Pressure injuries (PIs) are one of the largest unsolved healthcare challenges today and International pressure injury prevalence rates are estimated to be between 3-32% in Long Term Care facilities.¹ Under certain conditions PIs can begin to develop in a matter of minutes to hours^2,7. That is why once an individual’s PI risk is assessed and identified, prescribing the right intervention needs to be fast, simple and straightforward.

The relationship between pressure and time are critical factors in pressure injury development. Research conducted over many years has demonstrated that the magnitude of the mechanical load which may lead to tissue damage depends on the duration of time during which the loads are applied to the skin and tissues².

Generally the established principle is that tissue can withstand higher pressures for a short period of time and lower pressures for a longer period^7,8,9 (see figure).  There is no universally ‘safe’ pressure threshold, and it is difficult to determine an absolute time period beyond which a patient will go on to develop a pressure injury⁸. The speed and severity of the onset of a pressure injury will depend on many internal and external factors including individual anatomy, tissue tolerances and confounding factors².

Long term care residents and clinical needs vary considerably, and Arjo strives to equip care facilities with skills, tools and solutions to optimize clinical and financial outcomes.

Arjo’s commitment to optimize clinical and financial outcomes

To answer clinical needs in a speedy manner, Arjo, a global leader in the prevention and management of pressure injuries, offers a comprehensive range of rental solutions including medical beds; patient handling solutions; clinical seating; and therapeutic support surfaces, including alternating pressure, foam, low air loss, microclimate management and hybrid systems. With a nationwide network of Rental offices and Service centers it allows to meet the needs of Long Term Care facilities in a timely fashion.

With a full range of wound care solutions for prevention and management of pressure injuries, Arjo supports customers with added clinical expertise, and a high standard of service and education.

Are you looking for a rental solutions partner to support you in effective pressure injury prevention?

When you partner with Arjo for rentals, you collaborate with a Clinical Excellence Team of physical therapists and wound care clinicians. Arjo’s team can support you in providing recommendations based on clinical risk assessments; clinical protocol development and 24/7 education and training resources.

Talk to an Arjo Expert

References

1. Anthony, D. M., Alosoumi, D., and Safari, R. (2019). ‘Prevalence of pressure ulcers in long term care: A global review’, Journal of Wound Care, 28(11), pp. 1-7. DOI: 10.12968/jowc.2019.28.11.702.
2. Gefen A (2018) The future of pressure ulcer prevention is here: Detecting and targeting inflammation early. EWMA Journal 2018, 19(2):7-13.
3. Li Z, Lin F, Thalib L, Chaboyer W. Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. Int J Nurs Stud. 2020 May.
4. Moore Z, Avsar P, Conaty L, Moore D.H, Patton D, & O’Connor T (2019) The prevalence of pressure ulcers in Europe, what does the European data tell us? Journal of Wound Care.
5. Berlowitz D, Lukas CV, Parker V, Niederhauser A, Silver J, Logan Cet al. Preventing pressure ulcers in hospitals: a toolkit for improving quality of care [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2014 [cited 2018 Oct 2].
6. Anthony, D. M., Alosoumi, D., and Safari, R. (2019). ‘Prevalence of pressure ulcers in long term care: A global review’, Journal of Wound Care, 28(11), pp. 1-7. DOI: 10.12968/jowc.2019.28.11.702.
7. Gefen, A (2008). How much time does it take to get a pressure ulcer? Integrated evidence from human, animal and invitro studies. Ostomy Wound Manage. 2008b; 54(10): 26-8,30-5.
8. European Pressure Injury Advisory panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Advisory Alliance. The Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed). EPUAP/NPIAP/PPPIA, 2019.
9. Linder-Ganz E, Engelberg S, Scheinowitz M, et al. Pressure time cell death threshold for albino rat skeletal muscles as related to pressure sore biomechanics. J Biomech. 2006; 39(14):

How to positively impact resident care and safeguard your communities’ future

Long-term care providers play a crucial role in ensuring the health of the elderly and others who have complex medical needs and require a high level of care. Value-based care (VBC) incentivizes healthcare providers to work together to improve patient health outcomes while reducing costs.

