When a resident discharges from a Part A covered stay and subsequently resumes skilled care in the same skilled nursing facility during the interruption window, the readmission is treated as a continuation of the previous covered stay. The interruption window is defined as the first non-covered day, including the two immediately following days ending at 11:59 p.m. 

When the Interrupted Stay policy applies, there is no need to complete a new PPS 5-Day assessment for billing, as the original stay is continuing after a brief interruption and the per diem rate has already been established. Conversely, if a resident returns to the SNF for a Part A covered stay after the interruption window has passed, a new PPS 5-Day assessment will be necessary to establish the per diem rate for the new stay. 

While simple in theory, execution of this policy can be tricky in certain situations and requires a close eye on the calendar. If, for example, there is not a clear understanding of the interruption window, a required PPS 5-Day assessment may be inadvertently missed, leading to billing complications. 

If the SNF fails to set the ARD of a 5-Day assessment prior to the end of the last day of the ARD window, and the resident was already discharged from Medicare Part A when this error is discovered, the provider cannot complete an assessment for SNF PPS purposes and the days cannot be billed to Part A.

If the resident is still on Part A when the error is discovered, the SNF must complete a late assessment. The ARD can be no earlier than the day the error was identified and the SNF will bill the default rate for the number of days that the assessment is out of compliance.

Better late than never, but attention to census and payor changes is key to avoiding MDS scheduling snafus.  

Emergency preparedness plans require facility-based and community-based risk assessments to ensure facility operations continue and that the facility meets the needs of its patients. Based on the risks identified, facilities must develop and maintain training and testing. The program must be reviewed and updated at least annually. 

During the pandemic, some facilities may have missed their annual reviews. Nevertheless, the requirement remains — so now is a great time to review your program.

Emergency preparedness trainings must cover emergency preparedness policies and procedures for all new employees, volunteers and individuals providing services (including agency staff). Additionally, facilities must conduct and document ongoing emergency preparedness training twice yearly and with revisions. Ideally, trainings include lessons learned from recent exercises or real-life emergencies. Staff must demonstrate knowledge of emergency procedures. 

The facility must also conduct tests, including unannounced drills. That component must have: 1) a full-scale exercise, preferably community-based, or facility-based 2) an additional full-scale or tabletop exercise with facilitator-led group discussion; and analysis of the facility’s response. 

If the facility experiences an emergency requiring emergency plan activation, the facility is exempt from exercises for one year afterward. When analyzing the facility’s response of a real emergency or exercise, consider whether revisions to the emergency preparedness plan are needed. 

For further details, see Appendix Z of the State Operations Manual. 

Venous stasis ulcers are the most common wound found on the lower extremities and can be a challenge to prevent and treat. Risk factors include obesity, advanced age, diabetes mellitus, cardiovascular disease, a history of blood clots or varicose veins or lower-leg injuries. 

Prolonged lower extremity edema, particularly that found with congestive heart failure, leads to increased venous pressure in the legs, and failure of the venous valves that normally help return blood back to the core are compromised, leading to additional pressure in the lower legs. Lifestyle risk factors for these ulcers include smoking and jobs in which there are significant periods of standing or sitting. Venous ulcer symptoms include tightness or burning, but they are typically not painful.

They appear as an irregularly shaped shallow ulcer on the inner lower leg above the ankle. The ulcers usually have a reddish base and have some adherent yellowish fibrous tissue. There is often copious drainage or exudate. The tissue surrounding the ulcer is typically swollen, with the skin appearing reddish, brownish or shiny due to edema.

The goals of caring for venous stasis ulcers are to heal the ulcer, but also to control the causative factors, including swelling. These ulcers can be tenacious and take weeks or months to heal.

Wound care includes use of a pH-balanced wound cleanser, and application of a non-stick dressing that absorbs the right degree of wound discharge. Elevation of the legs and treatment of underlying CHF or other medical problems are mainstays of the healing process.

Your healthcare providers may recommend compression stockings to help control the leg edema, but care should be taken to ensure that the arterial supply to the legs is adequate before applying stockings. 

