By Patrick Conole
“Everybody wants to go home.” That statement has never been truer for long term care providers that have adjusted their caregiving and bottom-line priorities to include short-stay patients as well as traditional nursing residents in response to demographic shifts, new technology, economics, and the preferences of the aging baby boom generation.
As with the burgeoning culture change movement that is revamping the way skilled nursing facilities (SNFs) look and feel—the Eden Alternative, Green House designs—providers are now bolstering their rehabilitation (rehab), therapy, and temporary housing offerings to tap new revenue streams, while bucking stereotypes of what SNFs do.
SNFs Take On New Look
Scores of SNFs are extending their business lines into short-stay arrangements for residents whose stays are measured in days and weeks as opposed to months and years, or the rest of a lifetime. These new type of residents are often in their 60s or early 70s versus typical nursing facility clients who may be closer to their low to mid 80s.
The short-stay patients are not necessarily frail or elderly and may simply require physical, occupational, or speech therapy following time in an acute care hospital before they return to more independent living.
The focus on these new patients revolves around the “everybody wants to go home” line, which came in a conversation with Parker Jones, administrator of the 164-bed Heritage Hall Nursing and Rehabilitation Center (American HealthCare) in Leesburg, Va., one of a number of such facilities in Virginia. The Leesburg campus Jones operates is like many across the country, as it seeks to fill beds and fill new needs. Jones notes that his facility was built in 1979 but has evolved in many ways since that time.
“Folks do what they need to do and then go back to an assisted living facility [ALF] or independent living. Since January, 58 percent of our residents have been discharged and gone home or to assisted living, and that is fairly typical,” Jones says.
While noting that his facility is 91 to 92 percent occupied, Jones says the average length of stay for “therapy people” is around 28 days. This compares with the two-year-plus national average for a resident’s length of stay in a nursing facility.
“The short-term rehabilitation folks are a positive for us,” he notes, saying facility staff are emotionally satisfied that their work has resulted in success for the patient, while the patient is happy to be feeling better and going back home, and the patient’s family is gratified as well. “Everybody wants to go home,” Jones reiterates.
SNFs Enter Market
There is not much mystery as to why SNFs are eyeing short stays, since the patients in short-term situations represent a higher-paying client base than long-term stays. Medicare pays two to three times more for rehabilitative services than Medicaid does for long term care, pushing SNFs in the direction of expanding their rehabilitation units to attract higher reimbursement and stabilize their finances.
By treating “younger patients” in a post-acute care setting, SNFs are also looking to benefit from a push by the Medicare program to limit the number of enrollees who can receive care at higher-cost rehab hospitals. Medicare recognizes nursing facilities as a lower-cost resource for the scores of patients who need weeks or months in a rehab setting to convalesce following hip or knee replacement, stroke, or the like.
Estimates put these lower SNF costs at up to one-third to one-half of what a rehab hospital charges for what typically is a one-month stay for post-operative care.
What you are seeing is that there are a lot more short-stay acute cases [at SNFs], and this has been happening for a long time as nursing facilities offer more than just long term care,” says Irene Fleshner, senior vice president for strategic nursing initiatives at Kennett Square, Pa.-based Genesis HealthCare, a noted leader in the rehab and therapy space.
“The traditional nursing home is a dinosaur, yet we are still regulated and paid that way,” she says, noting that even though there will always be the need for 24/7 care, the future appears to be more assisted living for those who used to inhabit nursing facilities and more room for SNFs to take on major structural changes to attract short stays.
Mary Jane Koren, assistant vice president for the Picker/Commonwealth Quality of Care for Frail Elders Program at The Commonwealth Fund, says the market, as always, is ruling the decision-making process on where to put resources in the long term care sector.
One of the things going on is that skilled nursing facilities are seeing increased competition from assisted living, so they are reaching out to new populations to help fill those beds. They are finding a new service they can provide to a community and are trying to use this as a new revenue stream,” Koren says.