To accelerate the transition to VBC including Medicare Advantage, governments at the federal and state level are encouraging partnerships that enhance the ecosystem of care and technology.

A recent roundtable discussion sponsored by Curana Health and moderated by Kimberly Marselas, senior editor of McKnight’s Long-Term Care News, explored the potential reach of existing VBC partnerships, as well as the challenges and future of care delivery that aims to infuse the reimbursement system with a more holistic approach.

Participants offering insight were Jeremy Dressen, president and CEO of AllyAlign Health; Lynne Katzmann, partner at Perennial Advantage and founder/CEO of Juniper Communities; Amy Kaszak, executive vice president of strategic initiatives at Curana Health; Julie Kemman, CEO of Health Care Professional Consulting Services, Inc.; Lisa Leveque, vice president of strategic alignment and care transformation at Bandera Healthcare; Amy La Fleur, senior vice president of operations at Ciena Healthcare; Mark Price, CEO of Curana Health; and Paul Pruitt, CEO of Majestic Care.

Improving health outcomes

“[VBC] is fundamentally about creating an environment where everyone involved in caring for a patient is able to do the right thing for the right patient at the right time,” Price said. “If you do that, you produce good outcomes that create good outcomes for the organization as well.”

The push toward VBC has impacted hospitals and home care more than senior living and post-acute care facilities, La Fleur noted. “If you can put objective measures to execution, then it levels the playing field,” she said.

Ultimately, both VBC and long-term care are about promoting health.

“We want to capture the value that we create and be paid for what we did because it has a major impact on it,” Katzmann said.

When it comes to forming value-based partnerships, the industry has evolved from a position of begging for partners to being able to evaluate and choose among them, La Fleur said. As a result, Ciena Healthcare is restructuring the performance expectations of its medical directors and physicians.

“It’s a different mindset in VBC for nursing homes to be in the driver’s seat around that,” she explained.

Partnerships are a key component of successfully providing VBC.

“As we get into these relationships and we challenge our health plans in other states, we’re capable of getting creative with care,” Leveque said.

That will continue as the industry showcases VBC’s positive impact on beneficiaries through data. For now, many are rewarded for their ability to help residents and patients avoid hospitalizations or rehospitalizations. 

“We have to be able to talk about outcomes in a way that everyone understands,” Katzmann said. “What you want to do is keep people healthy, and the best way that everyone knows how to measure that or can relate to it is by keeping people out of the hospital.”

Overcoming VBC challenges

Many long-term facilities now have hospitalist-trained physicians serving as managing physicians. However, long-term-care residents often require different services than other subsets, including geriatric services, comorbidities management and chronic care management, Leveque explained. As a result, facilities are relying more on specialists, which can create additional costs —or value.

Technology also can help reduce expenses and facilitate communication among caregivers. 

“Performance management around VBC is much bigger than a transition from one level of care to another,” La Fleur said. “You have to be able to put into a practitioner’s hands what they need to look at.”

Unfortunately, most facilities use platforms that do not interact with one another, and existing platforms may not provide the exact data that partners want visibility into.

“There’s no one-stop shop,” Pruitt said. “We’re looking to hire our own person that can go in and build these reports. We want our destiny written by us, not somebody else out there that’s telling us how it’s going to work.”

Good data and technology, great training and support, and incentives are critical to VBC success, Price said. The entire staff must understand and be invested in the end goal.

“We make sure everybody, all of our physicians and nurse practitioners, are incentivized based on quality and all the communities we work in,” he said. “When you incentivize the community, amazing things happen.”

VBC is only as good as its relationships.

“We’ve taken the approach of developing a solution that’s going to meet where the operator or partner is at,” Dressen explained. “We bring to the table, ‘Here’s how you make a Medicare Advantage plan successful,’ but you need to help us know how we make it successful in your community.”

A VBC approach requires flexibility, integration and consistency, Kaszak added. It’s important to find a partner who is nimble and specializes in the industry, who can work with and understand the nuances of each level of the organization, and who has the size and scale to build a partnership that will continue to be of value as things evolve, she explained.

