in real time to the facility’s Electronic Medical Records system. <br></p><p>Assigning a dedicated clinician to a facility, including a dedicated after hours support team and providing them with the most advanced technology in the business are three things that separate leading telemedicine providers from the legacy providers. But there’s more, and it’s equally valuable. A dedicated clinician means daily rounds, wellness check-ups, appropriate follow-up, even admissions intake and transition-to-home care.</p><h2>Specialists Can’t Help You If You Can’t Get in to See Them </h2><p>Seeing a specialist is one of the most difficult appointments to get. If you’re a Medicaid patient in a suburban or rural SNF, your chance of seeing a specialist while there’s still time to take effective action is slim. Yet this is a population that needs the attention of specialists maybe more than any other. So, we bring specialists right to the bedside whenever needed. Cardiologists, pulmonologists, urologists, endocrinologists, even psychiatrists can all be brought to the patient’s bedside by their clinician, who also coordinates all specialist visits and oversees medication reconciliation. This doesn’t just enhance our service, it saves lives, and it’s all made possible – and profitable – through technology.</p><h2>What’s Next?</h2><p>What’s next is already making an appearance. The traditional telemedicine treatment cart is evolving to support remote medical technology that allows us to measure vital signs and upload them to the EMR in about one-third the time it would take a nurse. But we don’t stop there. Our clinicians look at any anomalies on every patient’s vitals and can immediately alert the facility if one or more readings indicate a possible problem. Potential disasters, like an outbreak of flu or Covid-19 can often be see coming days in advance of visible symptoms, allowing the facility and staff to prepare. Testing is already underway on our newest remote technology, robotic treatment carts, which will enable remote clinicians to navigate the facility and see patients without the assistance of a staff nurse.</p><p>Using today’s technology efficiently and effectively, helping to innovate tomorrow’s technology now so it meets the changing needs of post-acute care facilities, establishing a familiar clinician as the central point of care to oversee and coordinate a patient’s care&#58; these are the difference makers that have elevated independent care far beyond what was expected when telemedicine began. Today telemedicine is a vital tool in post-acute care and a major contributor to increasing reimbursements, reducing hospitalizations and stabilizing census, improving CMS star ratings, and enhancing reputations with local hospitals, all of which provides the balance between improved care and improved profitability. Not every provider can promise all this. Can yours?<br><br><em>Dr. David Chess is a geriatrician who pioneered the original concept of telemedicine. He has spent much of his career since then advancing the use of technology to improve both patient care and profitability in SNFs. He is the founder of TapestryHealth, one of the nation’s leading providers of healthcare in skilled nursing facilities. <br></em></p>2022-01-03T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2022/DavidChess.jpg" style="BORDER&#58;0px solid;" />Caregiving;TelemedicineDavid Chess, MDThere’s a reason why some skilled nursing facilities have one star and others have five, or why some struggle to maintain census and others are nearly full and selective about which patients they admit.
Questions, Connections Lead to Investment Solutions<p>​The Investment Solutions Program, held during the 72nd American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Convention &amp; Expo, was designed to connect providers with leaders in the funding and investment world, and it exceeded expectations.<br></p><p>Not only did participants hear about capital solutions and financing strategies for providers plus news, insights, and forecasts from the Department of Housing and Urban Development (HUD), they were able to interact, get answers to their questions, and share their challenges, concerns, and needs.<br></p><p>Overall, the program painted a clear picture of current conditions and opportunities, as well as a path for the future.</p><h2>Looking Ahead</h2><p>AHCA/NCAL President and Chief Executive Officer (CEO) Mark Parkinson started the program out on a positive note, saying, “There is a light at the end of the tunnel. If you look at where COVID is, nursing homes have had success keeping the Delta variant out of buildings.”<br></p><p>Nonetheless, recovery is slow. Fred Bentley, managing director of Avalere Health, explained, “Skilled nursing facility volumes plummeted at the outset of the pandemic and never really rebounded.” However, he noted that occupancy is up, currently at about 72 to 75 percent, from the 60s. This is impressive, he said, especially since “we’re not back to normal and we’ve had to deal with Delta.” <br></p><p>Bentley predicted that occupancy will be up to about 80 percent by next summer, although he admitted, “That’s the best-case scenario.” At the worst, he suggested, the rebound will take until the following March. <br>Parkinson and Bentley identified five factors that could speed up or delay recovery&#58; future virus surges, states’ commitment to de-institutionalizing Medicaid long term care supports and services, Medicare Advantage growth, declines in available workforce, and the impact of the “silver tsunami.” <br></p><p>While baby boomers may not really hit long term care facilities for several years, Parkinson said, “The demand is still there. The numbers are unmistakable.” Among specific areas of growth opportunity, Bentley said, are Institutional Special Needs Plans (I-SNPs).