Over the last month, a series of congressional hearings and confirmations shined a spotlight on the seniors housing and care sector as a whole, as well as a number of areas impacting the industry. The hearings followed a tumultuous year of navigating the COVID-19 public health emergencies and subsequent media scrutiny, and covered a wide range of topics, including staffing necessities, private equity investment, quality metrics, home and community-based services (HCBS) funding, reimbursement pressures, telehealth flexibilities, and dual-eligible care coordination.

Below is a summary of key points from each hearing.

Senate Committee on Finance: A National Tragedy: COVID-19 in the Nation’s Nursing Homes

On March 17, the Senate Committee on Finance, chaired by Sen. Ron Wyden (D-OR), held the hearing “A National Tragedy: COVID-19 in the Nation’s Nursing Homes.” The hearing included testimonies from a nursing care certified nursing assistant (CNA), an AARP Director, a long-term care ombudsman, American Health Care Association’s (AHCA) Chief Medical Officer, Dr. David R. Gifford, and University of Chicago Public Health Sciences professor, Dr. Tamara Konetzka.

AHCA’s Dr. David R. Gifford shared testimony that sought to educate the committee on the needs of nursing home residents, the emotional and physical toll the pandemic had on residents and staff, as well as the multitude of challenges operators faced during the public health emergency. These challenges included the constantly evolving and sometimes conflicting guidance from local, state, and federal governments, the lack of reliable and timely testing, personal protective equipment (PPE) shortages, and the workforce crisis that was exacerbated by the pandemic.

With regards to the existing standard quality metrics, Dr. Konetzka of University of Chicago highlighted that “multiple rigorous studies” have found standard quality metrics do not have a meaningful association with COVID-19 outcomes for nursing homes and that even prior infection control citations were not associated with COVID-19 outcomes. Konetzka’s comments echo a 2019 GAO report that quality measures should better align with CMS’s strategic objectives at improving care quality rather than simply additional obligations of providers.

Gifford’s testimony also emphasized that COVID-19 didn’t cause problems that exist in the sector, but rather exacerbated or brought them to light. This is true on the staffing front as well – staffing challenges predate the pandemic. Thus, when the pandemic hit, tight staffing levels went from a strain to a crisis itself. Adelina Ramos, a Rhode Island Certified Nursing Assistant shared key points on this topic, including the often-low starting wages for skilled nursing workers, the prevalence of skilled nursing workers working multiple jobs, and that the often-low staffing ratios themselves tend to feed into the employee turnover challenge.

Konetzka highlighted that “Though community spread of COVID-19 and facility size have proven to be the top predictors of nursing home outbreaks in multiple studies, staffing does have an effect on how a COVID-19 outbreak plays out. More staff did not reduce the chance of outbreaks, but more staff hours meant fewer deaths and cases once an outbreak occurred.”

Dr. Gifford cited a November 2020 survey of skilled nursing providers that found 70 percent of nursing homes had hired additional staff and 9 out of 10 asked staff to work overtime and provided hero pay. Gifford summarized AHCA/NCAL’s actions relative to staffing through the pandemic – developing free online courses to train temporary caregivers, urging Congress to direct financial aid to long-term care properties, and sharing a strategy roadmap with governors to address the workforce shortage. Gifford summarized the sector’s needs by saying, “We need ongoing staff support as this pandemic continues, but we also need a more long-term solution. … We need a comprehensive strategy to recruit more health care heroes to serve in long term care.”

A National Bureau of Economic Research (NBER) study on private equity investment in healthcare made its way into the hearing multiple times. The study included data on 1,674 nursing homes that were acquired by private equity firms in 128 unique deals between 2000 and 2017. The study cited instances of bad outcomes for nursing homes that were acquired by private equity owners. These include elevated risk of death for short-term Medicare patients, higher rates of antipsychotic drug use, and increased taxpayer spending on episodes of care.

The American Investment Council has pushed back on the NBER findings, saying that “private equity firms make long-term investments in…nursing homes to help rescue, build, or grow businesses, often providing much-needed capital to strengthen struggling companies.” The council also said that the NBER research hasn’t been peer-reviewed and doesn’t include data on Medicaid patients, who comprise most long-term nursing home residents. The paper is “inconsistent with recent peer-reviewed academic research that shows that private equity-backed companies are delivering high-quality care to nursing home residents, particularly during the COVID-19 crisis,” it said.