The future of VBC

“VBC is here to stay,” Kaszak said. “[CMS is] making it easier for more physicians to participate and they’re doubling down by backing up the accountable care organization (ACO) model with some baby managed-care steps for physicians who are not ready to be a part of an ACO, but can still participate in specific condition primary care models.”

With that more flexible model, Curana Health has been able to cover supplemental benefits from food delivery and on-site beauty services to cognitive therapy and companion care for residents in senior living, Dressen said. His advice: Think about how to drive value creation to expand the tenet of what encompasses VBC.

“We have to talk about our role in determining health,” added Katzmann, who found such value in the VBC approach that she jumped into the insurance business. “Good health saves money, good health means better quality of care and good health means happier consumers.”

Caring for those patients has evolved as the types of patients at long-term-care facilities have become significantly more complex over the years.

“We’re expected to care for our communities,” Leveque said. “We need to shift CMS to better understand the types of care that we’re being asked to provide.”

“It’s chronic care management, managing the person holistically through their life and understanding their whole life,” Pruitt added.

The ideal future of VBC is one in which everyone can focus on the right long-term plan for any individual resident to improve their health outcomes, Price concluded.

“If we had transparency and we had simplicity, and there was real money tied to a common scorecard everybody had around the country, it would unleash massive creativity and ability to go out and execute,” he said.

As staffing constraints and mounting regulations continue to challenge nursing homes nationwide, it is imperative for care providers to develop innovative strategies in adopting value-based care initiatives that will improve facility performance, occupancy and revenues.

During a recent webinar, McKnight’s Long-Term Care News Executive Editor James M. Berklan sat down with Scott Rifkin, MD, founder and executive chairman of Real Time Medical Systems (Real Time), to discuss the various types of value-based care payment models available and proven strategies that enable facilities to demonstrate value as high-performing providers for their hospital and health plan partners.

The value-based care payment model

Previously, the payment system model incentivized providers by “increasing length of stay, having people go to the hospital and come back as Medicare patients, and it hasn’t been good for the healthcare industry,” Rifkin explained. In contrast, value-based care “incentivizes good patient outcomes, quality of care, and keeping people healthy and out of the hospital.”

In addition to improving patient care and outcomes, the adoption of a value-based care mindset has many
benefits for skilled nursing operators.

“It opens up a whole new revenue stream if we can share in the savings created by reducing hospitalizations and keeping people healthier,” Rifkin said. “It’s a tremendous opportunity if we can change the way we think about providing care and nursing.”

While value-based care payment models pertain to both short-stay and long-term care patients, there are tremendous opportunities to work with insurers among the short-stay patient population, Rifkin said. While as the owner and operator of Mid-Atlantic Health Care LLC (MAHC), Rifkin partnered with a large insurer in Philadelphia to reduce the typical hospital stay of 23 days. The company handled its own case management, discharge planning and social work efforts and received the full Medicare rate for only 15 days. The result: “The actual length of stay was 10.8 days, the return to hospital rate was lower from the nursing home, and we dropped our readmission rates for short-stay patients from 20% to 22% down to 8% to 10%,” he noted.

“It opens up a whole new revenue stream if we can share in the savings created by reducing hospitalizations and keeping people healthier,” Rifkin said. “It’s a tremendous opportunity if we can change the way we think about providing care and nursing.”

As a former operator and industry veteran of over 15 years, I relate to the concerns and considerations of you, my former industry colleagues, examining alternative workforce structures. I also know that those concerns and considerations have been heavily influenced by concerted efforts to detract from models that truly empower the worker, and provide facilities with the data and insights to stabilize, scale, and care for more people. 

And, as someone who sincerely empathizes with your perpetual anxiety and sleepless nights over how to stay afloat with enough workers to provide quality care for the people who need it, I want to affirm the power of a workforce strategy I am convinced we cannot do without: The independent licensed professional.

I’ve spent many hours speaking with technology visionaries, workforce strategists, and policy experts on this topic – so I can say with confidence that it’s not only a promising and viable strategy, but also a necessary one. 