<br></p><p>“We’ve seen a steady growth in this area,” he said, adding, “We’re also seeing an increase in long term care accountable care organizations [ACOs]” and a growing trend toward risk-sharing. Home health also is attractive from a growth perspective, he said, but there are a whole range of economic challenges in this sector.</p><h2>Capital Solutions</h2><p><img src="/Topics/Special-Features/PublishingImages/2021/1221/Talya.jpg" alt="Telya Nevo-Hacohen" class="ms-rtePosition-2" style="margin&#58;5px;" />A panel on Financing Strategies for Providers of All Sizes featured Greg Stapley, chairman and CEO of CareTrust; Telya Nevo-Hacohen, chief investment officer, Sabra; Vikas Gupta, vice president, acquisitions and development, Omega; Bradley Clousing, managing director, Senior Living Investment Brokerage; and Doug Korey, executive vice president, LTC REIT.<br>Among the highlights of the panel discussion&#58;<br></p><ul><li>Senior living/long term care has been hit harder than most real estate sectors, but properties are generally selling at 2019 prices. Skilled nursing prices are steady. Private equity is paying full values, and interest rates remain at historic lows.</li><li>It is possible for good operators to expand without spending a lot of money. Investors/lenders are looking at the cash flow of buildings and seeking operators with some equity.</li><li>Operators’ experience and history with their properties is important to investors/lenders. It is not necessary to be a large company if the company has a strong, consistent track record. For new operators, investors/lenders will look at issues such as staffing, leadership, partners, and vendors. For all operators, they also will look at clinical capabilities and how the organization managed COVID-19.</li><li>The market is a moving target. It is possible to have an asset with different demands in different states.</li></ul><p>The good news is that operators may still qualify for financing even if they have been or are struggling. Many lenders are willing to talk to committed, hard-working operators who are going through a tough time, particularly in light of COVID. They see providers as partners. “If you take a hit, we all take a hit,” said one panelist.</p><h2>A HUD Official And a Lender Walk Into a Room</h2><p>In a HUD panel, Roger Lukoff, deputy assistant secretary of the Federal Housing Administration (FHA) Office of Healthcare Programs at HUD, was joined by Chris Boesen, founder and president, Tiber Creek Associates of Capitol Hill; Tim Eberhardt, co-lead healthcare real estate finance, Capital Funding Group; and Sarah Schumann, vice president of operations, Brookside Inn and at-large AHCA board member.<br></p><p>“It is important to find ways we can all succeed. We’re looking for ways to help distressed providers,” Lukoff said. “We believe it’s a win-win proposition. Our program’s focus is to ensure the vulnerable population is cared for and that financial obligations are controlled.”<br></p><p>Addressing COVID, he said, “We wanted to make sure all of our facilities had maximum flexibility to make it through financially.” <br></p><p>For instance, in the first months of the pandemic, facilities were allowed to use reserves for mortgage payments. Looking ahead, Lukoff said, “HUD is emphasizing the crucial role health care plays in the marketplace and, in particular, the role of long term care.”</p><h2>Valuing Provider</h2><p>HUD, Lukoff said, is “really proud of the quality of providers who come into the program.” For those who are interested in HUD funding, he explained, “We factor quality assessments into our financing program. At the same time, we’re looking at how your facility plans to improve and operate in the next 10 years.”<br></p><p><img src="/Topics/Special-Features/PublishingImages/2021/1221/BradleyClousing.jpg" alt="Bradley Clousing" class="ms-rtePosition-1" style="margin&#58;5px;" />The panel addressed FHA’s Negative Credit Subsidy Program, noting that it brings in more premiums than it pays out in claims. The premiums, Boesen noted, support other programs within HUD.<br></p><p>Schulmann said that there are many requirements for providers to participate in HUD programs, but the programs may be appealing and accessible. She pointed out that AHCA has many <a href="/Resources/HUD/Pages/default.aspx" target="_blank">HUD resources</a> for providers, including a useful mortgage calculator. “It’s a one-stop shop for everything HUD and enables providers to be fully aware of what will be expected of them.”