One subcommittee member spoke in favor of the for-profit healthcare system. Rep. Tom Suozzi (D-NY 3rd District) said “I’m not against making money as long as you are taking care of your patients.”

Senate Special Committee on Aging: COVID-19 One Year Later: Addressing Health Care Needs for At-Risk Americans

On March 18, the Senate Special Committee on Aging, chaired by Sen. Bob Casey (D-PA), held the hearing “COVID-19 One Year Later: Addressing the Health Care Needs for At-Risk Americans.” Much of this hearing focused on the disparities in care during the pandemic. Speakers noted the virus had a disproportionate impact on the elderly, people with disabilities, minorities, and rural Americans. While this hearing was not focused on seniors housing or skilled nursing, private equity investment in long-term care was brought up and questions were posed regarding its suitability for the sector.

Comments highlighted the two different types of patients that are found in skilled nursing, and how they don’t necessarily align with each other. Anthony Jackson, senior vice president and chief operating officer of Roper Saint Francis Healthcare, and a former nursing home administrator said “When you look at the viability of a nursing home, they started to move away from the responsibility for which they exist, which is to take care of patients from a long-term perspective. They moved toward taking care of short-term types of disease which provides for quicker turnover and a better reimbursement.”

On HCBS services, Senator Elizabeth Warren (D-MA) said “…the coronavirus has also highlighted the critical importance of providing care safely in home and communities. Here’s the problem: Millions of Americans can’t access HCBS services at home. … We must make HCBS a mandatory benefit in Medicaid and expand Medicare to cover more at-home, long-term care services.” Following this hearing, the American Jobs Plan was announced, which includes $400 billion to expand access to Medicaid home and community-based services.

House Ways and Means Oversight Subcommittee: Examining Private Equity’s Expanded Role in the U.S. Health Care System

A week later, on March 25, the House Ways and Means Oversight subcommittee, chaired by Rep. Bill Pascrell (D-NJ 9th District) held the hearing “Examining Private Equity’s Expanded Role in the U.S. Health Care System.” Skilled nursing and private equity ownership were the central themes for this hearing, again citing the February 2021 National Bureau of Economic Research (NBER) study. Ernest Tosh, an attorney specializing in nursing home abuse and neglect highlighted what he considers to be a lack of transparency in for-profit skilled nursing chains’ use of taxpayer funds. Tosh said “We really have no idea what the financial position of these facilities is. They can be made to look bankrupt, but, in fact, may be making millions and millions of dollars each.” Tosh proposes requiring skilled nursing operators to file consolidated financial statements for entire chains, not just individual properties.

In anticipation of another congressional hearing scrutinizing the sector, AHCA/NCAL’s CEO and President Mark Parkinson proactively released a statement before the hearing highlighting both the shortcomings of government funding coverage and the limited role of private equity within the ownership of skilled nursing properties. Parkinson said “In the long-term care sector, private equity companies own less than 10 percent of nursing homes, and large investor acquisitions are decreasing. However, the small number of nursing homes that have turned to alternative revenue sources underscore the financial and staffing crisis that nursing homes are facing due to the fact that Medicaid does not cover the cost of care.”

Senate Finance Committee Confirmation Hearings: CMS Administrator Chiquita Brooks-LaSure and HHS Director Andrea Palm

On April 15, the Senate Committee on Finance held a confirmation hearing for both the CMS Administrator and the HHS Director, which covered applicable topics of Medicare and Medicaid funding and reform, telehealth, staffing, oversight, and penalty changes for skilled nursing properties.

Senator Mike Crapo’s (R-ID) opening statement on both Brooks-LaSure and Palm touched on the topic of telehealth. “Patients and providers have benefited from expanded access to telehealth and expedited approval of COVID-19 vaccines, diagnostics, and treatments. Going forward, Medicare and Medicaid patients must have the same access to innovative items and services as those with commercial insurance.” Several other senators highlighted the need to ensure that the telehealth boom that started during the pandemic continued. In response, Brooks-LaSure said that she wants to examine what CMS’s authority is to extend the flexibilities that are set to expire at the end of the public health emergency.

Senator Bill Cassidy (R-LA) also commented that “We both know we spend lots of money on duals, and we get miserable outcomes. … One of the issues is that it is difficult for aligning incentives for both state and federal governments.” Brooks-LaSure responded that there needs to be better coordination between long-term care, nursing homes, and hospitals.

