Home health and home care providers are often viewed as competition for the senior living industry. But collaboration with outside agencies can create a better resident experience and extend the length of stay. 

What follows is an interview with Sarah Walmsley, national director of strategic partnerships at Bayada Home Health Care, Moorestown, New Jersey. She is the head of business development for Bayada Senior Living Solutions. The Q&A provides a good roadmap of how to collaborate with a home health provider and make the relationship work.   

Q: Tell us about Bayada Home Health Care. 

Walmsley: We are one of the top home health providers in the country with revenues last year of about $1.3 billion. We offer a full range of services including skilled home healthcare, hospice, private duty care, behavioral health, staffing, assistive (personal) care and habilitation services (for those with intellectual/developmental disabilities). We recently added hospital management services to develop joint ventures with healthcare systems. Bayada was privately owned for 40 years, but last year it became a nonprofit organization in order to ensure its long-term continuity,  

Q: Where does Bayada operate?  

Walmsley: Bayada provides care in 22 states and in six countries. We have 330 offices and just reached a milestone of caring for over 1 million customers since 1975.   

Q: How many senior living communities do you work with?   

Walmsley: Our Senior Living Solutions division is providing care or contracted fitness classes in over 1,200 communities across 14 states operating out of 37 offices. Since the division was launched in 2012 we have experienced an 84% increase in senior living census growth. Senior Living Solutions currently compromises 30% of our home health practice. We serve about 5,000 residents. 

We are currently the provider of choice for over 300 assisted living/independent living and CCRC communities. That bucket of business is growing about 20% a year.  We enjoy deep trusted working relationships with the healthcare team of these communities and we work collaboratively to implement customized programming and interventions.  The end result is that we achieve remarkable results in metrics such as resident satisfaction, increased length-of-stay and rehospitalization rates that consistently are under 8%.  

Q: Are your service offerings growing?    

Walmsley: We added hospice services in 2017 and fitness services in 2015.  Fitness is growing 50% year-over-year based on customer demand and we are adding new class types and offerings, such as Parkinson’s disease and memory care specific classes. We have over 4,000 residents participating in classes each quarter and provide over 21,000 classes a year.  We added hospice care because senior living owners and operators wanted one provider.  Senior Living Solutions Hospice has seven offices in three states and now makes up 15% of Bayada’s Hospice practice. We project that within five years, our senior living hospice services will be represented across our home health and therapy markets.  

Q:  What’s the best way to establish a working relationship?  

Walmsley: There are essentially three best practices we have learned are necessary to have an optimal working relationship. First, agreeing on expectations and what success looks like is paramount when initially launching a new relationship.  We have found the most effective way to do this is by following an integration plan we create which incorporates engagement, education and trust-building activities with residents, care providers and leadership early on. It also provides a roadmap to phase in all the services we offer to prevent confusion or disruption to the community. Second, customization is key.  As we know, no two communities are the same, each has a different culture and unique needs.  Our model at its core is based upon an established communication and execution framework centered on the delivery of our key services. We meet with each key stakeholder to build out their optimal model. Modifications could be as simple as providing our outcome data meetings on days when there are fewer meetings or when the physician is present to create a fitness class for residents with Parkinson’s disease.  Third, quality assurance measures must be established for a collaborative care model to work. Setting success and accountability measures upfront ensures a good working relationship. At a minimal, outcome data should be shared and discussed monthly to identify if hospitalizations could have been prevented and to put in interventions to prevent future issues.   

What should senior living providers expect from a home health company?  

 Walmsley:  First and foremost, providers should look to align with a company that echoes their own mission and values. During the vetting process, they should ask to see their quality metrics (hospitalization rate, SOC rate and CMS 5-star ratings for quality and customer satisfaction), determine what scope of services they offer across the continuum and ask them to explain their proactive approach. Ask how clinicians are trained. A senior living operator should insist on a one-point person for their community who oversees the day–to–day operations.  Lastly, the selected provider should be included in their referral source’s preferred networks. It makes sense to align with a provider that understands the senior living landscape.  

Q: What does the home health company expect?   

Walmsley: We need to establish deep collaborative relationships. The community leadership and healthcare staff should look at their healthcare provider as a collaborative partner and trusted advisor and provide time to review outcomes and strategize tactics to reduce adverse trends. The community leadership should be honest if there are concerns and both entities need to be open to figuring out what each can do better to enrich the lives of the residents.  

Q: What is the financial arrangement?  