The policy POV

My colleague, Regan Parker, is one of the leading experts in alternative workforce policy and strategies in the country, with a background in worker classification law. These laws are complicated, nuanced, and were written long before alternative models were ever considered. As she shared in an article earlier this year:

“Some industry leaders have conjectured or claimed that a platform with the 1099 model can ‘absolve themselves’ of responsibility and leave healthcare communities with the liability for an independent worker. That’s not possible in this area of the law – there are clear and enforceable compliance structures that protect the professional, the care community and the platform. If a company has misclassified a worker, there are a number of ways for an agency or a platform to be held accountable.“

Unfortunately, there are bad actors in the space who may try to take advantage of workers or facilities who understandably don’t specialize in this area of workforce law – that’s true to an extent in any model. That’s why it’s important to seek out partners who are known for operating with integrity, have dedicated legal expertise in-house, and can show the results for both facilities and providers impacting their quality of operation and life. 

The quality care POV

I’ve also heard facilities raise the concern that independent contractors may be less capable of, or committed to, providing quality care. ShiftKey was developed through the lens of leaders who worked in the credentialed care space for the better part of their careers – which is why the technology was specifically built to vet and house credentials. This isn’t like a traditional ‘gig’ app that just anyone can sign up for – there’s a thorough process for verifying credentials and the platform offers features that allow facilities to flag if they’ve encountered issues with a specific provider.

I’d also argue that the greatest risk to quality care is a workforce that’s understaffed, overstretched and overscheduled. There already aren’t enough licensed professionals to meet the growing demand in the post-acute and long-term care space – we must find creative ways to find as many professionals as possible who have invested the time and resources to earn the proper credentials. We can’t afford to have people sitting on the bench, and for some professionals the only way they’re willing to get back in the game is through the true independence that a platform like ShiftKey offers. 

The total workforce POV

We’re also combatting decades of negative experiences with staffing agencies. When facilities hear about platforms like ShiftKey, the same assumptions may unconsciously come to mind. But one thing our leaders have been clear about from the beginning is that we are not a staffing agency. Our model is built on data and transparency – equipping facilities with the insights to make long-term strategic workforce decisions at scale, while providing access to the largest marketplace for independent licensed professionals to meet facilities’ everchanging, unique needs. 

Most recently, ShiftKey introduced its Schedule Automation Marketplace Integration (SAMI) to facilities, with immediate and transformative results, including: 83% reduction in unfilled shifts, dropping from an average of 15% unfilled to just 3%. At the same time, this reduction yielded business returns, instead of coming at a premium cost, with facility partners reporting results that included a 7% increase in resident occupancy rate and more than $1 million in cost savings.

We need 3.5 million additional long-term care healthcare workers by 2030 (Institute of Medicine) and, in the meantime, 61% of long-term care facilities are limiting admissions because of staffing shortages (American Healthcare Association). My former colleagues and peers in the industry are all too familiar with these numbers, but I share them again in this context to emphasize that the needs in long-term and post-acute care are not overblown and true. Transformative solutions must be developed and embraced to make an impact. It’s critical that we partner together – the technology and data companies, workforce strategists, facilities and their employees, and independent licensed professionals – to empower a workforce to support our parents, grandparents and other loved ones with attentive, quality care.

Brandon Tappan is the Chief Revenue Officer for ShiftKey, a leading technology company transforming the future of work.

Collaborate more with vendor partners who have integrated services

Synchrony brought its rehab, wellness, lab, and pharmacy services under one umbrella to fully integrate its clinical offerings for better collaboration between them, and better collaboration with its client partners. The result? A more streamlined approach, less risk, and more communication leading to higher-quality experiences for residents.

Be innovative about keeping patients living independently

Synchrony designed a program to help support patients as they transition home or to independent living from the SNF setting, allowing them to gain or maintain greater independence. This solution, PackEDGE, is a customized medication delivery system where medications are sorted and packaged by time of day and delivered right to the patient’s home in an easy-to-open package. This improves medication adherence resulting in fewer rehospitalizations.

Whenever possible, deprescribe 

Because SNF patients are on an average of 11 or more medications a day, one remedy Synchrony employs is “Medication Optimization.” By decreasing polypharmacy, Synchrony helps SNFs decrease the medication burden for their patients, decreasing overall costs for the facility and the healthcare system while impacting the resident’s quality of life.

