The question came during a trade show I attended more than a decade ago. What was a bit jarring at that time was that all the people in the room were nonprofit operators.

Am I mentioning this to pick on nonprofit communities? Of course not.

The work they do is beyond reproach and routinely heroic. But at the end of the day, they too must pay for things like wages, lights, gas and water. Sometimes that can mean making uncomfortable adjustments.

That lone voice in the room was really posing less of a question and more of a battle cry. Increasingly, divestiture of stand-alone long-term care services is becoming the new game plan. And to be clear, it is happening on both sides of the taxation divide.

Motivated by a combination of new economic realities, concerns about being left behind, fear and sometimes greed, operators are changing strategies and tactics as never before. And in their search for new answers, many are giving up on some of the old ones. Not that it’s hard to see why.

A report released recently by the American Health Care Association notes that more than 300 nursing homes closed during the COVID-19 pandemic — and predicts another 400 could shut down this year.

The most vulnerable: smaller facilities located in urban settings where Medicaid pays most of the bills. In other words, what was once arguably the heart of the industry.

Meanwhile, the open secret on the nonprofit side is that stand-alone communities are being sold off in unprecedented numbers. It would appear this is no time for one-trick ponies. Especially if those horses are losing money.

So welcome to the new world of long-term care. One where service diversity is the price of admission, risk management is the phrase that pays, value-based care is the gold standard and insurance companies are increasingly calling the shots.

All we know for sure is this: Long-term care will be different in the future. Very different. In fact, it could become so different, we just might have to quit calling it long-term care.

Once again, I was reminded how dedication runs true and providers take advantage of every opportunity they can to stay in business, whether it means granting plenty of vaccination exemptions or doing just the opposite.

Take, for example, the small North Carolina operator who wrote to me that if it had not been for the opportunity to offer religious exemptions, his small facility would have had to close. An eye-popping 40%-plus received an exemption, he said. 

A human resources manager from Wisconsin vented in a 1,000-word email. She masks in public, shops at low-traffic times, has not traveled during the pandemic and has stayed COVID-free throughout. But she still balks at shots.

“I do not qualify under a medical exemption and I will not lie and say I have a fake religious exemption. These are all fake as the claims they base this on are not scientifically valid anyway,” she asserted. 

Faced with either leaving the profession she’s passionate about or getting a shot, however, she wound up doing the latter. But she says she will not get a booster.

A Virginia operator painted a recurring theme: “Only 1 or 2” employees were lost due to the vaccine mandate, but 25 — 36% of staff — had been granted exemptions. Most would have left without them, he feels.

An Iowa administrator gave a clearly bullish view of the staff mandate. Some 57 of 59 employees were vaccinated.

“The mandate may have saved some staff,” he told me. “If we didn’t have such a great response, some would have quit because of the danger non-vaccinated employees present.”

There were 100% vaccinated and no departures as the vaccine mandate deadlines arrived for a secluded, small Massachusetts facility.

“Well-run facilities with healthy management-staff relationships can get through this without a crisis,” the building’s executive wrote.

“Those staff unwilling to do what’s best for their residents probably shouldn’t be in this industry to begin with,” the exec added. “And management that doesn’t have the trust of their staff probably have turnover anyway.”

Ages-old truth that reminds: The basics still rule.

Many operators have started to prepare for more frequent mental health needs, building out networks and partners who can help identify specific behavioral needs of skilled care patients. Spotting changes in cognition and memory is just the start. CMS also will put more emphasis on addressing pain and substance abuse, and delivering quality treatments — and not just through medication.

The agency has said it wants providers to:

• Broadly improve access and quality of mental healthcare and services

• Provide better access to substance use disorders prevention and treatment across settings, to include nursing homes where such patients may come to recover from short-term health conditions

• Ensure effective pain treatment and management

• Promote equity and person-centered care that addresses language barriers and cultural needs.

• Use data for effective actions and impact

How all of this will play out for nursing home operators is unclear. But there can be little hope that the spikes in depression, anxiety and other mood disorders associated with the pandemic will resolve themselves. We are a more-stressed nation, living in a more stressful time in a stressed-out world.

How many nursing homes have resisted taking patients with coexisting but controlled behavioral health disorders because they fear a reputational backlash? It’s hard to quantify, but the widespread reluctance of skilled providers to admit patients who need medication-assisted therapy for substance use disorder is a telling sign.