</p><h2>Staffing, Staffing, and More</h2><p>No discussion in long term care, including financing, is complete without addressing staffing challenges. Scott Thurman, senior managing director at Greystone, one of the program’s sponsors, told <em>Provider</em>, “Staffing was always a bit of a pain point, but the pandemic exacerbated that. Reimbursement will never match up with staffing requirements, and staffing shortages are limiting the growth and rebound of occupancy levels.” <br></p><p>While there are no easy answers, he suggested starting by “getting out there with more positive stories about provider successes, the good things happening in their facilities, and how staff contribute to quality care and good outcomes.” He also suggested looking at out-of-the-box quality-of-life benefits for staff. <br></p><p>For instance, he said, “Negotiate with apartment operators to give people breaks on rent. That is how you incentivize people to show up, and they don’t want to leave when you create that kind of family.”<br></p><p>Reimbursement presents another challenge. “We need to match reimbursement with costs,” Thurman said. “We are expected to provide concierge-level services but we’re not reimbursed for them.” He added that there also needs to be a focus on affordable housing for the “forgotten middle” market.<br></p><p>Speaking of HUD, Thurman said, “The department’s focus will remain on quality of care through Five-Star ratings. They will focus on asset management for the long haul.” He added that HUD has done a great job of managing risk, although they have become more risk averse. “That’s been challenging for the lending community,” he said.<br></p><p>It is important for all providers who expect to be in this industry for the long term to keep their finger on the pulse of financing issues. “I’m concerned about the huge demand coming for long term care. We need to address all of these issues now if we are to be prepared,” Thurman said. “I’m excited to have a presence here and talk to providers about these challenges and possible solutions.” <br></p>2021-12-01T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1221/1221_HUD.jpg" style="BORDER&#58;0px solid;" />HUDJoanne KaldyThe good news is that operators may still qualify for financing even if they have been struggling.
Stephen Rosenberg: The Greystone Story<p>​<img src="/Topics/Special-Features/PublishingImages/2021/1221/StephenRosenberg.jpg" class="ms-rtePosition-2" alt="Stephen Rosenberg" style="margin&#58;5px;width&#58;220px;height&#58;220px;" />Creativity and hard work are common in successful companies, but growth, innovation, and industry leadership take something more.<br></p><p>“We have a culture that is the fuel behind our drive and success. Everyone knows our mission is to help people. Everything we talk about is how we can help others, and that applies internally as well as externally,” says Stephen Rosenberg, founder and chief executive officer (CEO) of Greystone. <br></p><p>As CEO, Rosenberg is responsible for the coordination and management of corporate matters. He founded Greystone in 1988 as an independent investment banking firm and has since developed it into a mature commercial real estate investment firm with a national reputation as the No. 1 Department of Housing and Urban Development (HUD) lender to the health care sector (as well as multifamily). It’s hard to believe now that Rosenberg’s first office was in the back room of a friend’s music store.<br></p><p>But those early days came with some strong lessons. Rosenberg recalls, “I definitely learned that fear is a strong motivator. When you have a family to feed, there is no such thing as 9 to 5.” Rosenberg has never forgotten his early days and the lessons he learned as an entrepreneur. “Over the years, we’ve figured out how to do things that others aren’t focused on, and we’ve figured out a way to make things profitable,” he says. <br></p><p>A huge part of this is customer service, and Rosenberg and his team put customers’ interests first. “Their success is our success. Magic really happens when you put others’ interests in front of your own,” he says.</p><h2>The Call of Culture</h2><p>The company’s culture has supported and driven its business for decades, and it shapes the way they work every day. While Greystone has grown and evolved over the years, the company’s values haven’t changed, Rosenberg says. “Our culture remains the engine of our business. It is how we attract and retain the best talent and stand out from the competition.” He notes, “Culture is a big motivator and magnet for all good people, not just millennials.”<br></p><p>Four standards define how Greystone works, how the company connects with their customers, and how they engage with the community&#58; integrity, excellence, entrepreneurship, and caring. <br></p><p>Greystone’s corporate culture actually is an extension of Rosenberg’s family’s beliefs and behaviors. He says, “Like many people, I was held to very high standards by my loving parents. Of utmost importance was treating others with respect and dignity, lifting others, and enhancing lives whenever the opportunity arose.” </p><p>He recalls that growing up, he and his father would go to the grocery store and buy groceries for older people and others in the area who were struggling. “The sensitivity and caring they showed for people, many of whom were strangers, had a real impact on me.”