The hearing did not highlight any major opposition to either nomination, and likely signals the confirmation of each to their respective roles at CMS and HHS.

Unprecedented change in healthcare has led to new expectations from payers, providers, and consumers. The latest NIC Leadership Huddle, titled “Telehealth’s Tipping Point: The New Norm in Care and How to Build for Success” brought together telemedicine experts to cut through the hype. Attendees benefitted from a substantive discussion on building the right-sized telehealth program; selecting relevant telehealth services; addressing staffing issues, and picking the right technology and business models, as the industry moves to kickstart or enhance telehealth programs as part of the new normal.

Moderator Ryan Brooks, Senior Principal, Healthcare, NIC, pointed out the timeliness of the discussion, saying, “The timing of this conversation really couldn’t be more appropriate. As we speak, the House Ways and Means Health Subcommittee is beginning their hearing, titled, ‘Charting the Path Forward for Telehealth,’ where they will be examining what needs to be done from the regulatory and legislative perspectives to sustain the current momentum of telehealth.”

Michael Kurliand, Director, Telehealth and Process Improvement, West Health, provided some context for the rise of telehealth in a brief presentation. He pointed to projected shortages of primary care physicians and specialists, as well as uncertainty on the numbers of nurses that will be available to serve the needs of what is already a quickly expanding population of seniors. In addition to these shortages, the numbers of unpaid caregivers is decreasing rapidly.

Kurliand also pointed to the extremely high cost of healthcare. Given the realities of COVID-19, telehealth, according to Kurliand, enables access to care for lower-acuity patients, who might otherwise defer care, and get sicker, out of fear of infection. Meanwhile, the technology is enabling physicians to use their medical offices to see only the higher-acuity, and more profitable, patients. Overall, he expects CMS to continue to support the technology, as it helps to deliver care while lowering costs and improving outcomes.

Before COVID, Kurliand, who has been in the telehealth industry for 25 years, pitched the many benefits of the technology, including access to care, timeliness of care, care coordination, and resident satisfaction. Post-COVID, however, according to Kurliand, the main driver of the growth of telehealth is safety.

Kurliand also highlighted the speed and intensity of the technology’s growth, going from 0.1% of Medicare beneficiaries using telehealth prior to the pandemic to 39% by November of 2020. Additionally, investment in health technology companies is on the rise, further fueling the development and improvement of the offerings that the technology is making possible.

Josh Hofmeyer, Senior Care Officer, Avera eCARE, provided some insight on how telehealth actually works. He emphasized that the technology offers many use-cases and should be matched to the gaps in care that occur within your organization, such as during transitions, which he said are a common area in which telehealth implementation can make a big difference in outcomes. Not every organization will have the same needs. “If you’re strictly doing psychiatry, that’ll only be video-to-video conversations, you don’t need the same type of setup as someone who’s looking for clinical support, that urgent care component,” he said.

Once you have selected your platform, according to Hofmeyer, its about looking at outcomes. He looks for improved transfer rates, reduced emergency room visits, rehospitalization rates, and increased ability to treat in place. He also pointed to increased length of stay and higher occupancy rates in nursing homes.

On that point, he said, “When I was managing assisted living, I cannot even count the number of times we didn’t have access to the clinical care we needed, so we’d transfer our resident to the hospital and the next thing we knew, they were going across town to a skilled nursing facility and we never saw them again. That’s very common because that’s the path of care that those people take. That’s not needed if we have the right access and the right things in place. We’re able to help stop some of that.”

Pam Ferris, President, and CEO, Seacrest Village offered an operator’s point of view. She provided her organization’s practical experience with new telehealth technologies implemented over the pandemic. While helpful, in Ferris’ experience, telehealth does not always eliminate the need for in-person visits with providers. It also required additional staff.

Overall, however, the experience was positive. “Right now, we’re just trying to get back to a sense of normalcy. We really do believe in telehealth and the benefits that will come from it. We just want to go back and really evaluate how it worked in various operations, and what would be the best way to go forward. It’s not a one-size-fits-all, as other panelists have mentioned, and it appears for us, at least, to have worked differently in different settings.”