Federal strategy will continue to target providers who reject without cause patients who have behavioral health needs.

There is also a shifting acknowledgement from regulators that many among us will just need help managing ADLs or other health needs while keeping behavioral conditions in check. Why can’t both needs be met in a nursing home?

With the latest dispatch from CMS, it’s becoming abundantly clear that more providers will need education on this. The time to hit the books is now. 

The earliest wound care practitioners used everything from honey to grease and alcohol to promote healing, a true example of necessity bearing invention.

By the 1800s, Joseph Lister was promoting a method of packing wounds with gauze soaked in carbolic acid.

It was only in the 1960s that modern moist healing techniques emerged — and it’s taken another half-century for engineering, chemistry and medicine to land on the kinds of products now being used by wound and ostomy nurses around the world. But the innovation has been fast and furious in terms of lasting impact.

“As moist wound healing and the concept of undisturbed wound healing have become more widely accepted, new technology and evidence-based practices have led wound care treatments into a new realm of innovation,” said Chrystalbelle Rogers, MSN, RN, CWCN, CENP, a wound care nurse with Medline Post-Acute Care Skin Health. “This, coupled with unprecedented limitations of resources, has proven the value of innovative products and practices that can help decrease pain, increase adherence to up-to-date recommendations and ultimately improve the overall quality of life.”

Moisture isn’t the only method that continues to be improved. Reta Underwood, wound care expert and president of CLTC Inc., says pressure-relieving and reducing mattresses have earned their place in mainstream wound care practice, too.

“If it’s not routine in a facility, it should be,” she said. “It is a beneficial must-do.” 

But there’s no limit to how wound care might continue to evolve, especially with new technologies in the mix such as wound-tracking cameras, moisture-assessement tools and products such as a surfactant based-gel that can manage devitalized tissue and promote cell survival. Underwood said she is hopeful the future will bring faster wound care interventions and lead to an ever-higher standard of care.

 “We have the power, with the current climate of change, to push for resources that are necessary to provide the most effective care for those we serve.” Rogers agreed. “The greater innovation is not in the product alone, but ultimately our ability to use it.”

Following the massive “Mega Rule” that solidified their role in nursing homes, infection preventionists had become instrumental in implementing antibiotic stewardship programs and were laying the groundwork for sweeping patient-worker safety educational programs.

But in March 2020, much of that work paused, followed by massive casualties due to COVID-19. While the industry found itself empowered to help prevent infections, it was still largely ill-prepared for the speed and volume of this new virus.

Still, infection preventionists picked up new skills in the early days of the pandemic and played pivotal roles in sourcing personal protective equipment and providing updated information on infection-prevention protocols.

All of that work has better defined the role, according to Evelyn Cook, associate director of the Statewide Program for Infection Control and Epidemiology at University of North Carolina at Chapel Hill.

“We should remember that there is no silver bullet that will address all the challenges that LTC facilities continue to face,” she said. “Having a full-time infection preventionist is really only the first step in developing robust infection prevention programs.”

That said, Cook has asserted nursing homes were never designed for pandemic care, and yet were “expected to provide the same compliance as acute care, without having the infrastructure to do so.”

But recognition of the challenge is growing. In March, editors at Infection Control Today said that COVID has underscored a need for even more infection preventionists in the years to come.

Going forward, Cook believes most facilities will have to come up with innovative ways of recruiting and retaining infection preventionists that will redefine their roles in light of the current workforce upheaval.

“Facilities that approach this as an opportunity instead of a punishment will notice an improvement in their care and services, and be better able to support residents and staff,” she added. “Because of the pandemic, facilities will be much better prepared to adhere to the never-ending regulatory guidance and regulations.” 

An American Health Care Association report created with CliftonAllenLarson in late April predicted 400 nursing homes could go out of business this year. It found a 5% reduction in Medicare rates ­— just over the 4.6% proposed — could put 38% of U.S. nursing homes at risk.

Federal regulators’ consideration of a direct care spending minimum and a new database tracking nursing home sales added to the pressures. Meanwhile, interest rates were increasing and inflation remained above 8%, according to data released in May.

“We could go through a list of five or six things that are very, very scary,” AHCA President and CEO Mark Parkinson said recently on a McKnight’s podcast. “This is a super hard time.” 

