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Provider-led Managed Care Continues to Attract Long Term Care Participation<p>Despite the turmoil caused by the COVID-19 pandemic, long term and post-acute care providers are continuing to increase their presence in the Medicare Advantage (MA) marketplace by forming on their own or in collaborative arrangements, so-called Special Needs Plans (SNPs), which allow providers more control of the care management of residents who benefit from an increased clinical presence allowed for under such health plans.</p><p>This trend is documented in a new report commissioned by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) and written by ATI Advisory.</p><p>Findings in the report include that long term care provider-led SNPs are one of the most promising risk models to emerge from the federal push to delegate risk to providers. The report said at their best, “they combine enhanced primary care with residential long term care [LTC] to reverse the revolving door between nursing homes and assisted living and emergency rooms and inpatient hospitalizations. This is better for residents, families, and the Medicare program.”</p><p>Anne Tumlinson, founder and chief executive officer of ATI Advisory, tells Provider the market seems to be embracing these provider-led I-SNPs, which is shorthand for Institutional-Special Needs Plans. In fact, the report said LTC provider-led I-SNPs grew from 9 percent of all I-SNPs offered in 2015 to 33 percent in 2020. Follow-up analysis shows the share growing further to almost 37 percent in 2021. <br>&#160;<br>To delve into the trend, ATI studied three LTC provider-led I-SNP plans, with average membership varying from 269 to 3,086 and time-in-market varying from fewer than five years to 16 years. The plans are offered by PruittHealth, Elmbrook Home, and Senior Select Partners. </p><p>Tumlinson said at their core, the three plans worked well because the I-SNP has taken on the full financial risk for the resident members. “This creates a degree of financial alignment with delivery of care that works with families and the members,” she says.</p><p>This alignment of care is vital and includes the need for a skilled nurse practitioner (NP) to carry out the health plan’s goals of keeping residents as healthy as possible in a proactive manner.</p><p>“Being at risk for the total cost of care gives the nursing home providers the ability to invest in all of the things that they truly need to do,” Tumlinson says.</p><p>Even though the pandemic has tested this model, given the higher costs of care necessary, Jill Sumner, AHCA/NCAL vice president of population health management, says interest among LTC providers has not waned.</p><p>“There is still a lot of interest and growth. Financially, it has been very hard on plans that were hit hard by COVID, because hospitalization costs can be quite expensive and were not budgeted for,” she explains. “But we also have heard loud and clear that without this model providers would not have been able to weather this storm as well as they have from a clinical perspective.” </p><p>Among the key highlights in the report are outlines of what providers need to do to have the best chance at being successful in the I-SNP universe. These requirements, the report said, include hiring onsite health plan staff, or member advocates, to help navigate member issues with SNP benefit coverage, services, and provideSecondly, the I-SNP needs a culturally competent NP to spearhead the clinical care aspects of the health plan.</p><p>“Care management and the Model of Care are not well executed without an engaged NP who takes the time to connect with their patients to not only recognize change in status in a timely manner, but also gain trust to skill in place [take skilled care in the facility]. This means going above and beyond traditional medicine by getting to know the resident and family and understanding culturally specific attitudes and values,” the report said.</p><p>Among the critical decisions and challenges to starting and operating an I-SNP are in recruiting NPs to serve in rural areas and finding experienced member advocates, the report said.</p><p>Find the report <a href="https&#58;//atiadvisory.com/wp-content/uploads/2020/04/An-Idea-Thats-Growing_ATI-Advisory.pdf">here.</a></p>2021-01-11T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/Elderly%20woman%20smiling%20someone%20helping%20her%20stand%20iStock_000019827227XSmall.jpg" style="BORDER&#58;0px solid;" />ManagementPatrick ConnoleLong term care provider-led SNPs are one of the most promising risk models to emerge from the federal push to delegate risk.