Going forward, Ferris said she is likely to partner with a hospital system, which she believes already has the infrastructure and resources in place for the right telehealth program. She also expressed the hope that CMS and her state’s health department will continue to relax restrictions on telehealth, even as COVID becomes a thing of the past. For the moment, she said, “This is a great way to start, on one of the biggest game-changers in the way medicine is practiced, and how seniors will be served, in the years ahead.”

You can register to attend upcoming NIC Leadership Huddles, including both the live webinars as well as the optional, first come, first served participation in peer-to-peer discussions, within the Events tab on nic.org. Registrants are provided with a recording of the event, compliments of NIC and our generous sponsors and partners.            

NIC MAP Vision clients with access to NIC MAP^® Data attended a webinar in mid-April on key seniors housing data trends during the first quarter of 2021. Findings reflected the impact of COVID-19 across the seniors housing and care sector and were presented by NIC’s research team. Key takeaways included the following:

Takeaway #1: Seniors Housing Occupancy Fell Further in 1Q 2021 as the Pandemic Continued to Take a Toll

• The 1.8 percentage point decline in the first quarter of 2021 all-occupancy rate for seniors housing to 78.8% pushed this occupancy measure to the lowest level since NIC MAP^® data began being reported in 2005.
• This drop in occupancy was directly related to the COVID-19 pandemic as demand (as measured by net absorption and as shown by the orange bars on the chart below) fell by nearly 8,000 units. Combined with the second, third, and fourth quarters of 2020, net absorption has fallen by more than 42,000 units since the onset of the pandemic.
• Separately, inventory as depicted by the blue bars, increased by nearly 5,000 units, for a total of roughly 18,000 units in the past year.  
• Since first quarter 2020, the occupancy rate has fallen an unprecedented 8.7 percentage points.

Takeaway #2: A Small Share of Properties Have 95% or Higher Occupancy

• As noted above, the average occupancy rate for seniors housing in the Primary Markets was 78.8% in the first quarter. However, that is an average and the range of occupancy rates is broad and the distribution wide.
• In the first quarter of 2020, 33% of properties reported occupancy rates above 95%. In the fourth quarter, this fell to 12% and in the first quarter of 2021 this slipped further to 9.6%.
• On the flip side, in the first quarter of 2020 there were 22% of properties that reported occupancy below 80%. This increased to 40% in the fourth quarter and 46% in the first quarter of 2021.
• Included in the properties with occupancy rates below 80% are those that opened in 2020 during a global pandemic. It also includes those properties that have slipped in occupancy during this period.

Takeaway #3: Assisted Living Occupancy Decline is Due to Both Pandemic-Related Drop in Demand as Well as New Supply

• Occupancy is affected by both demand and supply. The chart below shows how much of the drop in occupancy in the past year has been attributed to negative demand as the pandemic has taken its toll on move-ins and move-outs and how much of the occupancy change in the past year is due to inventory growth in a market.
• The top portion of the image shows the occupancy rate from first quarter 2020 to first quarter 2021. The length of the line shows the absolute drop in occupancy over the past year. San Jose’s occupancy rate for assisted living fell from 92.2% to 72.4%, hence the longest line in the upper left.
• The lower part of the chart shows how much of that decline was due to demand falling and how much was due to growth in inventory.
• In the case of San Jose, most of the drop was due to a demand impact, but inventory growth also had an impact as property was added to the inventory.
• On the right is San Antonio which saw assisted living (AL) occupancy drop from 78.9% to 70.6% in the past four quarters. Most of this decline was due to negative demand; inventory changed very little. This is shown in the chart as the red portion of the line (95% of the change in occupancy is due to the demand effect; 5% due to supply effect). Other markets that had limited supply shocks were Pittsburgh, San Diego, San Francisco, and Los Angeles.
• Miami is a market where occupancy fell 13.5 percentage points since the onset of the pandemic, but it was not just a demand shock that pushed occupancy lower. Inventory also grew during this time (58% demand, 42% supply shock). The other markets that had the lowest demand shock, where supply was also a considerable factor were Sacramento, Washington, D.C, New York, Minneapolis, and Las Vegas.