Embrace pharmacogenomics

Synchrony has partnered with GeneIQ for innovative technology to help assess how each individual uniquely metabolizes medications. Pharmacogenomics is a simple lab test that shows how a person’s genes can dictate their response to a variety of medications. Synchrony supports the utilization of this science with our consultant pharmacists who are trained to help interpret the results and provide actionable recommendations.

To learn how you can expertly deploy these four steps in pharmacy approaches, schedule a no-obligation consultation. 

Key elements of the new guidance include more detailed assessment of the vascular access device and the resident’s ability to report signs and symptoms of complications. Is your facility prepared?

Just a quick reminder for the audience—ISNPs or Institutional Special Needs Plans—are Medicare Advantage plans that limit enrollment eligibility to Medicare beneficiaries who live or are expected to live in a long-term care facility for 90 days or longer. You have to be an ISNP owner if you want to share in savings.

By Tom Ellis, President & CEO, ShiftKey

In my more than 20 years of experience in industries ranging from retail to healthcare and beyond, a common challenge all industries face is scaling the business or organization while balancing a workforce strategy that both preserves quality and continuity of service. Complex challenges were consistently met with static traditional solutions. Entrepreneurial and fresh thinking, grounded in technology and data, was long overdue, especially in the healthcare industry among licensed professionals and facilities. I started ShiftKey to be the intersection of technology, data, and business strategy to solve broader economic, workforce, and business challenges. 

The ShiftKey model is bold, yet practical – providing facilities access to a marketplace of independent professionals that would allow them to make short and long-term workforce decisions without passing through a go-between or third-party that drains resources and time. Our platform gives licensed professionals independence and flexibility – every shift is a choice. The licensed professionals provide services to facilities because they care deeply about patients and providing quality care.

Over the last year, we’ve made major strides through a strategic investment in OnShift, and now the launch of the Schedule Automation Marketplace Integration (SAMI). SAMI is a first-of-its-kind system that combines the full power of ShiftKey’s workforce marketplace and OnShift’s schedule view and analytics, presenting facilities with the resources and insights to make strategic workforce decisions in the short and long-term.

SAMI uses a tech-forward approach that equips facilities with workforce patterns, information and analytics to make informed decisions that have an impact on their business – but ultimately driving more effective and consistent patient care.

We’ve tested SAMI at Tutera Senior Living & Health Care, among many others in post-acute care and senior living. Tutera has been a strong partner in this, showing compelling results and providing honest feedback. 

With Tutera, here’s what we discovered:

7% Increase in Resident Occupancy Rate

Tutera focuses on getting to know residents and team members on a personal level, leaning into their unique preferences and personalities to inform care and actions. This is precisely what SAMI is meant to elevate: Getting facilities out of survival mode, back into growth mode, with a focus on attentive patient care and relief as needed for facility employees.

Ultimately, the goal is to be able to serve as many patients as possible with quality of care that they deserve. For years, we’ve heard from facilities that the balance between workforce and resident levels remains elusive. While the aging population in need of care grows, facilities have been forced to make the difficult decision to turn away residents due to inadequate workforce levels. With SAMI, those days are over.  

90% Reduction in Unfilled Shifts

With all the tools to proactively build a comprehensive schedule, SAMI has given Tutera the ability to view employees and independent healthcare professionals in a single system. Paired with SAMI’s consolidated real-time reporting, Tutera has been able to make strategic decisions and tap into a network of licensed professionals any time they need it. Dynamic access to independent care professionals reduces burnout among your current team and complements them with individuals who are not only qualified, but who also want to be there. Every shift they pick up is based on their choice – when and where they want to work.

20% Increase in Employee Shift Requests

Yes, at Tutera, full-time facility employees are requesting more shifts after the integration than ever before. This is a theme I’ve seen consistently across different facilities using the technology. Facilities are using SAMI’s comprehensive data to forecast available shifts and facility employees can now plan ahead and tap into future schedules. However, when additional workers are required to support occupancy growth and fill openings, SAMI provides automated access to the ShiftKey marketplace, leveraging a vast, licensed talent pool to fill select shifts. This seamless integration and consistent shift coverage provides relief for scheduling directors and facility employees.

