Digital version of Dealmaker’s Handbook 2021

Download the Dealmaker’s Handbook 2021

Among the articles:

• Q&A: NIC’s Brian Jurutka on how the sector has evolved
• Strategic shifts: Some pandemic changes are permanent
• Emerging juggernaut: Home care is too big to ignore

Managed care contracts can be difficult to navigate, and you’re likely seeing more than ever before. The first step is thoroughly reviewing and understanding each contract and its differences. What are the authorization requirements? Does the plan pay by PDPM? RUGs? Levels? What is covered? 

For plans paying by levels, you will have to identify what each includes and manage the patient daily for any type of level change. PDPM reimbursement is reliant on information from the MDS; levels are not. Daily case management will be your key to success. 

For example, a “Level II” for a given plan might include less than 90 minutes of therapy per day, no less than three days per week. But what if the individual needs more? What if he or she experiences a condition change and requires IV medication — a “Level III” service? Failure to identify these changes or communicate with the plan provider are reimbursement risks. 

Many facilities rely on the MDS coordinator to fulfill the case manager role. Determine if it is appropriate for your circumstances, considering the volume and types of managed care beneficiaries you serve. SNF managed care responsibilities can include:

• Reviewing contracts

• Following authorization/extended authorization requirements

• Identifying and reporting exclusions 

• Monitoring approved therapy limits

• Evaluating changes in conditions/services and communicating them

An interdisciplinary approach and ongoing communication will lead to successful outcomes. Have effective systems from admission to discharge.

And when necessary, don’t be afraid to appeal!

With any vaccine mandate, employers must provide religious exemptions under Title VII of the Civil Rights Act. Once a facility is on notice that an employee’s religious belief prevents them from getting the vaccine, the employer must provide a reasonable accommodation unless it would pose an undue hardship. 

“Religion” is very broadly defined and encompasses not only organized religions, but also informal beliefs. As such, an employee need not provide proof that they are a member of a recognized religious group. 

However, the religious belief must be “sincerely held.” This doesn’t necessarily mean involving a “traditional” religion, or even what some may consider a religion at all. For example, courts have found veganism can be considered a sincerely held religious belief. Because religion is so broad, the EEOC advises employers to ordinarily assume an employee’s request is based on a sincerely held religious belief.

However, if an employer becomes aware of facts that provide an objective basis for questioning either the religious nature or the sincerity of a particular belief, the employer can request additional supporting information.

The employer may ask for an explanation of the employee’s sincerely held religious beliefs and, if necessary, appropriate documentation. That request can be for religious materials describing the religious belief or practice, written statements or other documents from third parties, such as religious leaders, practitioners or others with whom the employee has discussed his or her beliefs, or who have observed the employee’s past adherence to the claimed religious practice.

“We as therapists and in general, healthcare workers, are very good at dealing with change and challenge,” says Kristy Wikum, president and CEO of Centrex Rehab. “We must adapt more quickly to truthfully, in this case, save lives.”

The pandemic has forced healthcare workers behind and on the front lines to reach deep down and find a level of courage many didn’t know they had.

When a top manager for Vertis Therapy visited a facility early in the pandemic, she encountered a group of therapists who were hesitant to work with infected residents.

“She had to sit them down and say, ‘This is us running into a burning building right now. This is our 9/11,’” recalls Paul Riccio, the company’s vice president of finance and development. “She went on to tell them if they couldn’t rise to the challenge, they were in the wrong industry.”

Hilary Forman PT, RAC-CT, chief clinical strategies officer for HealthPRO Heritage, said the changing regulations “required us to make very quick decisions and communicate clear, concise guidance for our clients and therapists.”

“This was especially true during the early part of the pandemic. Today, we continue to invest in infection prevention measures so that we can continue to provide rehab services safely for the residents who need and rely on our care,” Forman adds.  

Recognizing “the tremendous pressure on skilled communities,” Forman says HealthPro Heritage therapists altered their work schedules and loads to help reduce the burden for their nurse counterparts. They received training in wound care and incorporating functional treatments, such as dressing, dining and preparing residents for bed.

2. The best way to deal with limitations and narrow windows is to efficiently maximize therapy time and effort.

To get around some of the challenges of staff onboarding and supervising new therapists, iN2L used video calls and provided email accounts to therapists, generally a rare practice in the industry.

“Having access to a simple video chat is key for proper collaboration, sharing ideas and coping mentally through the daily struggles of a job as a therapist,” says Therapy Success Manager Kristin Hoffman. 

The company also used video calling to host discipline-specific therapist treatment groups and in other cases, opportunities to discuss goals, discharge planning, activities of daily living and dietary changes with family members.

“One-on-one telehealth therapy visits — and even virtual group therapy — can be effective in supporting patients’ physical and psychosocial needs,” adds Forman. “Moreover, therapists even use technology to create functional treatment sessions. For example, our occupational therapists worked with patients on how to use technology to schedule medical appointments, order groceries, arrange for medication delivery and communicate with loved ones.”