Health Reform Law Has Impact
Robert Kramer, president of the Annapolis, Md.-based National Investment Center for the Seniors Housing & Care Industry, says when a SNF adds a specialty rehab unit, the quality mix of nursing care in the community immediately improves.
“This is particularly true in an area where you have older skilled nursing properties,” Kramer says.
He sees the trend for more rehab and therapy patients headed to SNFs and says the reasons are based on the economics of long term care and related moves by investors, SNF companies, and related entities to attract more business by updating aging buildings and infrastructure.
“The skilled nursing setting is the lowest-cost facility setting for providing this type of care,” Kramer says. If properly staffed and operated, these rehab units will be very attractive to managed care companies who will be looking to take advantage of opportunities to bundle services. “This makes for a very attractive post-acute care-bundling scenario” with the low-cost SNF and the new rehab and therapy emphasis, he says.
Kramer says the new health care reform law, when implemented over the next few years, will be focused clearly on figuring out cost efficiencies. “There is a lot of discussion going on with [Health and Human Services Secretary Kathleen] Sebelius and the new leaders of CMS [the Centers for Medicare & Medicaid Services] on finding the best quality and clinical outcomes at the lowest-cost setting. They have a lot on their plate, but this is a key area of cost savings by reducing rehospitalizations,” Kramer says.
He thinks it will take CMS the rest of this year to plan guidelines and funding mechanisms to support pilot programs for bundling services, and actual programs will not emerge until 2011, with start dates in 2012.
The shifting economics for SNFs factor in the fact, according to Kramer, that nursing facilities have lost the private-pay customers to ALFs and home-based care, leaving opportunities elsewhere to revamp and remodel and attract the “younger” rehab market.
To attract the new breed of patient/resident, SNFs are putting money into plant restructuring and equipment purchases, along with the most important factor of finding and retaining the skilled therapists and nurses necessary for quality care, or contracting out to companies to get the job done.
Heritage Hall’s Jones points to a number of enhancements to the rehab programs at his 31-year-old facility, including purchases of modern equipment to help improve results and shorten stays.
Some examples of the capital expenditures are the purchase of ACP Omnicycle and NUStep machines for endurance and strength, ultrasound technology for pain relief, Megapulse II Diathermy for pain management and edema control, E-Stim Omnisound 3000 for pain management, and a QualCraft Exerciser for physical rehab.
Jones says electric beds and mechanical lifts have been added for resident comfort and convenience as well as resident and staff safety. There have also been plant upgrades, with the addition of outdoor siding to keep the facility “looking good and presentable to our clients,” he says.
Many nursing facilities have taken the upgrade of their rehab and therapy spaces further, to the point of separating the short-term residents from the long-term, traditional clients, including the use of separate entrances and exits and even changing the facility’s branding to get the words rehab or therapy in the title.
For Jones and his Virginia SNF, the changes are not so dramatic, as all residents enter and leave from the same entrance and exit, but there are distinct differences inside the building related to staffing and logistics.
“We haven’t done [separate entrances]. Everybody comes in the one entrance, but the short-term residents are kept in one unit. This is usually easier for us because our staffing is heavier in the acute units,” Jones says.
Heritage Hall has the equivalent of 10 full-time therapists on staff, but they have distinct skills apart from the nurses and nurse assistants working in the acute wings, Jones says. He notes the occupational, physical, and other therapies are offered six days a week, and a seventh day is possible if an insurance company issues an order for such service.
In Miami, the management at Miami Jewish Health Systems (formerly Miami Jewish Home and Hospital) took a look at the market for its range of long term care services and saw a potentially explosive opportunity in the rehabilitation and short-stay space, noting the expanded demand for a new style of nursing facility care that stresses temporary and targeted therapy over permanent residency.
Blaise Mercadante, chief marketing and communications officer with Miami Jewish Health Systems, says the company markets its rehabilitation services to doctors and hospitals to show the quality of their services and to demonstrate “we’re not just a skilled nursing facility.”
Wednesday, May 2, 2012
Nursing facilities embrace short stay residents
SNFs Take On New Look
SNFs Enter Market
Health Reform Law Has Impact