Takeaway #4: Construction Starts Slowed in 1Q 2021 for Both AL and IL

• Construction starts were weak in 1Q 2021, with 1,079 units of independent living (IL) initiated in the first quarter. On a four-quarter aggregate basis, IL starts totaled 3,862 units, the fewest units started since late 2012. As a share of inventory, this amounted to only 1.1%. For perspective, at its most recent peak in early 2018, it was 3.8%.
• For assisted living, there were 4,863 units started on a four-quarter aggregate basis in the first quarter, equating to 1.5% as a share of inventory. For perspective, at its peak in late 2015, it was 6.0%.
• Like other residential and commercial real estate sectors, starts are also being affected by rising prices and shortages of labor, lumber, and other key building materials as well as higher land costs.
• It should be noted that the starts data often gets revised in subsequent quarters.

Key Takeaway #5: Preliminary Closed Seniors Housing and Care Volume: $2.4 Billion in 1Q 2021

• Transactions activity remained relatively muted in the first quarter of 2021 as the number of deals closed decreased significantly from the fourth quarter of 2020 as many buyers remained on the sideline for the most part and perhaps some would-be-sellers elected to wait.
• However, with deal count low there were two larger deals—one with Omega as the buyer in a $400M deal and one with Brookfield as the buyer in a $600M deal. The seller was HealthPeak in both of those deals as they continued to sell seniors housing properties.
• In terms of dollar volume, the first quarter 2021 registered $2.4B. The $2.4B represents an 8.9% decrease from the fourth quarter of 2020 when volume registered $2.6B, but it is a 28% decline from a year ago when volume registered $3.3B in the first quarter of 2020.      
• Dollar volume continues to be lower than prior to the pandemic but has picked up since the second and third quarters of 2020.

Interested in learning more?

While the full key takeaways presentation is only available to NIC MAP Vision clients with access to NIC MAP data, you can download the abridged version of the 1Q21 Data Release Webinar & Discussion featuring my exclusive commentary below.

Download Abridged Presentation

To learn more about NIC MAP data, powered by NIC MAP Vision, and about accessing the data featured in this article, schedule a meeting with a product expert today.

“The market fundamentals in the Wave 26 Executive Insights survey data through mid-April show signals of headway. Leads volume is up and the shares of organizations reporting accelerations in move-ins continues to trend positively with each of the care segments reaching new high points in the survey time series. Exactly when these leading indicators will translate into higher occupancy rates being reported across the sector is yet to be seen.”

–Lana Peck, Senior Principal, NIC

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space as market conditions continue to change. This Wave 26 survey includes responses collected April 5 to April 18, 2021 from owners and executives of 81 small, medium, and large seniors housing and skilled nursing operators from across the nation, representing hundreds of properties and thousands of units across respondents’ portfolios of properties.

Detailed reports for each “wave” of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Wave 26 Summary of Insights and Findings

• According to Wave 26 seniors housing and care survey respondents, on average, nine out of ten residents (91%) of their respective properties—including all care segments across their portfolios—have been fully vaccinated for COVID-19. Having residents vaccinated has made a significant impact in opening communities. As stipulated by a variety of disparate state guidelines, many respondents commented that their organizations are now able to resume in-person tours, offer limited/socially distanced communal dining, and allow small indoor gatherings, worship services and larger gatherings outdoors. Others are now allowing family visitations in apartments and resuming off-site excursions of vaccinated residents. Many organizations indicate they continue to mandate mask wearing in community areas. 
• Staff uptake of the vaccine, however, leveled off between Waves 22 and 24 and has just recently increased slightly from over half (55%) to nearly two-thirds of staff in survey Waves 25 and 26 (63% and 64%, respectively). As a result of the vaccination rates, one-half of organizations have been testing staff at least once a week for COVID-19 since the Wave 24 survey, but two-thirds are testing residents only if symptomatic (up from half in survey Waves 24 and 25).
• Aside from the need to test staff more frequently, and the costs associated with testing, one-half of respondent organizations indicate they probably will not or definitely will not make the COVID-19 vaccine mandatory for staff (52%); however, one-quarter probably will or definitely will (24%). The share of organizations that would consider making the vaccine mandatory for staff has remained steady since the Wave 23 survey conducted in late-February to early-March. A NIC blog post on April 15 reported that new cases among staff have fallen, but less so than for residents and that new cases for staff are 2.4 times higher than among residents, the highest rate since CMS started reporting data in late May. Whether mandatory COVID-19 vaccination for staff will grow among operators is yet to be seen.
• In the Wave 26 survey, respondents were asked if their organizations had seen an increase in resident lead volume since the beginning of the year—and if they had—is lead volume above pre-pandemic levels? As shown in the chart below, roughly four out of five organizations reported an increase in lead volume (84%). However, only one in five reported lead volume currently above pre-pandemic levels (20%).