I know of many facilities that have received deficiencies for having tubing or a Foley bag touching the floor. It’s a difficult thing to keep catheters from dragging on the floor, especially when a low bed is used for a resident.

Many facilities use basins to prevent lapses in hygienic storage.

Put the foley bag and any extra tubing into a new or clean wash basin (depending on your facility’s policy) and sit the basin on the floor next to the bed.

Some residents move a lot at night, and the basin may slide, depending on your floors. The foley bag could slip out. Use some no-slip or Dycem (generic no-slip is sold at dollar stores in a roll with the household items) on the floor under the basin to keep it from sliding around. 

There are also Foley bag floor stands to keep the bag from touching the floor. However, if the resident moves a lot, these can tip over easily.

They also might require Dycem to prevent sliding. This same product can mount to wheelchairs in several places. 

Some facilities also use a “low profile” Foley bag. It’s about half the size of the regular bag, about 1,000 cc or less, so it may need to be emptied more often than a regular size bag, which can hold 2,000 to 4,000 cc, depending on the brand your facility uses.

Bag and tubing covers can also keep these items from touching the floor. If you use these items, be sure you have a policy on how and when to use them, how often they are changed, and what to do if they get soiled.

All of these catheter and tubing products should be available from the company from which you routinely purchase your medical supplies.

A:It was developed by the UCSF Center for Excellence in Primary Care to teach vaccine outreach specialists how to engage with people skeptical about the vaccine. We have trained more than 2,500 workers. HEAR stands for:

Hear: Use an open-ended question to invite the person to share their perspective, such as, “What are your thoughts about the vaccine?” Or use reflective listening to show they have been heard. 

Express appreciation: Showing gratitude lets the person know you value their opinion to help develop rapport. 

Ask about pros and cons: “What would be the bad things about getting a vaccine? How about the good things?” Understanding personal motivations can open doors to more discussion.

Respond: Share new information to address concerns and build on reasons they would like to be vaccinated. 

For free resources, see cepc.ucsf.edu.

Q: How does it combat hesitancy? 

A:The HEAR technique is a powerful shift in perspective that draws on 40 years of studies showing arguing is not an effective way to build motivation. The more effective technique is to draw out and build on someone’s intrinsic motivations. Our long-term fight against the SARs-CoV-2 virus depends on people believing in the value of vaccinations and having accurate information about the vaccine. There’s no way around having those one-on-one conversations.

Regulators said detailed guidance on the rule’s logistics would be issued in September.

Provider lobbyists and many facility leaders immediately protested, claiming that employees would flee to other healthcare sectors that aren’t subject to similar mandates, worsening existing staffing shortages.

Some operators had already announced their own vaccination mandates, setting the stage for showdowns as early as Aug. 23, when Genesis HealthCare’s self-imposed “universal” requirement kicked in.

As of early August, 62% of nursing home staff nationwide were vaccinated.

An industry survey in June  revealed 94% of providers were already reporting worker shortages, heightening anxieties over increasingly strident calls for mandates.

Those specialty providers happen to be skilled nursing facilities with dedicated pulmonary units featuring onsite, board-certified pulmonologists; staff respiratory therapists; access to lab and radiology services; and seven-day-a-week therapy.

They include places like Laurel Brook Rehabilitation and Healthcare Center, managed by Marquis Health Consulting Services, one of many providers nationwide using specialization to maintain or grow local post-acute market share.

While specialty programs have a long history in skilled nursing, the latest iterations depend largely on bringing advanced practice clinicians and hospital staff into buildings and implementing technology that drives outcomes — while making results easily reportable. Those strategies are key differentiators as providers look to secure hospital referrals and stay in network with insurers, especially crucial as COVID-19 continues to riddle the U.S.

The pandemic accelerated the push of somewhat healthy patients toward home, leaving the sickest of the sick for skilled nursing. Against that backdrop, delivering high-quality care for high-needs patients might be one way to limit acute care’s reliance on alternatives such as hospital-at-home.

