1. Anticipate eased regulations. One benefit could be labor-related. 

“Any improvement in the regulatory environment that potentially increases productivity for direct care staff would be a positive,” says Imran Javaid, managing director at BMO Harris Bank.

Anthony Luzzi, president of Sims Mortgage Funding, similarly, notes that reform creating a potentially “less burdensome operating environment.”

The new order could strongly favor regional providers, according to David Sharp, managing director, real estate at MidCap Financial Services LLC. 

“Several providers feel that regulations will ease and more focus can be shifted to providing better care,” says Sharp. He also notes that possible changes to the Affordable Care Act could allow operators “to provide more appropriate insurance coverage for employees.”

Chad Elliott, managing director of mergers and acquisitions at Lancaster Pollard, sees skilled care networks narrowing and urges providers to “be in front of that reality,” sooner than later.

2. A strong recovery, as well as immigration tightening, could exacerbate an already challenging staff shortage issue.

Javaid urges providers to amp up efforts in vocational training and certification programs as well as college recruitment.

Jeff Binder, managing director at Senior Living Brokerage, says staffing is “at the forefront” of client concerns right now. 

“Retaining quality staff will continue to be costly,” he says, “Progressive thinking on attracting and keeping staff will be needed to not only contain costs, but constant turnover is a proven negative influencer on resident satisfaction.”

It’s not only about salary. Binder says while higher wages can undoubtedly place increased pressure on the short-term financial profile, “attractive compensation packages, enhanced benefits and a positive culture can possibly minimize the tremendous costs of employee turnover.”

3. If economic forecasts continue to improve, providers can think more about undertaking capital improvements.

“While interest rates are rising, they are still low by historical standards and this provides an opportunity for operators to be strategic with their capital needs to benefit in the long-term,” says Binder, who sees the coming months creating “an active acquisition market that could allow owners to dispose of non-core assets while pricing hovers at near record levels. Conversely, attractive costs of capital could allow an opportunity to strategically acquire in an effort to increase scale.”

Still, experts urge providers to avoid taking on big debt. 

“Long-term care asset prices have risen sharply during 2016, with an average of just under $100,000 per bed,” explains Sharp. “An easy mistake to make right now would be paying too much for an asset despite supporting comparable sales data.” 

But caution is needed when looking at interest rates. For long-term care, which has “notoriously low margins,” according to Javaid, “excessive variable rate leverage could be the undoing for many providers.”

4. Stay focused on the big picture.

“We are in a turbulent political environment. With all three branches of the federal government controlled by a single party, the opportunity for significant change will be present for at least the next two to four years,” Luzzi predicts.

Many advisors say providers should explore new partnerships.

Steven Anderson, managing director at Capital One Commercial Banking, recommends working with insurers.

“It’s more important than ever for care providers to solidify their relationships with their payers, and make sure that their organization and infrastructure is right-sized for the new environment,” he says. 

Canadian researchers urged reconsideration of how drugs are administered to nursing home residents with dementia shortly before death.

They found that 86% received at least one “medication of questionable benefit” — including statins, anti-dementia drugs and antiplatelet agents — in their last 120 days of life. 

The percentage dropped to 66% in the residents’ last two weeks, and 45% in the final week. But it should be even lower, said researchers from the Women’s College Research Institute in Toronto. 

The 2017 McKnight’s Excellence in Technology Awards are now accepting submissions from long-term and senior care providers.

The fifth edition of the free program focuses on how operators use technology to better their communities and residents’ lives. 

Gold, Silver and Bronze winners will be honored in five categories: 1) Quality Through Technology, 2) Dignity Through Technology, 3) the High Tech/High Touch Award, 4) the Innovator of the Year Award and 5) the Transitions Award.

Providers can learn more at www.mcknightsawards.com. Entries are due by July 14; winners will be announced this fall.

CareRise INDEX is the exclusive sponsor of the awards.

The Medicare Payment Advisory Commission voted in April to recommend an accelerated timeline that would see implementation of a site-neutral post-acute care payment system kick off in 2021.