NIC Points to Unprecedented Challenges for Skilled Nursing as Occupancy Remains Low<p>Occupancy at nursing homes gained slightly between the second and third quarter of 2020 to 74.0 percent, but remained significantly below levels recorded in February (84.9 percent) and March (83.5 percent) when the COVID-19 pandemic began impacting the United States, according to data from NIC MAP® Data Service (NIC MAP) provided by the National Investment Center for Seniors Housing &amp; Care (NIC). </p><p>NIC said the falloff in occupancy has been more severe in urban areas, as occupancy fell 11.8 percentage points since February versus the 8.0 percentage point decline in rural areas in that same period.</p><p>The dual factors of sharply declining occupancy coupled with the high cost of personal protective equipment, COVID-19 testing, and hazard pay for workers is placing the skilled nursing sector under unsustainable financial strain, the group said.</p><p>“Significantly lower occupancy and greater operating expenses have created unprecedented challenges for skilled nursing operators,” said Bill Kaufman, senior principal at NIC.</p><p>“They are bracing for a difficult winter, given the latest surge in COVID-19 cases and no immediate additional government intervention,” he said. “Due to COVID-19, NIC expects occupancy to remain dangerously low in the fourth quarter before vaccines become available to health care workers and skilled nursing residents.”</p><p>In the preceding months, the nursing home sector has been aided by the CARES Act and Paycheck Protection Program, which helped keep major sectors of the economy afloat during the pandemic. In addition, the Centers for Medicare &amp; Medicaid Services waived its three-day hospital stay requirement, which extended coverage to more people impacted by COVID-19, which is evident in NIC MAP’s recent Medicare data trends.</p><p>“Many skilled nursing facilities survived the spring and summer because Congress authorized unprecedented financial aid,” said Beth Burnham Mace, NIC’s chief economist. “But as funds become exhausted and COVID-19 cases rise with little likelihood of immediate government intervention, it will be difficult for many facilities to continue sustainable operations.”</p><p>NIC said in a recent survey by the American Health Care Association, 72 percent of nursing home operators said they will not be able to maintain operations for a year under current conditions. Forty percent said they would be unable to last six months.</p><p>Data from NIC’s Skilled Nursing COVID-19 Tracker shows that nearly half of 1 percent (0.48 percent) of residents tested positive for COVID-19 at the end of September. During the week ending Nov. 1, that figure had risen sharply to just under 1 percent (0.94 percent).</p><p>Click here to access the latest NIC-provided skilled nursing data.<br></p>2020-12-04T05:00:00ZManagementPatrick ConnoleDue to COVID-19, NIC expects occupancy to remain dangerously low until vaccines become available to residents and health care workers.
CMS Issues Nursing Home Visitation Guidelines<p>Everyone's mental health has been tested over the past eight months. This includes the staff, the residents, and the visitors in long term care facilities. Daily routines have been disrupted, contact with loved ones has been disjointed and visitations suspended. Decreased interactions with loved ones leads to anxiety and stress for everyone involved.<br></p><p>Prior to the COVID-19 pandemic, mental health disorders represented a public health challenge of overwhelming proportions and a known gateway to more ominous problems. When skilled nursing facilities begin allowing in-person visits with the residents, staff need to be mindful of the emotional and psychological impact this pandemic has had on the residents and also on visitors and staff. &#160;<br></p><p>Many residents have undergone an unfathomable experience with loneliness, confusion, and questions about why the situation is impacting them. Many visitors are faced with unemployment, isolation, and uncertainty about the future. According to the World Health Organization, COVID-19 could lead to upwards of 75,000 deaths from substance abuse and suicide.<br></p><p>Many staff have continued to risk their own lives caring for the country's most vulnerable population while simultaneously experiencing the same challenges as the resident and the visitor. <br></p><h2>New Visiting Guidance</h2><p>While guidance from the Centers for Medicare &amp; Medicaid Services (CMS) has focused on protecting nursing home residents from COVID-19, it recognizes that physical separation from family and other loved ones has taken a physical and emotional toll on them. In light of this, on Sept. 17, 2020, CMS updated the federal visitation guidelines for nursing homes to provide reasonable ways for them to safely facilitate in-person visitation.<br></p><p>CMS says visitation can be conducted in different ways, depending on a facility's structure and its residents' needs, such as in resident rooms, dedicated visitation spaces, or outdoors. Regardless, facilities must follow CMS' nine core principles of COVID-19 infection prevention to remain in compliance with regulations.<br><br>1. Screen all individuals who enter the facility for signs and symptoms of COVID-19. <br>Nursing homes should designate an entrance for visitors to use to access the health care facility. At this location&#58;<br></p><ul><li>Complete a temperature test.