• The shares of organizations reporting acceleration in the pace of move-ins for each of the care segments set new high points in the time series. Between two-thirds and one-half of respondents note that the pace of move-ins accelerated in the past 30-days. Increased resident demand was cited by nine out of ten respondents (88%) as a reason for acceleration in move-ins. The majority of respondents report no change in the pace of move-outs for each of the care segments (74% to 91%).

• The Wave 26 survey data continue to show a trend in the shares of organizations reporting higher occupancy across all four care segments, and each of the care segments set new peaks in the time series. Between one-third and more than one-half of organizations reported upward changes in occupancy.

• The degrees of occupancy change vary. As referenced and shown in the chart above, occupancy increases in organizations with independent living residences peaked in survey Waves 25 and 26. As shown in the chart below however, while fewer reported occupancy declines, more reported no change in occupancy rates in Wave 26 (50% vs. 39%).

• In the face of historically low occupancy rates according to NIC MAP data in the first quarter of 2021 (record low of 78.8% seniors housing occupancy rate), on average, about 50% of respondents to the survey since July 20 indicated their organization was offering rent concessions. As of Wave 26, three out of five respondents (61%) with multiple properties in their portfolios are offering rent concessions in more than half to all of their properties.

• Most rent concessions included discounts and/or free rent for a specific amount of time (73% and 65%, respectively). Non-monetary and other benefits frequently mentioned by respondents included move-in assistance and/or covering all or a portion of the new resident’s moving expenses.

• Like prior waves of the survey, four out of five respondents to Wave 26 indicated their organization was experiencing staffing shortages in their properties. Of those respondents with multiple properties in their portfolios, 80% had staffing shortages in more than half to all of their properties.
• Staffing shortages that were experienced by many operators prior to and exacerbated by the pandemic persist. Nearly all respondents to the Wave 25 survey were paying staff overtime hours, and four out of five organizations were tapping agency/temp staff. In Wave 26, survey respondents described various strategies that operators are implementing to attract staff. As depicted in the word cloud below, most organizations commented that they are offering hiring/sign-on bonuses, bonuses for employees who refer new hires, and wage increases. Others are staging job fairs and recruiting events, offering flexible shifts/schedules, and enhancing benefit packages. This qualitative data will be quantified in the Wave 27 survey.

Wave 25 Survey Demographics

• Responses were collected between April 5 and April 18, 2021 from owners and executives of 81 seniors housing and skilled nursing operators from across the nation. Owner/operators with 1 to 10 properties comprise 60% of the sample. Operators with 11 to 25 and 26 properties or more make up 40% of the sample (19% and 21%, respectively).
• Roughly one-half of respondents are exclusively for-profit providers (48%), 43% are nonprofit providers, and 9% operate both for-profit and nonprofit seniors housing and care organizations.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 71% of the organizations operate seniors housing properties (IL, AL, MC), 31% operate nursing care properties, and 40% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, please help us tell an accurate story about our industry’s performance.  Now, more than ever, we need your response so that we can track firsthand the inflection point on occupancy. This will be a turning point and we want all of our industry stakeholders to know when this important moment occurs. 

The current survey is available and takes 5 minutes to complete. If you are an owner or C-suite executive of seniors housing and care and have not received an email invitation to take the survey, please click this link, which will take you there.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and create a comprehensive and honest narrative in the seniors housing and care space at a time when trends are continuing to change in our sector.

Unlike home health and other post-acute sectors, skilled nursing operators and hospitals have not entered into many joint venture partnerships. The COVID-19 pandemic, however, may be the wakeup call hospitals need to consider more integrated relationships that strengthen alignment. In the latest NIC Leadership Huddle, titled “Skilled Nursing Integration: Will COVID be the Catalyst for Tighter Hospital Partnerships?” health system executives got together to discuss joint ventures with skilled nursing partners.