3. COVID has shown everyone the importance of improvising, adapting and modifying routines.

“Therapists are change warriors,” says Forman. “They are trained to be solutions-focused, so they are able to pivot and adapt as new situations arise. If we can bolster social interaction, enhance engagement and enjoy therapy sessions, why not consider hosting classes and providing treatment sessions in hallways and outside doorways?”

Therapists who focus on function can create entire treatment sessions around everyday tasks and items found in the patients’ rooms or nearby areas, says Karen Welsh, senior director of clinical outcomes for Functional Pathways.

“Think outside the gym!” she emphasizes. “It’s not about the fancy weights and equipment, especially knowing the patients won’t have access to those items once they return home. It’s just as easy to set up an obstacle course in a patient’s room to work on balance, gait and sequencing as it is in the gym, and is most likely a closer simulation of their home environment.”

4. COVID has taught those managing workforces about the need to treat staff as carefully and mindfully as they do their patients.

“At the core of our profession, we’re taught to look at the whole person, even with the physical therapist who says, ‘I’m just the muscles and bones person,’ or the occupational and speech therapist who says, ‘I just deal with the cognitive stuff,’” says Riccio.

“As a country, how we look at frontline, first-responding providers has forever changed post-COVID,” he adds. “Because if that hero culture goes away or, even worse, if we just keep printing the sign out front but we don’t invest in mental health counseling and improving healthcare benefits inside, then we’re going to be in a bad way down the road. It’s important we never stop looking at them as heroes long after the pandemic has passed.”

COVID also has driven home the power of human connection, and it must be constantly nurtured in staff and those in their care. “Most residents would rather share a donut in a two-star double room than sit alone for months on end in a five-star suite,” Riccio adds.

One of the latest stilettos in the neck comes courtesy of his replacement, Kathy Hochul. Early in her term, she revealed the Empire State had experienced nearly 12,000 more COVID-19 deaths than were officially reported under the Cuomo regime. Nursing home residents figured disproportionately among the omitted.

Even by New York standards, that’s a pretty substantial amount. For some context, 12,000 people could fill up 100 average-sized nursing homes. How do you miss a number that large? You don’t.

But truth be told, her revelation didn’t spark much outrage. Even last year, it was well known that Cuomo was playing fast and loose with COVID death totals.

Yet this hanging offense never did get him hung. Or anything close to it. What did? In two words: grabby hands.

A report by New York Attorney General Letitia James alleged Cuomo sexually harassed 11 women, creating a “hostile” work environment. It was the political firestorm ignited by her findings — and the realization that he was probably going to get canned  — that convinced a defiant Cuomo to finally step aside.

Now think about that juxtaposition for a minute.

Cuomo is by all appearances a self-entitled creep. Many autocrats are. There is no excuse for what he allegedly did to women who were unfortunate enough to get within grabbing range. Yes, he should have been fired for that, too. And, by the way, also charged with criminal behavior.

In my line of work, young journalists are told to avoid burying the lede. They should make sure the most critical information in a story appears first.

In the same vein, Cuomo should have been tossed last year for denying and/or covering up the deaths of so many nursing home residents. That he was never held accountable for such an obvious dereliction of duty reveals something fairly damning about our current state of political affairs.

It reveals something even more disturbing about the relative value that’s placed on the people you serve. 

After all, while they had hoped for the events of Sept. 9 and 10 for a while, nobody was sure when — or if  — they would happen.

One thing’s sure, though: None of the fortuitous events happened by coincidence. Maybe there’s something to the saying that if you howl loud and long enough, you’ll get somebody’s attention.

For many months, nursing homes had been begging authorities to make available the remaining $25.5 billion in provider federal relief funding. Then, it just happened on a Friday morning (Sept. 10). Hopefully you’ve already filed for your fair share by now. 

For three weeks before that announcement, however, nursing homes also had been howling about the unfair treatment of being solely designated for a staff COVID-19 vaccination mandate by the federal government.

“CMS needs to finish the job,” I wrote in an Aug. 20 blog post on mcknights.com, adding my voice to the mix. “Don’t punch a hole in the bottom of long-term care’s already leaky workforce boat and walk away.” At a minimum, include other healthcare sectors, I said. 

On Sept. 9, President Biden did just that, and then some. That afternoon, the administration added other healthcare providers and tens of millions of other U.S. workers to the “get it done” list.

It’s generally not proper to wish burdens on others, but at least now the challenge has become how to keep everyone’s boat afloat, not just nursing homes’. That’s how it should be, of course. Public health matters do not exist simply for an individual’s sake, no more than public driving rules exist only for those who feel like heeding red lights at busy intersections.

The pandemic is far from over. But it’s no longer just nursing homes’ problem. As if it ever was.