</li><li>While maintaining social distancing, question visitors regarding recent travel, if they have had recent contact with ill people, or if they are experiencing any symptoms themselves. </li><li>Those found to be ill or who may have been exposed should be denied access but may be encouraged to visit another time, or to use alternate means of visiting such as calling or perhaps conducting a visual chat behind clear glass or Plexiglas barriers if the provider can accommodate them. &#160;<br></li></ul><p>2. Hand hygiene—the use of an alcohol-based hand rub is preferred.<br>Instruct visitors on proper hand hygiene, which means washing hands with soap and water for at least 40 seconds and/or applying an alcohol-based hand rub with at least 60 percent ethanol or 70 percent isopropanol for at least 20 seconds.<br><br>3. Face covering or mask that covers mouth and nose.<br>Ensure the availability of personal protective equipment (PPE) for visitors such as facial masks, gloves, and gowns, as it applies to the residents.<br></p><ul><li>Remind the visitor of the importance of PPE and how it impacts both the visitor and the resident.</li><li>Educate the visitor on the proper use of PPE.</li></ul><p>4. Social distancing—keep at least six feet between persons.<br>When providing opportunities for residents and visitors to visit in place&#58;<br></p><ul><li>Encourage meetings within a designated area.</li><li>Discourage travel throughout the facility.</li><li>Provide opportunities to maintain social distancing from other family groups.</li><li>Limit visiting hours/length of visits.</li><li>Encourage the use of outdoor areas.<br></li></ul><p>5. Post instructional signage throughout the facility, and provide proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices such as hand hygiene and the use of face coverings or masks and specified entries, exits, and routes to designated areas.<br>Post reminders to visitors that the facility may decide to limit or temporarily stop visitors or others from the facility should the number of infections increase or become more widespread in the local community.<br></p><ul><li>Facilities should provide opportunities for visitors to receive education regarding best practices to minimize or limit the transmission of any infectious disease. This may be accomplished with family newsletters, visual aids, or brief instruction on arrival.</li><li>Remind all visitors about respiratory hygiene and cough etiquette (covering mouth and nose with a disposable tissue when coughing or sneezing).<br></li></ul><p>6. Clean and disinfect high-frequency touched surfaces in the facility often and designated visitation areas after each visit.<br><br>7. Ensure staff use PPE appropriately.<br><br>8. Effectively cohort residents (for example, with separate areas dedicated to COVID-19 care).<br><br>9. Resident and staff testing should be conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH).<br></p><h2>Indoor Visitation</h2><p>While taking a person-centered approach and following CMS' core principles of infection prevention, outdoor visitation is preferred due to increased space and air flow. However, with winter approaching, indoor accommodations may become necessary.<br></p><p>Nursing homes should accommodate indoor visitation, including visits for reasons beyond <a href="/Monthly-Issue/2020/December/Pages/Compassionate-Care-Visits.aspx" target="_blank">compassionate care</a> situations based on the following guidelines&#58;<br></p><ul><li>There has been no new onset of COVID-19 cases in the past 14 days, and the facility is not currently conducting outbreak testing;</li><li>Visitors should be able to adhere to the core principles, and staff should provide monitoring for those who may have difficulty adhering to them, such as children;</li><li>Facilities should limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time, based on the size of the building and physical space. Consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and</li><li>Limit hall movement. For example, visitors shouldn't walk around the facility but should go directly to the resident's room or designated meeting space. Visits for residents who share a room should not be conducted in the resident's room.</li></ul><h2>Community COVID Positivity Rate a Factor</h2><p>Nursing homes should use their county's COVID-19 positivity rate, found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate indoor visitation&#58;<br></p><ul><li>Low (&lt;5%) and Medium (5%-10%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond compassionate care visits) and</li><li>High (&gt;10%) = Visitation should occur only for compassionate care situations according to the core principles of COVID-19 infection prevention and facility policies.</li></ul><p>While not required, CMS encourages nursing homes in medium- or high-positivity counties to test visitors, if feasible. If so, facilities should prioritize visitors that visit regularly (weekly, for example), although any visitor can be tested.<br></p><p>Orchestrating visitation of loved ones with residents in a nursing home is a top priority for health care leaders and staff. Visitors and residents may be unfamiliar with the process and uncomfortable with the guidelines. In order to alleviate the mental health ramifications mentioned earlier, it is important to approach the process with grace, patience, and respect. <br><br><em>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>.​</em></p>2020-12-01T05:00:00Z<img alt="" src="/Monthly-Issue/2020/December/PublishingImages/1220_mgmt.jpg" style="BORDER&#58;0px solid;" />Management;COVID-19Kris MastrangeloMany residents have undergone an unfathomable experience with loneliness, confusion, and questions about why the situation is impacting them.