100% Total Workforce Transparency 

Across the board, SAMI provides total workforce visibility, optimization and cost savings – all in one system. Tutera has been able to leverage SAMI to achieve complete workforce transparency, building employee trust, reducing burnout, meeting staffing ratios and delivering high-quality care. Joe Schiller, Tutera’s Vice President of Human Resources, will tell you himself that SAMI has elevated the way they do business: “The way SAMI seamlessly integrates ShiftKey’s robust marketplace with OnShift’s scheduling capabilities has completely transformed our workforce strategy. We now have access to workforce coverage paired with key data insights to help us strategically grow our business, take great care of our residents, and put us in a prime position for our hospital referral partnerships.”

At ShiftKey, we will never stop developing and leveraging tech solutions to efficiently solve workforce needs. We’ll continue to transform and expand empowered work through tech to meet strategic business, resource and workforce needs for licensed industries. The SAMI tech integration is just the tip of the iceberg as we continue to serve as a trusted business partner for facilities who share our core values in solving workforce challenges, unlocking the full potential of technology, and keeping people – patients and the licensed professionals that care for them – at the center.

Revenue recovery & diversification

Post-acute care, which nationally has tended to be less than 25% of patient days of care but has been the lifeblood of financial viability, has been hit hard — first, by a sharp decline in elective surgeries and overall declines in utilization across many types of care, as well as a strong preference for home-based rehabilitation.

These trends drove a steep decline in post-acute care utilization. The percentage of patients discharged to SNFs from hospitals declined five percentage points from its 2019 average to just 14% in October 2020, according to a study of more than 70 million commercially insured individuals, including Medicare Advantage (MA) beneficiaries. Use of SNFs for post-acute care declined to 51% of the pre-pandemic rate, from an average of 324 admissions per 100,000 insured members to 167 admissions per 100,000. As a result, SNFs saw their share of post-acute spending drop eight percentage points. (See chart.) The study’s authors state that these trends point to “a fundamental shift in providing post-acute care at home, rather than in nursing homes.”

Will this shift to home last? The answer largely depends on whether lawmakers strengthen the home health benefit, which has shrunk over the course of the last decade. But the pandemic could represent an inflection point, given the imperative to reduce infection rates.

The Choose Home Care Act of 2021 proposes to supplement the traditional Medicare home health benefit with expanded services, including transportation, meals, home modifications, remote patient monitoring, telehealth services, and personal care services. Some industry leaders have expressed concern that the bill would limit options for Medicare beneficiaries, but others in the SNF community see advantages in creating incentives for more SNFs to offer at-home services.

Meanwhile, the number of Medicare Advantage plans offering home care as a supplemental benefit is on the rise, although managed care plans cap the benefit at a very low level (around 60 hours).

Whether you see home care as a complement or a competitor, all of these factors cast a specter of doubt on the long-term financial viability of the transactional, post-acute care side of the business.

New revenue streams for long-term care business

Given the decline in utilization of post-acute care, SNF owners and operators are understandably turning their attention to how to make the long-term care side of the house more attractive to residents and financially viable for the long haul.

Population health strategies carry the potential for long-term care operators to create new revenue streams while improving residents’ quality of life. One of these options is the institutional special needs plan (I-SNP), a Medicare benefit for residents of long-term care institutions. Enrollment in I-SNPs saw strong growth in the years leading up to the pandemic. And while enrollment growth slipped in 2021, these plans remain one of the best vehicles for providers of long-term care to embrace first.

Nursing home owners and operators benefit from a new revenue stream associated with the I-SNP contract. In addition to a monthly fixed payment to help coordinate the care of the beneficiary, the nursing home also has opportunities to share in savings from managing the resident’s overall care costs, including hospitalization. Nursing homes can choose from a range of options that entail different levels of risk and reward. Some providers even establish their own I-SNPs.

Most importantly, the I-SNP will partner with the facility to strengthen clinical competencies that will help to avoid unnecessary hospitalizations and emergency department visits. This benefits residents and will also help facilities prepare for the continued growth of value-based contracts.