Walmsley: Home health services, including hospice and physical therapy, are reimbursed by the resident’s Medicare and private insurance.  Our fitness programs are customized for the community and the operator pays us directly for the program. In some cases, we lease gym space from the operator for our physical therapy program.   

Q: How do you handle workers coming in and out of the building? 

Walmsley: This is the pain point I hear about every day and that’s why people are calling us. We provide a dedicated team so the community always receives the same nurse, physical therapist, occupational therapist, speech therapist and social worker. The executive director knows who is coming into the building. A program manager is assigned to the community as their point person.  They own the relationship. We provide regular updates on who is on the service, how many visits the resident received, progress, discharge date, and other details. We have an electronic medical records portal to chart updates.   

Q: Do you need office space in the building? 

Walmsley: We don’t need office space. It is rare that we rent office space. We do in cases where we have a relevant enough census that would mandate us to have onsite staff on a day-to-day basis and the distance is too far from our office, then it makes sense.

Q: Are teams assigned to more than one building? 

Walmsley: We typically work in communities of 50-400 apartments. If a lot of residents require services we assign a team and backup team.  Most teams are working at 2-3 buildings.  Our mission is to keep patients from bouncing back into the hospital.    

Q: Do operators sign a contract? 

Walmsley:  We have a service agreement that maps out the communication and execution framework.  It includes a collection of best practices that if implemented will result in positive outcomes.  

Q: What percent of residents pick Bayada as a provider? 

Walmsley: Of course, residents always have a choice. The majority work with the recommended home health provider unless they have a prior relationship with another provider. Residents are usually looking for guidance. And they want to stay in their apartments as long as they can. We hold resident meetings to explain our services, answer questions and share our results 

Q: Do you work with physicians and other healthcare groups? 

Walmsley: Under healthcare reform, hospital groups, doctors and skilled nursing facilities are creating their own networks. Quality outcomes matter in a value-based payment system and that is our focus. We are in a lot of these preferred networks which is a reason why the senior living operators want to work with us. They know we have a seat at the table. It makes sense. For example, we have transitional care managers to ensure the resident makes a safe transfer from the hospital or skilled nursing center back to the community. A busy nurse at a community does not have time to call social workers to find out about med changes, check the paperwork, and be there when the resident arrives. We are a great value-add.   

Q: What’s ahead for collaboration? 

Walmsley: The silos are coming down. It’s exciting. We are talking to each other as true colleagues. We share the same goal to keep residents healthy. Health care systems, payers, insurance companies are looking for quality care at a lower cost. But they don’t think of assisted living as healthcare even though the sector is managing an elderly, frail high– risk population. We need to work out more creative models of care. 

One of the most important elements of success for a business or an industry is the continued development of leadership to ensure that the necessary human capital is available to embrace the challenges of the future, prepare for growth, and navigate critical issues. NIC and the seniors housing and care sector are no different. Leadership development is essential, especially for the continued success of delivering on the NIC mission which is to support access and choice for America’s seniors by providing data, analytics, and connections that bring together investors and providers. As the need for housing and care increases with an aging population, so too does the need for innovative thinking and the ability to solve the challenges ahead and embrace the opportunities for the future.

Over the years and since its founding in 1991, NIC has been driven by very talented volunteer leadership in its numerous industry initiative committees and in its Board of Directors. These talented volunteer leaders are largely responsible for the success of NIC and the need to have this continue is vital for the industry to continue growing and serving America’s seniors.  An avenue NIC has pursued to ensure this leadership continues is the NIC Future Leaders Council (FLC).  Established in 2009, the Future Leaders Council represents the best and brightest of the industry, which continues to develop emerging leaders within the industry bringing innovative thinking, fresh ideas, and new energy to ensure the industry/NIC is prepared for the future. The FLC has been extremely dedicated over the years and continues to grow into more of an important role for NIC and the industry. For example, the FLC was instrumental in delivering the latest version of the NIC Investment Guide which was released last Fall in 2018. 

The FLC is comprised of only 24 members and given that, it is very selective.  These smart and dedicated professionals come from the companies in the seniors housing and care and finance sectors that have volunteered time and resources to support NIC’s mission. As members of the FLC, these individuals contribute a significant amount of time to the NIC mission which includes working on various NIC committees and task forces and initiatives.  They also get the chance to develop volunteer leadership skills and have ample opportunity to form meaningful professional relationships with current NIC leaders while functioning as an extension of the Board.   