</p><h2>Living the Culture</h2><p>Rosenberg honored his family and the values they instilled in him by establishing the Murray &amp; Sydell Rosenberg Foundation, Greystone’s philanthropic arm with a mission to alleviate suffering. The Foundation attempts to both identify and address the most acute needs of those who are otherwise disempowered and neglected. Areas of focus include humanitarian aid, education, community enhancement, and health care. <br></p><p>“My deepest sense of satisfaction involves the thousands of lives we have impacted, the families in dire straits we’ve been able to help,” says Rosenberg. An important aspect of this, he stresses, is the ability to provide the help quietly and as respectfully as possible. <br></p><p>“We are all in this together,” he says. “I don’t believe the financial resources belong to me. I tell each family that we are honored to partner with them.” He adds, “I’m receiving so much more back than we give.”<br></p><p>Greystone’s Annual Day of Service is another way the organization lives its culture. This company-wide event reflects charity and camaraderie, two pillars of the company’s culture. Each year, Greystone offices close for one day so that employees can volunteer their time for a local cause. “This is a popular program. People are wired to help others. There is no greater pleasure than lending a hand to someone else,” Rosenberg says.<br></p><p>Doing good work quietly is important to Rosenberg. He says, “You’ll never see our name on a building or anything like that. We like to help in situations where people have run out of options and have nowhere else to turn.” If he has the ability to solve a problem, he’ll do it without the fanfare.</p><h2>Changing Face of The Industry</h2><p>Rosenberg and his team have been consistent in their efforts to serve customers and make a positive difference in the lives of people in need. But they have seen changes in the industry. For instance, he says, “Borrowers are somewhat more educated about debt products. People are better informed, which is good news. Knowledge is power.”<br></p><p>The challenges of the pandemic have been motivators for growth, Rosenberg suggests. “When the deck is being shuffled, you can’t rely on all the same old tricks. There are opportunities to leap forward with personal and professional growth.” This isn’t always easy. As he says, “Mixing things up can cause tremendous discomfort, but it’s also an opportunity for positive change. You need to face the challenges and think about how you can be better moving forward.”<br></p><p>Rosenberg is proud of his business success. “There is a competitive side to me,” he admits, adding, “I like to win, and I am very happy that we are the No. 1 commercial HUD lender in the country. I am proud of what we’ve accomplished, but nowhere near satisfied. There is much more we can do, and we’re excited about the opportunities for the future.” <br></p><p>Prior to joining Greystone, Stephen Rosenberg was a national director with Dean Witter Reynolds. He has a DMD degree from the University of Pennsylvania School of Dentistry and an MBA from the Wharton School. ​</p>2021-12-01T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1221/StephenRosenberg.jpg" style="BORDER&#58;0px solid;" />ManagementJoanne KaldyPeople matter to the leader of the No. 1 commercial HUD lender to the health care profession.
The Positive Domino Effect of Cost Containment<p>​​There is light at the tunnel’s end. Long term care facility census is slowly rebounding, and while COVID is still of concern, facilities are managing it with far fewer illnesses, hospitalizations, and deaths. However, profit margins continue to be razor thin,&#160; and staffing shortages linger. More than ever, providers and their teams need cost containment that does more than just streamline expenses.&#160;</p><p>These efforts must help impact other challenges—such as staffing and census—in a constructive way.&#160;</p><p>Embracing this holistic approach to customer service is second nature to PharMerica. “We know that while the future is looking brighter, providers are still struggling with challenges that could slow or restrict their post-pandemic recovery, and we are working to turn these struggles into successes,” says Stephen Creasy, PharMerica director of clinical services. Tina Carrasco, vice president of strategic accounts, adds, “Staffing is tied to cost containment. If you don’t have consistent staff, it breaks down efforts related to compliance, communication, costs, and—ultimately—growth and success.”</p><h3>​​TI Ties to Team Harmony<br></h3><p>“Our Therapeutic Interchange [TI] programs save medication costs,” Creasy says. “But once they’re implemented, they’re also automated, so they not only continue to manage costs over time but they also take the administrative burden off of nursing staff so they can focus on what they love—patient care. At a time when there are historic levels of staffing shortages and turnover, this prevents issues from falling through the cracks due to lack of staff time, experience, or knowledge.”</p><p>Facilities and their teams can trust these TI programs&#58; They are designed by physicians and pharmacists who specialize in geriatrics and long term care to assure clinically appropriate and cost-effective pharmaceutical care for nursing home residents. “Not only are these programs designed by experienced practitioners, but they are reviewed by our Pharmacy &amp; Therapeutics Committee,” Creasy says. “We don’t just look at costs but we make sure that each medication is clinically sound and appropriate for this patient population. This involves a deep-dive literature review and assessment before it even gets to P&amp;T for approval or denial. It’s a very structured process and unique to PharMerica,” he says.