Q: Tell us about your decision to affiliate, creating one of the nation’s 50 largest not-for-profit aging services providers.

A: We were all stretched to deal with the complexities that COVID brought into our lives. That certainly sparked us to lean further into this process …This gives us an opportunity to express our mission and live out our mission in a bigger way. We think that by coming together, we’re going to be able to be much more creative in the way that we find opportunities to support people and let them live their purpose.

Q:How did you determine fit? 

A: Garden Spot is a little bit more weighted on the independent living side. Our partners are a little more heavily weighted on the healthcare side. That brings great expertise in both areas as we think about best practices, and sharing ideas and processes. It gives us more strength in all of those areas to go forward.

Q:How will each organization keep some of its individuality? 

A: There are a lot of differences between Philadelphia, Altoona and Lancaster. Even though we’ll share strong alignment around core areas, culture gets interpreted in different ways. We’re planning to celebrate that and allow each community to maintain aspects of its culture.

A: With the elderly drinking less, along with the extra heat that they like in their rooms, it can be difficult to keep the skin moist. 

Also, with poor nutrition and age in general, it is hard to keep the skin moist. The skin, which is the body’s largest organ, is affected like all aging organs. People tend to forget that.

Studies  show that the dryness, scaling and breakdown of skin is a direct reflection of the aging process, poor nutrition and poor intake of fluid. All of these things affect the skin immensely.

There are many approaches people have tried  to successfully assist with skin moisture and pliability, such as increasing fluids, the use of natural oils, oils in the tub or shower, and also nanobubble hydrotherapy. This product came into the market around five years ago and the machine inserts large amounts of oxygen into the water, making the water appear milky. However, it makes the skin smooth, heals small scabs and sores, and also takes away the scaling of dry, rough skin.

Of course, nothing takes the place of good nutrition and hydration. Try small sips or drinks of water, milk, juice or whatever the resident likes to drink. Popsicles, making ice cubes from juices to increase calories, and hydration also will make a difference. In addition, live plants in the rooms can add moisture. Reducing the temperature of the room, or adding a humidifier, if allowed per your state regulations, also may help with making the skin less dry.

Trying several different “tricks” may work best, as not many people enjoy change, if at all. But adding a small amount of fluid, a hand cream, lowering the temperature one degree at a time (remember: start low, go slow), adding a plant …  these all can help make a big change in the dryness of skin.

A: I am often asked if wound care is a medical specialty, and the answer is a surprising “NO.” Despite the surge in chronic wounds,  there is no credential provided by the American Board of Medical Subspecialties for wound care in either medicine or surgery. 

Wound care has been around since the first recorded medical records in ancient Egypt, but it fell off the map of medical education in the late 19th century. The gap has been filled by a variety of certifications, some sponsored by for-profit entities and often with industry support. Certification can be conferred upon a variety of practitioners, sometimes with only brief online education. 

The absence of medical specialty certification has resulted in a knowledge gap in assessing and treating wounds for most doctors, which impacts many patients, including the geriatric population. The consequence is a profusion of educational materials and gray literature from outside the bounds of traditional academic channels that supports a variety of products and technologies. Various surgical specialties also entered the arena, creating a Tower of Babel for wound care with different practice styles, procedures, techniques and treatments. 

The gap in long-term care is partially filled by third-party wound care providers. An array of national companies employ practitioners with various backgrounds, training them in wound assessment, procedures and medical billing. Most are physician-based, but some provide nurse practitioners. 

Wound care is a complex topic that demands knowledge in areas including geriatrics and palliative care. The practitioner must be knowledgeable regarding physiology, products, and differences in caregivers and systems across the healthcare continuum. Hopefully, future generations of physicians will break down interprofessional silos to provide comprehensive training and certification for physicians treating wounds.

A: Spending significant time on one issue can be overwhelming. You mentioned two: staffing and the need to work the floor to cover shifts. Addressing the former will alleviate the latter. 