“You’ll continue to see more and more of this,” says Jennifer Hertzog, vice president of marketing and business develop- ment for Marquis. “COVID was reinforcement that specialized programming, enhanced acuity-management partnerships and collaborations via this specialized programming work.” 

The rise of accountable care organizations and the steadily increasing prevalence of managed care are also creating opportunities for skilled care providers, especially those who can demonstrate prowess with cardiac, pulmonary, renal failure, sepsis and neurologically impaired patients. 

Health systems and insurers are “going to have to start looking at these specialty providers not just as another vendor, but as partners,” says Justin Border, OTR/L, who helps facilitate SNF-hospital partnerships as founder and president of Titan Healthcare Solutions. “They are helping them achieve operational outcomes that they never really give them credit for.”

Andrea Rizik is vice president of clinical integration and clinical operations for Integrated Care Solutions and formerly worked with nursing home operator National Health Care Associates. NHCA launched clinical pathways during the early days of value-based care. Those models led to a Passport Program covering more than a dozen conditions, and Integrated Care now uses similar models to help skilled nursing clients build out specialties of their own.

“Preferred networks (need) to make sure patients are appropriately referred to skilled nursing facilities that can manage their care,” Rizik says. “If a patient has CHF, for example, they should be going to a facility that can push Lasix. … We also look at the complement of coverage. Do they have mid-level provider coverage gaps? If a patient starts to have health concerns at 7 p.m. on Friday, do they have somebody who can start IV hydration?”

Choosing a specialty

Today’s providers are tackling a wide range of specialties.

In Vermont, Berlin Health and Rehab reported a 75% reduction in facility-acquired pressure ulcers after adding weekly rounds with a board certified wound ARPN and extra coverage from a third-party wound care specialist. The facility also is part of the Sepsis Alliance, which provides additional training and certifications to help improve detection and trigger earlier treatment of infection.

Those factors, the site’s managers said, contributed to a 41% drop in hospital readmissions over the last year.

Symphony Care Network this summer announced its new Serenata Geropsychiatric Care program to address behavioral concerns related to dementia or other neurological issues in seniors. It will include a multidisciplinary team of geriatric psychiatrists, social workers, therapists and nurses; provide additional neuropsychological cognitive assessments and screenings; and train staff in crisis prevention and de-escalation strategies.

Building out a program can be a lengthy process that includes collaboration with local health systems; data sharing; goal setting; best practices that span settings; and investments in personnel, equipment and physical plant. One thing it shouldn’t include: any kind of guesswork as to what the market will support. 

“With skilled nursing facilities, you’ll now see them reaching out, saying, ‘I feel like we have all this clinical capability but yet our census still hovers around 60 or 70%, and I feel like there’s so much more we can do,’ ” Border says.

He suggests facilities start by assessing what they’re doing, what they can provide and what they can further develop. It isn’t just consideration of personnel, but physical requirements, too. Renal programs may need dedicated space for bedside dialysis, as well as the capacity to handle biowaste. Respiratory units will require supplemental oxygen delivery, either pumped through in-wall piping or through concentrators.

“The worst thing you can do is say you want to go gung-ho, full-on specialty service but not be prepared to provide it,” Border says. “The payer sources and the referral sources tend to have long memories. When they think you weren’t as prepared as you maybe you presented yourself to be, it’s a long time before you’ll get another chance.”

Tech and teamwork

Understanding what partners truly need starts with opening a dialog with a hospital’s service line leaders before any additional investments are made, Hertzog says.

“Then our first step is to recruit and align specialists,” she says. “We look for a partner that is aligned with our primary hospitals and the goals that we have overall. But it’s speciality programming that is more than just a specialist at the bedside.”

Each building’s team reviews monthly metrics including length of stay and readmissions; clinical outcomes; and how well patients move through the continuum of care. To that end, management is implementing technology that can help smooth care transitions and put patients, as well as provider partners, at ease.

One recent investment is in HillRom’s Life2000, a one-pound, portable ventilator for patients who prefer to be mobile. They can begin using it in the skilled nursing facility, then program coordinators ensure similar durable medical equipment is delivered to home.