</p><p>“This gives prescribers and other practitioners peace of mind knowing that all recommendations are backed by the best and most current clinical evidence.”</p><p>At the same time, Creasy says, “Our programs continually evolve. We are always looking for new opportunities to go from higher-cost to lower-cost medications that have demonstrated clinical efficacy and comparable effect. And if new evidence says that a medication is no longer cost-effective or efficacious, we will replace it with a more appropriate drug.”</p><h3>​Don’t Stop, Won’t Stop Cost Containment<br></h3><p>The company’s efforts to contain costs while maximizing outcomes and quality don’t stop there. PharMerica’s Standard Quantity Level Limits program lowers clients’ costs by setting dispensing limits based on quantity or days supply.&#160;</p><p>This program delivers two distinct advantages to customers. The first is limiting financial exposure on high-cost medications that may not be used, thus reducing waste. The second advantage is that it helps improve nursing facility staff productivity by reducing the time spent on medication returns.&#160;</p><p>The categories for inclusion of medications in the standard program focus on themes that are particularly prone to waste and/or returns. These include short-stay residents, hospital carry-over therapies, package-size opportunities, medications covered by alternative payers, and high-cost drug exposure.</p><h3>​Collaboration for the ​Continuum<br></h3><p>On admission to the facility, when new orders are started, PharMerica’s cost containment programs go into effect and continue throughout the person’s stay. For instance, through the Global Authorization program, prescribers can pre-approve interchanges to lower-cost preferred medications for future medication orders, and prescriber-approved forms stay on file at the applicable PharMerica pharmacy for future reference.&#160;</p><p>But it doesn’t stop there. The consultant pharmacists conduct interim reviews when a resident transfers between settings, such as from assisted living or memory care to the nursing home or from the nursing facility to home. And at discharge, PharMerica implements DischargeRx.</p><p>“This is a seamless integration process designed to keep each individual safe and on track with their progress. It also helps prevent them from having adverse events that send them back to the ER or hospital,” says Creasy.&#160;</p><h3>​Happy Staff, Healthy Census<br></h3><p>All of these programs and efforts have at their heart not just cost containment but, most importantly, quality care. And this is linked to both staff stability and census.&#160;</p><p>“When staff have the time, tools, and skills to focus on quality care and the best possible outcomes for residents, they are more likely to take great pride in their work and feel a loyalty to their teams,” says Carrasco.&#160;</p><p>One source of staff stress is lack of training, and PharMerica’s programs cover this. “Our teams go in and constantly educate staff to help ensure there are no gaps in knowledge with turnover. We educate them on pharmacy issues, and we have great tools to support them. We take these efforts off the facility, so it’s also one less burden on managers and team leaders,” she says.&#160;</p><p>At the same time, customers can always come to their PharMerica team and request any specific education, training, or tools they need. “We’re always there as their partner, not just for pharmacy services but for overall quality care and quality,” Carrasco says.</p><p>As for occupancy, this is driven by several factors, including staffing, Five-Star rating, and readmission rates. “Our consultant pharmacists get involved from day one, reviewing records on admission, ensuring there are appropriate diagnoses—essential for the Patient-Driven Payment Model (PDPM), identifying and addressing any issues or concerns, and working with the team on care planning,” says Carrasco.</p><p>“Our efforts help ensure that census builds in a cost-effective way that also ensures and enables the best possible care and outcomes for each resident,” she says.</p><p>“Facilities are looking at opportunities from vendors to lower costs,” Creasy says. “There are lots of moving parts when it comes to medications and lots of variations and options, often within the same drug class. Our clients appreciate that we take the time and effort to ensure quality while giving them the lowest costs possible,” he says.&#160;</p><p>“At the end of the day, if what we do improves outcomes and enables our customers to be successful, we have accomplished what we set out to do.”&#160;​​<br><br></p>2021-12-01T05:00:00Z<img alt="" src="/Monthly-Issue/2021/December/PublishingImages/SteveCreasy.jpg" style="BORDER&#58;0px solid;" />CaregivingPharMerica​There is light at the tunnel’s end. Long term care facility census is slowly rebounding, and while COVID is still of concern, facilities are managing it with far fewer illnesses, hospitalizations, and deaths.