It’s a financial wellness benefit many operators have been considering recently, as a way to both help workers better manage their day-to-day finances, but also differentiate providers and help with recruitment efforts amid staffing shortages. In addition to DailyPay, vendors such as OnShift and PayActiv provide similar services.

Leaders at Mission Health say the move has been a top retention strategy when it comes to supporting valued healthcare staff. Research by the Mercator Advisory Group, commissioned by DailyPay, indicates that healthcare workers stay 73% longer on the job with access to DailyPay, helping to enable them to provide essential care to members of their community for a longer period of time. The data also shows that offering DailyPay reduced turnover by 50%.

More than half of Mission Health’s staff took part in the first few months of its launch, said Cheri Kauset, vice president of customer experience and communications at Mission Health Communities, who called it “a differentiator in our space.”

The service works by allowing employees to move money they have earned that week from the DailyPay app into a checking or savings account or on to a pay card provided by Mission Health, said DailyPay’s CMO and workplace expert, Jeanniey Walden. She added that having access to wages on-demand can be “truly life-changing” for workers who may live paycheck-to-paycheck and easily fall into debt when faced with unexpected financial emergencies, fees from taking out a payday loan or late fees for bills they couldn’t pay on time.

“The app allows workers to easily see what’s coming in their next paycheck, and whether that is enough to pay their bills,” Walden said. “If it’s not, they can pick up extra shifts. It really allows them to proactively manage their money, and even start to put a bit aside into savings.” 

1. Take stock of all they do. Typically, not many people realize the full scope of their duties or capabilities.

“Consultant pharmacists are responsible for the entire process of pharmacy in the nursing home,” said Chad Worz, PharmD, CEO of the American Society of Consultant Pharmacists. “Their primary role is to ensure that ordering, receiving, storing and administering medications are sound and rigidly followed.”

2. Realize the pandemic changed everything, including pharmacists’   roles. Thanks to a decimated workforce that has yet to recover, they took on myriad new functions, including administering COVID-19 vaccines. Worz believes administering vaccinations for influenza, pneumococcal disease and more will be key in the future. 

“This could improve the percentages of residents and staff vaccinated and better report data to quell future outbreaks,” Worz noted. In the end, the process will lead to more efficient med passes and create more time for the nurses and nurse assistants, he said.

“CPs will play even more critical roles in supporting staff and improving quality of care, while providing an invaluable learning bridge for new hires from administrator on down,” added Bethany Bramwell, RPh, BCGP, consultant pharmacist and senior director of customer experience at Guardian Pharmacy of Missouri and Kansas.

3. Take steps now to be part of the bigger picture.

“Providers see that their consultant pharmacists’ relationship should go beyond just providing medication regimen reviews,” said Erin M. Foti, PharmD, vice president of consulting services for Remedi Senior Care. “We’ve also learned in the past two-plus years that timely and effective communication is paramount to shared success.”

“Working closely together with a consultant pharmacist can be beneficial to reduce clinical costs, save nursing time, reduce readmissions to the hospital, and improve the quality of care for our residents,” Foti added.

Kevin Coggin, PharmD, consultant pharmacist at Turenne PharMedCo,said there’s a perfect opportunity now for CPs and clinicians inside nursing homes to forge even closer ties.

“Administrators and DONs should seek out their expertise when evaluating residents who have issues with swallowing, frequent falls, repeated sedation, (and) behavioral changes,” said Coggin. “They can help consultants maximize their time by providing a list of residents experiencing suspected adverse consequences (so) we can … make meaningful interventions.”

4. Embrace more meaningful ties. The pandemic has accelerated a pivotal change in the traditional relationship between consultant pharmacists and the staff they serve, according to Marti Wdowicki, PharmD, director of clinical operations – South for PharMerica.

“For years, most inside healthcare have viewed pharmacy as a very transactional business,” Wdowicki said. “In the past few years, we’ve begun to see a shared vision and a key shift toward being true, consultative partners.”

Both parties are exploring collaborations and strategies to harness data on disease state management, fall risks and hospital readmission rates, she added.

An extension of that can be seen in PharMerica’s “Partners in Nurse Advancement” educational initiative designed to support DONs and other nurse leaders in long-term and post-acute care with needed resources and education, said Lisa Bowen, vice president of marketing for PharMerica.