The selection process for the FLC is a highly competitive one, which includes a member application in addition to a nomination submission. Nominations originate from senior level executives within the industry.  The emerging leaders that are nominated are individuals within their companies that represent passion, commitment, strong leadership potential, the ability to think creatively and strategically, in addition to having 5 to 10 years of relevant work experience. The FLC is a three-year commitment, and members meet as a group quarterly. Each class focuses on different NIC initiatives and programs, always working closely with each other, the NIC Board, and various committees and task forces. 

One of the overall goals of the Future Leaders Council is to produce future volunteer leaders for NIC, and truly, the industry and NIC needs this as the next generation cycles through to leadership positions in an industry that is now more than ever in the spotlight given its importance to serving an aging population. Embracing the talent of the FLC is one way NIC is providing a solid path to prepare for the future and continuing to deliver on its mission. 

Please see the link below for current members of the FLC: 

https://www.nic.org/nic/future-leaders-council/senior-housing-investment-members/ 

We have to think about what’s best for this person, this patient, this resident, and carry that expertise throughout the different settings.

In today’s value-based care model, the focus is increasingly on incentivizing providers to do what’s truly best for the individual, the customer. Good outcomes are the goal, and the intent is to incentivize provider behavior that will produce such outcomes, at lower cost. That’s led to the realization that we need to have good hand-offs from one setting to another. In order to achieve coordinated, integrated care, information must immediately be transferred along with the individual. That means patient information including prescriptions, the treatment plan, the conditions they’re being treated for, and so forth, all must go along with the individual, from one setting to another. All of this is good – and important. But it’s not enough. 

Under the fee-for-service system, each of the silos within the continuum of care was incentivized to hold on to the individual using their services for as long as possible. Should that person have reentered a given care setting after being discharged or transferred elsewhere, it was all the better because payments would continue to be made as long as that person was in your bed. It was a perverse incentive, sometimes resulting in the hope that that patient would return, rather than heal and move on. It also placed different settings at odds, competing for dollars, rather than focusing them on working together to achieve good outcomes. As a result of these and other pressures, each setting functioned as a stand-alone silo and profit center. 

It’s time for those silos to break down and start working with each other. If that doesn’t happen, and coordinated care is just about good handoffs from one silo to another, we won’t actually benefit the customer, nor will we truly save money in terms of total healthcare spend. We will still be furthering that siloed mentality, in which experts in each silo still make decisions, independently of the experts in other silos, such as the hospital, skilled nursing, assisted living, or home health care settings. 

Each time you hand off to a new setting, the senior healthcare professional in that setting becomes like a dog marking its territory.

I can offer two illustrations of this problem. The first was related to me by a skilled nursing executive. Because the family members of a resident knew this executive, they called him to discuss their mom. She was on a managed care plan and had just been discharged to one of his properties from the hospital. Within 72 hours, they received three phone calls, from three different care coordinators: one from the health system, one from the managed care plan, and one from the skilled nursing facility. In each case, the call was to advise the family as to what was the best care plan for their mother. They clearly had not spoken to one another, let alone coordinated, as they each offered a different approach to her care. The family’s reaction was “no wonder health care is so expensive, and so screwed up.” All of the calls were made in the name of executing a good handoff. 

Another illustration I use comes from my time as a Maryland state representative. I sat on the committee which regulated all the different healthcare professions in the state and got to see all of their turf battles. Every group, from Podiatrists to Ophthalmologists, would come in and argue about who was qualified to do what. Each group would argue that only they were qualified. Today what I see, in terms of these different settings, even if there’s agreement on the need for integrated, coordinated care, reminds me that not much has really changed.  

If we just have a different team of experts in each setting, we’ll have turf battles – and the loser will be the individual receiving care. 

Each time you hand off to a new setting, the senior healthcare professional in that setting becomes like a dog marking its territory. They routinely overrule the other silo. You might hear a hospitalist say: “I don’t know why the consulting doctor in the skilled nursing facility recommended this prescription and that you do that therapy.” The skilled nursing physician might say: “I don’t know why they put you on that in the hospital; that’s nuts, given your history – they must not have looked at that.” Then the managed care company comes in, saying: “I don’t know why either one of them is doing this; that’s so expensive, and so uncalled for.” In each case, they’re saying, “we’re the experts” and they show it by stepping all over the advice the patient got from the other care settings. 