First, tackle retention issues. Identify core problems making staff unhappy and develop a plan to fix them. For example, if nurse aides leave because they don’t like their schedule, provide self-scheduling options. If staff say they lack training or orientation, revamp orientation. When issues linger, turnover continues. Even if you find and hire new employees, they won’t stay if problems persist. 

Next, convene all nurse managers and the administrator to discuss how facility leadership will recruit staff. Consider innovative strategies. Rethink past approaches and explore new ideas. One idea could be shorter shifts to accommodate staff with school-age children who need to be home before and after school. This also can be attractive to nursing students doing clinical immersion rounds, as it allows them to pick up shorter shifts to work around school. While eight- or 12-hour shifts theoretically allows for continuity of care, if there is no staff available for them, nurse managers must fill gaps. 

Additionally, ask staff for their ideas. In one situation, staff reported friends couldn’t work at a particular facility because there was no public transportation. To address that barrier, leaders implemented rideshare opportunities. 

By stemming the tide of attrition, you can bolster your current team and position your facility for success with coming recruitment efforts — which lets you return to other leadership functions.

Their fully automated imaging system compares photos of serving plates at the start and end of the meal to gauge how much a resident has eaten. The software then links to the LTC facility’s recipes and meal plans to get information on the type and nutritional value of the foods included in each meal. By analyzing factors such as the color and depth of the food that’s left on the plate, the software determines how much of each food type was consumed, and how much nutrition the resident received.

While LTC staff already estimate food consumption by manually checking how much food is left on plates, the researchers point to error rates of at least 50% with this method. The AI system claims an accuracy within 5% in Scientific Reports.

“One of the biggest findings from this study is the tremendous potential for this type of technology as a game-changer for really aiding LTC homes in improving not just the quality of care they can provide but also improving efficiency,” said study co-author Kaylen Pfisterer, Ph.D., who co-led the research with her husband, Robert Amelard, Ph.D. “By developing and co-designing the technology directly with stakeholders, we feel we’ve landed on a solution that considers the day-to-day constraints of bustling LTC life.”

The technology also would provide facility dining staff with data on most-loved foods, allowing them to examine ways to make these foods more nutrient-packed, and enable staff to detect a resident’s malnutrition risk earlier and intervene sooner. 

“By more accurately tracking intake, this could also help reduce food waste, inform menu planning and provide insights into opportunities for enhanced recipes,” said Pfisterer. 

A: There is no penalty at this time, but you will receive a warning edit on the MDS 3.0 NH Final Validation Report that will inform you that the patient has been reported to have exceeded the 25% limit. 

The edit will state: “The total number of group and/or concurrent minutes for one or more therapy disciplines exceeds the 25 percent limit on concurrent and group therapy. Consistent violation of this limit may result in your facility being flagged for additional medical review.” CMS also will monitor provision patterns and be aware of facilities that exceed the limit and will revisit the idea of a penalty for exceeding the limit in the future.

The priority in these instances is to review the information for accuracy and then validate that the mode of therapy was appropriate. Concurrent therapy skilled intervention must be clearly documented and connected to at least one individualized goal in the plan of care; group therapy must be justified in the resident’s medical record and include:

• The specific benefits to that person; 

• The documented type and amount of group therapy; and

• How the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals.

In some cases, the 25% limit may be surpassed due to circumstances beyond your control. The percentage is calculated based on the resident’s total therapy, and if the resident discharges unexpectedly, for example, group or concurrent minutes may exceed what was initially projected. Again, the emphasis will be on the appropriateness of the treatment provided.

A: A coalition of 16 state filed a complaint on Feb. 4, 2022, asserting that the federal vaccine mandate for healthcare workers was based upon then-current data around the delta variant. At that time, delta accounted for 98.7% of U.S. cases.  