Speeding up implementation is needed, MedPAC members said, since previous efforts to overhaul PAC pay have dragged.

“Having an open-ended implementation with no specific date would lead to this never getting done,” member Kathy Buto said at the group’s April meeting.

Despite the sense of urgency, MedPAC members also identified barriers to the accelerated start date, such as the effects the system could have on vulnerable patients and the “major impact” the overhaul could have on the post-acute sector.

Provider groups expressed similar worries ahead of MedPAC’s vote. Mike Cheek, with the American Health Care Association, told Bloomberg BNA that his group plans to provide input on the proposed system.

The advisory panel will present its non-binding recommendations on the unified PAC pay system to Congress in June.

LeadingAge executives met with new Centers for Medicare & Medicaid Services Administrator Seema Verma in April, prioritizing regulatory concerns.

A “dramatic” rise of Immediate Jeopardy citations around the country was one focal point raised by LeadingAge President and CEO Katie Smith Sloan and Senior Vice President for Public Policy and Health Services Cheryl Phillips, M.D., along with provider representatives.

The provider advocates also discussed the CMS final rule and its requirements of participation. Phase 2 requirements must be in place by Nov. 28, 2017.

LeadingAge said the discussion gave the group a solid foundation for a relationship moving forward.

“Our members and state executives kept the focus of the meeting on mission, care and community,” the group said. “Administrator Verma seemed receptive to the points made and asked us for follow-up on the issues discussed.” 

It wasn’t too long ago that thousands of nursing homes were fleeing the Medicaid program.

Not that it was hard to see why. Medicaid rates were never enough to cover the price of delivering three squares, a cot and services each day. For decades, facilities had to count on the kindness of more generous Medicare payments to get over the hump.

Then around the turn of the century, some savvy operators realized that Medicare could be more than a supplement; that it could, in fact, become their main payment source. The trade-off was that facilities had to focus on post-acute services, especially rehab care. Thus, a quiet revolution took root. Some operators quickly saw revenues triple, or more. But alas, while that party may not be over, it is probably going to be a lot less fun going forward.

One reason is that Medicare invoices are getting a much closer look these days. Not to insinuate anything, but a lot of the bills that were approved in the past are no longer so fortunate. Expect that trend to intensify as the proverbial funding cupboard gets bare. And it’s not like the Medicare managed care companies are interested in lowering their profits so skilled care operators can eat better.

Not that the envelopes being sent to your accounts payable department care about such matters. So operators need to find the money to compensate someplace else. And funny enough, we’re actually seeing Medicaid days increase.

Is Medicaid’s renaissance due to Medicare changes? In part, yes.

But Medicaid per diems are also getting better. In fact, the national average is now over $200 a day, for the first time ever. That’s hardly going to cause flop sweat among the top Reimbursement Utilization Group categories, but it’s a dramatic upgrade from days not long ago.

So will we continue to see more operators giving Medicaid a second chance? It’s a fair question. My guess is that the answer will vary by state. That Obamacare’s repeal-and-replace effort has been shelved (at least for now) may help in this regard.

Here’s my advice to facility operators: Don’t throw out old ties or state Medicaid manuals. You never know when either might come back in style.

A Pennsylvania court in March dismissed a lawsuit filed against 25 Golden LivingCenters by the former state attorney general. 

The suit was first announced by then-Attorney General Kathleen Kane in July 2015. It targeted 14 facilities operated by Golden Gate National Senior Care LLC and its related entities. It claimed the facilities failed to provide basic care to residents, and were misleading consumers about their services.

Eleven additional Golden facilities were added to the complaint later that year. Kane was later charged with perjury and abuse of office, forced to resign and sentenced to 10 to 23 months in prison in October of last year. 

Golden sold operations of several Pennsylvania facilities involved in the lawsuit earlier this year, but maintains ownership of the real estate for the facilities. 

In a statement to
McKnight’s, Golden said it is “pleased with the decision from the Commonwealth Court dismissing the case.”