Andre Maksimow, senior vice president, Kaufman Hall, began the discussion by illustrating how a Kaufman Hall client’s discharge pattern has changed over the pandemic. The Northeastern health system, which typically discharges 22,000 Medicare and Medicare Advantage patients annually, sent far fewer patients to skilled nursing facilities (SNFs) last year. “It’s a two-order effect, a compound issue,” he explained, pointing out that, on one hand, there was “less volume coming out of the hospital,” and on the other, “less going to skilled nursing versus home health.” Skilled nursing providers in the area are currently seeing a 25% reduction in overall discharges.

“I can tell you that we have fundamentally shifted as a provider organization in how we view our post-acute discharge process,” explained Dr. Mark Terpylak, D.O., FACOG, senior vice president, Population Health, Summa Health. His organization used to ask what kind of care they could qualify a patient for upon discharge. “We don’t do that anymore,” he said. Instead, his staff ask whether they can send a patient home. “If we can’t, then we work our way up the ladder in the other direction. That comes in large part with our movement into risk.” He explained that he looks to his network of providers to deliver lower-cost, value-based care, as his organization shifts their financial model.

Asked whether discharge volume to skilled nursing facilities would remain lower than pre-COVID rates, Dr. Terpylak responded that, “when possible, we’re not going to discharge to another facility…if it serves the patient and their family well, we’re going to try to get them discharged to the home.” Only if the patient fails to qualify for that course will the hospital send them to skilled nursing. He looks for skilled nursing partners who share the health system’s values and are, “committed to providing care for those folks in the most cost-effective fashion.” He also noted that for healthcare organizations and providers who bear risk, “we are not financially aligned with the typical skilled nursing operator.” He explained that this presents an opportunity to align in a different way, which he spoke to later in the discussion.

David Dafilou, CAO, CIN & vice president, Capital Health System, agreed that his organization would not revert to pre-COVID patterns. “Patients would much rather go home…they don’t want to be in the hospital at all. They don’t want to go to another facility. When possible, they want to go home.”

Maksimow asked why healthcare organizations are now interested in closer relationships and partnerships with skilled nursing facilities. In answer, Bryan Crum, director, Post-Acute Care Management, Summa Health, said, “We still have a big need for the right level of care at the right time…we want more patients that had been going to SNFs…going to home health. But we still want to utilize our SNF partnerships more.”

Addressing the same question, Dr. Terpylak explained that his system has historically been facility-based – and, as a result, was more comfortable sending discharges to another facility. “We had a very narrow-sighted view of what happened after folks left us. We didn’t really think much about it.” That is changing, and the healthcare organization is looking more closely at what happens when they discharge patients to a skilled nursing facility, and also at what happens once they leave that facility on the other end of a stay. “We need to find a different way to align ourselves with the skilled operators in our market that are open to partnering around a different methodology, different metrics, and a different level, frankly, of care integration.”

Given the new interest amongst healthcare organizations in forming partnerships and joint ventures with their post-acute providers, are SNF operators reaching out to upstream providers? Brian Cloch, principal, Innovative Health, LLC, pointed out that in years past his organization tried – but couldn’t get their calls answered. That, too, is rapidly changing, although in Cloch’s experience, many healthcare organizations, even when taking on risk, are still not fully embracing value-based care. When an organization understands the benefits of value-based care and takes an interest in working with a partner downstream, they are likely to find SNFs willing to work with them.

Cloch went on to explain that, in such a partnership, he hopes to gain referrals that might otherwise have gone to other facilities, such as ERFs or LTACs. Part of his strategy is to capture that portion of the market. “We scratch our heads and wonder ‘how does that happen?’ I get paid $600 a day, they get paid $3,000 a day or $2,800 a day. Why would somebody pay $1,800 a day more for the same care? That’s the target that we’re after.”

Not everyone on the panel is looking to partner in a joint venture. Dafilou pointed out that patients value choice, and that geographic considerations are important, and that in his area of the country, with a very high population density, there are many facilities nearby. He is looking at other ways to align with SNFs, such as putting healthcare providers within a facility, for example. In return for working with his organization, the SNF should be able to expect a greater volume of referrals. Capital Health recently reduced their preferred provider network down from 12 facilities to eight. He hopes that will enable a boost in referrals to each remaining SNF in his network.

Asked where he sees SNFs heading in the near future, Cloch said, “I think we’re going to be okay.” He pointed out that quality SNFs boast a very low hospital readmittance rate. When compared to higher readmittance rates in home health, in his view, SNFs may compare very favorably, in terms of total cost of care.