Skilled nursing providers also have opportunities to build on the momentum to provide more healthcare services in the home. Two population health programs create opportunities to provide nursing home services “without walls.”

An institutional equivalent SNP (IESNP) is designed for residents who live in their homes or in assisted living communities but require an institutional level of care (LOC). A determination of institutional LOC is based on the use of the same state assessment tool that’s used for individuals residing in an institution. The assessment must be administered by an independent, impartial party with the professional knowledge to identify the institutional LOC needs. IESNPs may be appropriate for life plan communities and assisted living providers. In addition, skilled nursing providers that have experience with I-SNP are considering how to leverage that model into other settings with IESNPs.

Program of All-inclusive Care for the Elderly (PACE^®) is an integrated care program for nursing home-eligible residents that have both Medicare and Medicaid benefits and who can live safely at home. The PACE model of care has been around since the 1970s, but the high cost of building and regulating PACE centers has been a limiting factor in their growth. Success with PACE is greatly correlated to state Medicaid payment rates. There are some compelling reasons why senior care and living providers should weigh the benefits of a PACE program. During the pandemic, the model proved a successful alternative to skilled nursing care, with PACE providers pivoting almost overnight to home-based services. In response to pandemic success, and increased funding for home and community-based services, many states are looking to expand PACE programs.

Optimizing existing revenue streams

Long-term care providers also must find ways to optimize their existing revenue streams.

The most significant change in Medicare payment methodology in 20 years, the Patient-Driven Payment Model (PDPM) was initially viewed by the industry with some trepidation. However, PDPM so far has been overwhelmingly positive for skilled nursing providers, who have seen average increases of 5 to 10% over previous reimbursement rates.

The COVID-19 pandemic, which hit only five months after PDPM was implemented, has been a significant factor in driving higher reimbursement rates, as PDPM rates are higher for patients with greater clinical needs. Since PDPM was designed to be budget-neutral, skilled nursing providers should prepare themselves for a possible reckoning in fiscal year 2023.

Providers also are seeing significantly reduced therapy services. Total therapy minutes per patient-day declined sharply following PDPM implementation, followed by more gradual declines over the next six months for a total decline of 14.7% by the end of March 2020. Physical and occupational therapy disciplines experienced roughly parallel declines. (See chart below.)

SNFs must engage in ongoing monitoring to ensure these therapy reductions don’t have negative implications for patients. However, the reduced staffing costs have been welcome at a time when staff is in short supply and nearly every other expense has escalated significantly.

To achieve optimal PDPM rates, SNFs should:

• Focus on accurate capture and coding of each patient’s entire clinical diagnoses. Take the time to revisit training and processes that were put in place when PDPM was first implemented. Given today’s staffing shortage, overwhelmed MDS nurses might overlook some of a patient’s clinical diagnoses at admission. For example, speech language pathology requires close coordination between the dietary and speech departments, and lack of communication between those departments can hurt reimbursement.
• Monitor your region’s average PDPM rate. If your organization’s rates differ significantly from those averages, investigate whether there are opportunities to capture more detailed information to increase those rates.
• Review any Medicare Advantage contracts. Some MA plans have adopted Medicare’s reimbursement methodology, so optimizing the PDPM rate can have a beneficial effect on multiple revenue streams.

The past two decades have seen a steady shift from traditional Medicare to MA. In 2021, Medicare Advantage plans had more than 26 million enrollees — about 42% of the total Medicare population and 46% of total Medicare spending. On the current trajectory, MA enrollment will be higher than the traditional Medicare rolls by 2030.

Perhaps most astonishing is the fact that the average Medicare beneficiary in 2021 could choose among 33 MA plans, which means that providers are keeping track of a staggering array of claim criteria, reimbursement rates, submission processes, and billing time frames.

Optimizing managed care reimbursement from MA or other commercial plans comes down to three things:

• Cost containment. Make sure you’re managing your ancillary costs for the managed care individual. Therapy is a huge cost area for both Medicare and managed care. Each plan has different requirements for therapy delivery. Whereas one plan might require 80 minutes of therapy per week, another requires 100 minutes. With the conversion to PDPM, many administrators aren’t placing the same level of priority on tracking therapy minutes, but keep in mind that oversights can lead to denied claims and underpayments.