In the aforementioned blog post, I had two pleas for CMS and its forthcoming vaccination mandate plan: Make it workable and make it fair.

The agency took a giant leap toward doing at least the latter, while possibly also helping the former, during a pivotal 20-hour span across two memorable days in September. Such victories are rare in this line of work. Savor and capitalize on them.

That’s not because COVID-19 is keeping out visitors. It’s because the pandemic is hastening the speed at which the industry invites takeovers from well-heeled and often well-cloaked private investors. Diversicare will shift from being a publicly traded company to being an asset of Ephram “Mordy” Lahasky, an investor and operator whose complex ownership web already weaves together at least 100 nursing homes.

It’s part of a trend that some see as troubling: Large numbers of once publicly traded, publicly accountable organizations are moving into tighter ownership circles, draping their business practices in relative secrecy as federal regulators hash out how best to deal with private equity’s rise in the industry.

Lahasky’s DAC Acquisition will buy all the operators’ outstanding shares of common stock at $10.10 each — or a premium of approximately 256% compared to the $2.84 closing price on Aug. 19, the last trading day before DAC announced its proposal. With offers like that, who wouldn’t want a piece? Especially given uncertainties about an evaporating workforce and its impact on admissions, remaining threats to resident health and a lack of long-term government funding that recognizes the ongoing crisis. And it’s not just public behemoths — pressured as they are by their own shareholders — that are falling to sky-high offers. Nonprofit and mission-based organizations are also increasingly selling out in this COVID/post-COVID/re-COVID market. For distressed operators short on cash, the threat of being poached will become even more real.

But Congress, where some members have been on a year-long campaign to limit private equity’s influence in healthcare, has done little to act on its distrust of related entities and shadowy ownership structures.

As the buyouts continue, it’s fairly obvious that the feds have one key resource that could keep more PE investors on the sidelines: Paying existing providers more to deliver care and lessen their daily operational burdens.

Funding the nation’s nursing homes at a level reflective of the work they do and the crisis they’ve been stuck in since March 2020 would certainly make it a little easier to resist all those flashy offers yet to come.

That’s one thing the pandemic has taught us: That our lives were never as safe and stable as we thought. Humans throughout history have mostly understood their insignificance and vulnerability, and only a few generations ago school children dove under desks to practice for nuclear annihilation. But somewhere along the way, we started assuming everything would always be OK. Now, with the Four Horsemen of the Apocalypse frothing in the wings, our fragility has our full attention.

For learning how to accept that troubling fact, there’s no profession better than long-term care. Many of our residents have endured incredible trials and learned the secrets to survival. Never believing life would be anything but difficult, they embraced hardship and change, took nothing for granted and appreciated every moment. They’re the perfect role models for this unsettling time.

I’m thinking of Les, a senior care resident and Holocaust survivor who recently passed away. As a young boy, he was separated from his mother and sister at Auschwitz and never saw them again. “It wasn’t easy to be positive in the camp, but we looked forward to every living day,” he once told me. “There was no time to cry.” After enduring unimaginable hatred and loss, he somehow emerged with love and positivity to share.  

His resilience still moves and strengthens me, and as you walk your facility hallways, you’ll find mentors like him everywhere you look. 

Stop and ask what their greatest challenge has been, and how they dealt with it. 

“It’s just life,” they’ll probably say. “There’s no time to cry.”

“Generally speaking, I have heard some vendors indicating rollouts of new technology initiatives have been delayed due to COVID and having access to the buildings,” said Scott Code, senior director, the LeadingAge Center for Aging Services Technologies (CAST).

Particularly hard hit have been new deployments, such as network infrastructure upgrades, that required physical access to buildings, according to CAST Executive Director Majd Alwan.

“The pandemic did impact when and how rollouts occurred,” said Mike Abcunas, senior solutions manager at STANLEY Healthcare. “There was a period when many communities needed to manage strictly who was on site, and of course had to focus all their time and resources on resident care. But that was an opportunity of another kind. We had more time to engage deeply with providers to truly understand their needs, which has led to a range of new collaborations.”

Trade show activity, of course, took a major hit across all industry sectors. That said, most “techies” and early adopters saw positive signs that lockdowns failed to stifle creativity.

“We’ve been busier in the last several months than ever before,” said Abcunas. “We’re seeing very strong demand for technology that communities believe will help them retain and rebuild census, provide better resident care and empower and motivate their staff so they are productive and fulfilled.”

Alwan said he witnessed “unprecedented interest” in use and support of social connectedness and telehealth technologies as providers leveraged off-the-shelf devices.

The pandemic itself has led to a slew of innovations in infection control and contact-free applications such as touchless elevator buttons, biometric remote monitoring using imaging and QR codes for thermometers, and infrared cameras. Also flourishing have been dynamic face-detection displays and COVID kiosks that automatically check temperature while logging vital visitor management data and apps around virtual therapy visits.