The states involved in filing the new lawsuit are Louisiana, Montana, Arizona, Alabama, Georgia, Idaho, Indiana, Mississippi, Oklahoma, South Carolina, Utah, West Virginia, Kentucky, Ohio, Tennessee, and Virginia. Those states argue the mandate “utterly fails to account for changes in data and circumstances …” They allege the changes constitute a structural defect and that the mandate will do little — if anything — to prevent transmission of the now dominant omicron variant to patients and staff.

The new complaint alleges that: (1) CMS failed to consider that the pandemic is continually evolving; (2) that the delta variant has given way to omicron; and (3) the vaccines do not protect against omicron. The states claim that this makes the vaccine mandate arbitrary and capricious under federal law. 

In January, the U.S. Supreme Court was fairly unequivocal in upholding CMS’s authority to issue the mandate. Although the legal arguments in the new complaint are essentially the same, the factual differences around the omicron variant might lead the federal courts to view the CMS mandate in a different light. If the case makes it to the U.S. Supreme Court, the prior ruling would most likely be upheld However, the changed factual circumstances related to omicron could cause the court to give the case a second look, and may persuade some on the court to agree that the changed circumstances make the rule arbitrary and capricious.

The National Institute for CNA Excellence (NICE) virtual platform is designed to help address the current workforce shortage by providing both certified nursing assistants and skilled nursing providers with recruitment, certification, job placement, continuing education and ongoing career support in one place. Through NICE, CNAs can access instruction from post-acute and long-term care physicians, aging services policy leaders, and experts on topics that include Alzheimer’s disease, person-centered care, infection prevention and control, palliative care and regulations.

For its part, ShiftMed will tap its database of more than 1,500 healthcare professionals to provide a purpose-driven career pathway for uncertified personal care aides through NICE. Once prospective CNAs have completed their online education through NICE, they will download the ShiftMed mobile app and be matched with nearby healthcare employers, where they can get on-site, hands-on experience required for certification

“NICE takes successful training programs one step further by going beyond the normal requirements to educate the learner on essential skills such as team-building, conflict resolution, person-directed care, and much more,” said Lori Porter, NAHCA CEO and NICE creator.

Senior Living Properties LLC, a 50-location skilled nursing provider in the state of Texas, signed on as an initial launch partner. 

“By educating, training and empowering CNAs, we will improve access to care and improve quality of care and quality of life while addressing the shortage,” added Todd Walrath, CEO of ShiftMed. 

At the time, most skilled operators saw little reason to worry about these new upstarts. After all, assisted living was basically a concierge service, right? This new model certainly wasn’t in the business of delivering healthcare services. Besides, assisted living was a private-pay enterprise. Why sweat over these new pipsqueaks with so many real problems?

Now, private-pay, lower-needs residents have all but disappeared from the skilled care scene. Why do you think that is? And by the way, Medicaid now reimburses those pipsqueaks in just about every state. Small wonder there are more than two assisted living communities for every U.S. skilled facility.

I mention this cautionary tale because skilled care operators are very much at risk of repeating the mistake. Except this time, the overlooked challenger seems even more harmless. It goes by the name of home care.

Home care a threat? Really, John? They don’t offer the same high-end, 24-hour care that skilled care can deliver, right?

Well, yes, that is technically correct. At least for now.

But here are a few things home care can offer:

• Care at a lower cost

• A la carte service options and per-hour pricing

• Care in a preferred setting

• An increasingly complex array of care and assistance options that’s reducing the gap.

We keep hearing about how value-based care is going to be the new litmus test for Medicare and Medicaid payments. Compared to skilled nursing facilities, home care options hold the promise of similar outcomes at a fraction of the cost.

So are skilled nursing facilities doomed? Not necessarily. But they are going to have to up their value game.

They also might want to start treating home care operators less like a nuisance and more like a partner. Some more enlightened skilled care operators have begun doing exactly that.

Still, far too many continue to see home care as a nothingburger. Let’s hope they wise up, and soon.