In an opinion filed in late March, the Commonwealth Court of Pennsylvania sustained eight of Golden’s 12 objections to the attorney general’s claims and dismissed the state’s complaint against the provider.

Among the upheld objections was Golden’s argument that marketing statements criticized in Kane’s complaint were not false advertising, but rather “puffery,” or exaggerated sales talk. 

Those statements include claims about the facilities’ nursing staffs, snack and beverage options, linens, plans of care and focus on residents’ “individuality and dignity.”

The court’s opinion describes several of Golden’s marketing statements as including “motives and intentions, or general statements of optimism,” which don’t violate the Unfair Trade Practices and Consumer Protection Law.

The AG’s office may pursue the option of appealing the decision to the Supreme Court of Pennsylvania. 

In a win for providers, the United States Supreme Court declined in late March to review an arbitration dispute between an Extendicare facility and the family of a deceased resident. 

The High Court’s denial of the case means a September decision from the Supreme Court of Pennsylvania will stand, and the resident’s family must submit to arbitration with the provider over survival claims.

Taylor v. Extendicare Facilities, Inc. was filed by the family of a resident who died in April 2012 after being admitted to an Extendicare facility in Pennsylvania. Her family filed wrongful death and survival claims against the provider in October 2012.

The resident’s family, who had signed a pre-dispute arbitration agreement upon her admission, argued that their survival claims couldn’t be forced into arbitration since state law mandates that such claims must be joined with wrongful death claims, which are required to be tried in court.

Pennsylvania’s highest court ruled that the family’s arguments didn’t mesh with the Federal Arbitration Act — which takes precedence over the state’s rules — and that arbitration must be compelled.

The state court’s decision “reinforces the right of nursing homes to require plaintiffs in survival actions to stick to agreements to arbitrate, even when that may be contrary to Pennsylvania law,” Katherine Benesch, principal at Benesch & Associates LLC, told Bloomberg BNA.

An attorney for the resident’s family told Bloomberg that he was “disappointed” but “not surprised” by the Supreme Court’s denial of the case. 

He has since filed a petition for Supreme Court review of a case involving an HCR ManorCare facility that he believes will be a “better vehicle” for the justices to review nursing home arbitration agreements. 

What should we know and/or do about the right-to-die movement, which seems to be growing?

There are five states and Washington, D.C., that have passed Death with Dignity statutes: Oregon (1994); Washington (2009); Vermont (2013); California (2016); Colorado (2016); and Washington, D.C. (2016). 

Also, in Baxter v. Montana, 234 P.3rd 1211 (2009), the Montana Supreme Court found that Montana law allowed a physician to honor a terminally ill, mentally competent patient requesting medication to hasten death. 

Healthcare providers can allow staff and independent contractors to participate without incurring liability for abuse or neglect. However, a healthcare provider can have a written policy with notice to staff and contractors prohibiting participation on the premises owned, managed or directly controlled by the healthcare provider. 

While residents under DWD laws have the right to participate in the self-infliction of ending their life, providers may prevent staff or independent contractors from participating in the process and even prevent them from witnessing the written request. The healthcare provider, based upon the sponsor or owner’s religious beliefs, may seek to prohibit the process in their facility.

In sum, if you or your residents try to exercise their rights to participate in self-administering aid in dying medications, you must have your policy on such activities written with all necessary procedures complying with state law. You should notify prospective residents of your policy, especially if you intend to prohibit staff or independent contractors from participation. 

You should have legal counsel assist in developing and implementing your policies because DWD statutes are being considered in many jurisdictions.

Heart failure patients who went to a nursing home were 50% more likely to be readmitted to the hospital than patients who returned home instead, according to a study in the Mayo Clinic Proceedings.

Researchers examined records of 1,500 Minnesota residents to reach their findings.

More than 40% of heart failure patients were admitted to a skilled nursing facility at some point after diagnosis; more than one-third of those spend two or more subsequent stints in a skilled nursing facility.

In general, hospital readmissions for patients from a skilled nursing facility were for reasons unrelated to cardiovascular function, researchers added.