NIC Expert Says Occupancy Will Evolve as Owners, Operators Look for Recovery<p><em>Provider</em> posed a series of questions to Beth Burnham Mace, chief economist and director of outreach at the National Investment Center for Seniors Housing &amp; Care (NIC), on issues tied to the COVID-19 pandemic and occupancy levels across the seniors housing sector.<br><br class="ms-rteForeColor-1"><em class="ms-rteForeColor-1"><strong>Provider&#58;</strong></em> What is the current trend for occupancy, and which of the market segments is showing the most negative impact from the pandemic?<strong class="ms-rteForeColor-3"><br></strong></p><p><strong class="ms-rteForeColor-3">Mace&#58; </strong>The distinction between nursing care/skilled nursing and seniors housing is especially important to consider in discussing occupancy performance because the frailest elderly are often patients of skilled nursing’s higher acuity setting with around-the-clock nursing attention. And, it has been these elderly patients with significant pre-existing conditions that have seen the highest rates of COVID-19 incidence and fatalities. &#160;<br></p><p>Partially as a result, according to data from the NIC MAP® Data Service, the occupancy rate for skilled nursing properties fell more than other segment types with a 6.5 percentage point decline from the first quarter to 80.2 percent in the second quarter of 2020.<br></p><p>This was significantly more than the 2.8 percentage point drop in seniors housing properties to 84.9 percent, and when the aggregated seniors housing category is broken down into its subcategories, there was a 3.2 percentage point decline seen in assisted living properties to 82.1 percent and a 2.4 percentage point decline in independent living properties to 87.4 percent from the first to second quarters.<br><span><br class="ms-rteForeColor-1"><em class="ms-rteForeColor-1"><strong>Provider&#58;</strong></em> </span> A big if, but if the pandemic is under control and vaccines available to all, what do you expect the occupancy outlook to be once this terrible time abates? <span><strong class="ms-rteForeColor-3"><br></strong></span></p><p><span><strong class="ms-rteForeColor-3">Mace&#58; </strong></span> As you point out, the pandemic holds the cards. At this point, the outlook for the sector is tied to the path of the pandemic, its infection and penetration rate within properties, and the impact of the pandemic on broad economic growth. The seniors housing and nursing care industry as well as the broader national economy will be negatively affected by the COVID-19 virus until a vaccine is available and widely distributed. <br></p><p>And, whenever that happens, I do not believe that we will go back to business-as-usual. I believe that there is a transformational change in the seniors hosing and care industry and that the change will continue to evolve. Occupancy will eventually return to pre-pandemic levels, but the industry will be changed.<br><span><br class="ms-rteForeColor-1"><em class="ms-rteForeColor-1"><strong>Provider&#58;</strong></em> </span> And, we have the demographics to consider?<span><strong class="ms-rteForeColor-3"><br></strong></span></p><p><span><strong class="ms-rteForeColor-3">Mace&#58; </strong></span>&#58; Yes, more broadly, the underlying fundamentals and drivers of seniors housing remain in place. First, the demographics alone support the growing need for care and housing for seniors. Today, there are seven adult children aged 45 to 64 to care for every senior over the age of 80. By 2030, this ratio shrinks to 4&#58;1, and by 2050, it becomes 3&#58;1. Fewer caregivers suggest that community-based congregate settings will be needed more than ever. &#160;<br></p><p>Second, with nearly two of every three properties built before 2000, the inventory of senior housing properties is relatively old, and often a property refresh is needed for design, functionality, and efficiency. And, as obsolescence increases, new supply is needed at least in some markets. <br></p>2020-11-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/housing_2.jpg" style="BORDER&#58;0px solid;" />Management;COVID-19Patrick Connole​Provider posed a series of questions to Beth Burnham Mace, chief economist and director of outreach at NIC, on issues tied to the COVID-19 pandemic and occupancy levels across the seniors housing sector.