The company also  teamed up with the National Association of Directors of Nursing Administration to provide information and insights from DONs and pharmacy consultants for improved outcomes, care excellence and a better future for nurses.

5. Seize the time now to tackle the highest risk areas, in light of the still-precarious position that so many nursing homes find themselves in.

“When looking at an individual facility’s quality indicators or other metrics of high-risk medications, a consultant pharmacist can make recommendations to improve the quality of life for our vulnerable geriatric population, create medication administration efficiencies and save valuable nursing time,” Foti said.

“It helps out a lot. We’ve been working our butts off,” said traveling nurse Lakisha Brown. 

The effort, dubbed A Saucerful of Giving, was started by Des Moines resident Dan Tripp before the COVID-19 pandemic. Tripp started cooking and delivering a weekly meal for an elderly friend who went to his church.

He continued the tradition after she was placed in a nursing home and expanded the effort to include her friends. Residents’ dietary restrictions prevented him from continuing, so he shifted to helping the workers instead. Now, he delivers a meal to about 30 employees at a local nursing home each week. 

Meals he’s made have ranged from steak, to chili and cornbread, Cuban sandwiches and fettuccine Alfredo. His friends also have joined in to help with the cooking chores. 

“Some weekends I still do it on my own,” Tripp said. “But most of the time, there’s a group of us, and we all have a lot of fun. We all make good food and we’re helping people — so it’s just a win-win for everybody.”

When she was 6 years old, her mother was diagnosed with cancer and passed away a year later. Schumann’s paternal grandparents moved in to help her father raise her and her two siblings.

“While that experience had heartbreak and sadness, it also set me up in a divine way to understand illness, death and loss and to value my elders,” she says. 

Schumann’s paternal grandfather, Roy “Pete” Schumann, took on the role of primary caregiver while her grandmother, who helped establish a nursing program at the local college, continued teaching. Schumann spent her childhood running through their peach orchards in Colorado, reading before bed with her grandfather and playing sports — lots of sports. Her grandfather never missed a game. 

Schumann, now 6-feet-2-inches tall, ran track and played soccer and basketball in high school. She left home in 1992 to play basketball for Mt. Holyoke in Massachusetts. After graduation, she returned to help her father build his new nursing home, Brookside Inn. She joined the construction crew, putting in handrails and helping to lay the roof. When she reflects on that time, Schumann can’t help but think her blood, sweat and tears are part of the nursing home she has led for the past 20 years. 

Still, Schumann left briefly when invited to join the European basketball circuit with a Swedish team. But almost as quickly — despite games with  double-digit points, rebounds and assists — Schumann felt the call to return to Brookside Inn.

She stayed in Colorado and dedicated her career to serving residents, but has traveled frequently to Tibet and India. There, she developed an abiding interest in alternative care and even “adopted” a neighborhood of monks. She also studied with Zen, yoga and tantric masters to train in Japanese acupressure, essential oils and energy work, elements of which she has incorporated at Brookside.

Schumann also earned a second-degree black belt in tae kwon do. She recalls the extreme training taught her about perseverance, and she has drawn on it  throughout the pandemic.

As a board member of the American Health Care Association, she also is sharing others’ stories of fortitude, sacrifice, service and devotion to better highlight elder care at its best.

“There is a lot of love, devotion, service and compassion in our nursing homes,” she says. “We have people who came in day in and day out … and put themselves and their families in harm’s way in order to serve our elders, and that is a level of dedication that is frequently forgotten.”

For Schumann, at the heart of it all is service. She wants to serve as many people as she can in the finite time she has on Earth. It’s something she learned from her grandmother, who chose to teach to expand her reach as nurse. Schumann, too, is passing on her teaching in a multitude of ways.

– Nicole Bowman

Resume: 1996, Earns bachelor’s degree from Mt. Holyoke College; 1997, Helps build Brookside Inn in Colorado; 1999, Named admissions coordinator for Brookside; 2002, Becomes director of operations at Brookside; 2003, Begins volunteering with the Baby Girl educational project in Kenya; 2009, Earns master’s of divinity from Naropa University; 2013, Becomes future leader graduate with AHCA; 2014, Appointed board member and treasurer for Tibetan Village Project; 2016, Joins AHCA political action committee; 2019, Founds the Schumann Family Foundation for Health, Health Education and Cultural Exchange; 2021, Becomes AHCA Executive Committee Liaison