• Understanding your organization’s financial performance. Providers need to clearly understand each plan’s requirements and how their actual costs (routine and capital costs from Medicare cost report plus ancillary costs, such as therapy, pharmacy, lab, and X-ray) compare to the managed care rates. Many providers will find that the managed care rates are lower than their actual costs. Armed with this information, they can make informed decisions about renegotiating or terminating these unprofitable plans.

• Annual contract renegotiations. While it can be all too easy for overwhelmed administrators to let contract renewal periods slide, a provider’s long-term financial health depends on regular evaluation of contracted rates. Come to the negotiating table armed with research on market rates and your cost to provide services under these contracts.

Pandemic financial performance: How bad was it?

Overall financial performance of the SNF industry is regularly evaluated by various stakeholders, primarily using public data provided on Medicare cost reports. These reports are filed five months after a provider’s year-end and aren’t available for public analysis until several months after that.

The Medicare Payment Advisory Commission (MedPAC) reported findings in March of 2022 that reflected an industry “all payer” net margin. Aggregate Medicare margins also increased from 11.9% in 2019 to 16.5% in 2020. These findings informed its recommendation to reduce SNF payment rates in fiscal  year 2023.

While this margin growth may seem hard to believe, keep in mind that the financial impacts of the pandemic have unfolded in waves. For example, census drops were most dramatic late in 2020, whereas labor costs rose steeply throughout 2021. MedPAC acknowledged that the improvement in margin was largely due to both federal and state public health emergency funding.

Also consider that individual providers experienced the pandemic’s financial impacts at varying rates and time periods that may not align to the overall trends. There has also been significant variation in the timing and amount of federal relief funds, state Medicaid, and other assistance.

We expect that 2021 cost report data will reflect significantly lower industry all payer and Medicare margins, reflective of continued slow census recovery and the rising cost of labor. Individual facility results will continue to vary widely, particularly for entities that have been able to file for payroll protection program loans and employee retention credits.

How does my organization compare?

In prior reports, we have provided extensive historical benchmarks on revenue drivers and operating costs. Given the impact of the pandemic, benchmarking current key performance indicators can be far more informative than looking back at historical data. While it can be a challenge to find current benchmarks, two reliable sources of benchmarking data for SNFs include:

• The National Healthcare Safety Network (NHSN) database, which was expanded during the pandemic to include the reporting of weekly census information.
• Payroll-based journal data published by CMS, which provides insight on competitor staffing levels.

As you benchmark your financial performance against peers in your market and seek ways to optimize current revenue streams, be sure to learn about the risks and opportunities of population health strategies with the potential to create new sources of revenue while improving residents’ quality of life.

Reimagining the future of senior care

Demand for senior care services will continue to build, even if the pace of recovery remains uncertain. Organizations that remain agile will be prepared to respond to the long-term demographic boom of seniors, while those that cling to status quo will be left behind. Now’s the time to future-proof your senior care organization with strategies that balance the needs of today with the long-term care landscape of tomorrow.
Let’s work together to reimagine the future of senior care and find ways to thrive amid uncertainty

Given the direct correlation between staffing levels and adverse outcomes — including increased mortality, hospitalizations, and ED visits — how can facilities improve the safety and quality of care when workers can’t be had?

Back by popular demand, our panel will discuss ways nursing homes can maximize staff efficiency by putting first things first. Panelists are McKnight’s Editorial Director, John O’Connor; Pharmerica SVP LTC Operations and Chief Pharmacy Officer, TJ Griffin; Covenant Living Communities & Services National Director of Human Resources, Tina T. Johannessen; and Covenant Living Communities & Services VP of Health Services, Sheryl White. Among the issues our provider panel, presented by Pharmerica, will address:

• Streamlining workflows and optimizing processes
• Systematic and consistent use of operating protocols
• Training and development to boost capabilities and versatility
• Support that can ease staff burdens like feedback, variety, and growth, because when employees are satisfied, work is completed faster and with better results

You will walk away with proven methods to enhance operational efficiencies while improving outcomes.