This dynamic is why, if all we focus on is good hand-offs, we will fail to truly produce the best outcomes for the patient, at the lowest possible cost. Instead, we have to have coordinated, integrated care not just in the hand-off, but across all the settings and throughout the individual’s care journey. We have to think about what’s best for this person, this patient, this resident, and carry that expertise throughout the different settings. If we just have a different team of experts in each setting, we’ll have turf battles – and the loser will be the individual receiving care.  

There are practical examples in which coordinated care teams disrupt old silos and achieve integrated care at lower cost. For an excellent read on the practical aspects of coordination, you can download the paper “How Disruptive Innovation Can Finally Revolutionize Healthcare”. Written by Clayton Christensen, Andrew Waldeck and Rebecca Fogg of Innosight and Christiansen Consulting, the paper, which is subtitled, “A plan for incumbents and startups to build a future of better health and lower costs” provides evidence that this approach is not only cost-effective, but necessary if we really wish to achieve great outcomes for Americans. We recommend anyone interested in achieving better outcomes, at lower cost, read the paper. I welcome further discussion and comment from those in the business of caring for people – across every setting – on how best to achieve meaningful results. 

NIC is pleased to welcome you to the new look and feel of our blog, which up until a week ago was titled NIC CARES. The old blog, which was designed and launched back in March 2015, was, according to our marketing vendor, in need of an update. We’re excited to have launched the new platform over the July 4th holiday, with no major bugs or any complaints – but, of course, will be looking for any feedback from our subscribers and readers.

Not every new feature will be visible to visitors. The new blog is operating on a platform that is easier to work with on the publishing side – and has better tools for tracking visitors and their reading habits. It is our hope that, in addition to reducing the effort required to publish each post, the new platform will help provide some insight into which posts are valuable to our readers, and which ones perhaps fail to attract attention. Over time this approach should help us fine tune the blog to suit our readers’ needs and interests. 

The update provided an opportunity to make some design changes as well. The new interface, which is easy to read on any type of device, also makes loading images easy – so we’re planning to include images in most of our posts going forward. The new layout was designed to be easy to read and to make scrolling through easier as well. 

The new blog’s search function has also been refined. We have developed a much shorter, more useful list of search categories, designed to make it easy for our various audiences to quickly find relevant material. You will find the categories in a drop-down list next to the search button at the top of the page. The entire catalogue of posts, which still dates back to 2015, can also be searched by any keyword users wish to enter. 

Another change, of course, is the name of the blog. “NIC Notes” replaces “NIC CARES” to help remove any misconceptions around our mission and brand, particularly as new readers, and those who may be new to the sector, continue to find the blog online. “NIC Cares,” for some, may imply a medical or skilled nursing focus, which would be inaccurate. While this is not a big problem, we have been aware of the possibility for confusion, and took the redesign as our opportunity to better align the blog with our overall brand. 

Please keep reading NIC Notes – and look for further updates as we continue to refine and improve what has become one of NIC’s favorite sources of insight, news, and commentary on seniors housing and care. 

The Labor Department reported that there were 224,000 jobs added in June, above the consensus estimate of 160,000. The June increase in jobs marked the 105th consecutive month of job growth. The latest six-month average increase is 172,000, less than last year’s 223,000 monthly average. Nevertheless, the pace of job gains is strong and generally stronger than the levels that have usually prompted the Federal Reserve to cut interest rates in the past. This suggests that the Fed will not be cutting rates immediately despite other concerns about a slowing economy or trade-related threats to the economy. In recent months, the Fed’s has indicated that it is paying close attention to the risks of an economic slowdown.

Revisions subtracted 11,000 to the prior two months. The change in total nonfarm payroll employment for April was revised down from 224,000 to 216,000, and the change for May was revised down from 75,000 to 72,000. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors. In June, employment in health care rose by 35,000. In the past year, health care has added 403,000 jobs.

The unemployment rate edged up 3.7% in June from 3.6% in May. This is still close to the lowest rate in 50 years. A broader measure of unemployment, which includes those who are working part time but would prefer full-time jobs and those that they have given up searching—the U-6 unemployment rate—rose to 7.2% from 7.1%.

Average hourly earnings for all employees on private nonfarm payrolls rose in June by six cents to $27.90. Over the past 12 months, average hourly earnings have increased by 3.1%, the same as last month. For 2018, the year over year pace was 3.0% and in 2017 it was 2.6%.

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was unchanged at 62.9% in June, very low but up from its cyclical low of 62.3% in 2015. The low rate at least partially reflecting the effects of an aging population.