Marquis has a readmission rate of 8% for patients in their cardiopulmonary program, which helps attract more resources. In some locations, service line hospital staff come to the SNFs to further educate staff “because they see value in the outcomes we’ve been able to produce collaboratively,” Hertzog says.

Letting the heart guide

At Connecticut-based iCare Health Network, dedicated specialty programs grew out of a longstanding focus on complex patients, ranging from those with substance use disorders to those in need of memory or HIV care. A congestive heart failure program was a logical extension of the organization’s model blending social support with advanced nursing services, such as medication-assisted therapy.

When several local hospitals were having a hard time placing residents who needed inotropic drips, iCare built a program to accommodate them, according to David Skoczulek, vice president of business development.

More recently, the organization added pulmonary specialists to round in the same four buildings, each operating as a Touchpoints Rehab facility. ACOs have made service requests on top, including the latest addition in June.

“It sort of layered on itself until (the Touchpoints buildings) became really specialized,” Skoczulek says. “Once we built the program, the rest of it continued to follow.”

Two corporate LPNs and a registered nurse director track CHF patients and others who need a readmission prevention protocol. They work with APRNs, cardiologists and discharge planners to coordinate, which has led to several quarters without hospital readmissions, Skoczulek says. Transitional care nurses also work with patients who need advanced therapies, such as the inotropic drip milrinone.

“We obviously want all these patients to follow a very specific clinical pathway, and we do that by trying to be the experts on it,” says Skoczulek, noting that includes guiding patients into home care arrangements known to successfully handle infusion or other advanced treatments. 

The logistics planning and investments iCare has put into its specialty programs are now coming full circle: Hospitals “frequently identify iCare as the ones that will create a program from scratch to meet their needs,” Skoczulek says.

“The level of integration just continues to build, and we love that,” he adds. “We don’t find that the networks feel like they’re being squeezed out of centers. That really is the future.” 

Friends and colleagues say there is no other person you would want more by your side during a large-scale crisis.

“I seem to thrive, and have always thrived, in situations that aren’t normal,” she confesses.

Hood took on the challenge of supporting Haitian-American staff at her former workplace, HCR ManorCare, after the Haitian earthquake of 2010. The “cataclysmic” event resulted in more than 200,000 deaths, some among her staff’s families.

Hood set up phone cards for her staff to get in contact with survivors and hosted memorial services. Weeks later, she flew to Haiti with a group of nurses and doctors from the Haitian American Nurses Association of Florida (HANA) to provide medical assistance and tents for employees’ family members who found themselves homeless.

Marjorie Lozama, a nurse and second vice president of HANA in 2010, worked alongside Hood and immediately recognized her unique levels of compassion and energy. 

“She embraced the pain we were going through, despite the heat and the conditions we were staying in,” Lozama says. “She opens her heart to many people.”

At Principle LTC, Hood has used her crisis-management experience as a helpful advantage in the fight against COVID-19. 

Her hands-on mentality comes from being exposed to humanitarian issues early. Born in Kent, England, Hood spent much of her childhood traveling with her mother, a homemaker, and father, a project manager who oversaw powerplant construction. They went to Canada, Australia and South Africa before finally settling in Windsor, CT. 

“Everyone thinks I was a military brat,” she joked.

Hood described being thankful that her parents never shielded her and her brother from “the bad” side of life.

“I always wanted to play a part in making the world a better place from what I was seeing,” says Hood, who today lives with her mother, a dear friend and three dogs in her home in Kinston, NC. 

“My life is very full outside of work,” she says. She enjoys spending time with family and friends, going on walks, kayaking and traveling. She also enjoys a glass of good South African wine from time to time.

Though a capable leader in her own light, Hood understands the importance of having a high-quality team, with sharp minds and varying viewpoints, on her side. 

Diversity and inclusion are all-important factors for her. She surrounds herself with a team of people from different walks of life and enjoys the diversity of the human experience, races, cultures, religious beliefs and sexual orientations.

“If someone is not like me, that gives me the opportunity to learn and grow,” she says. “I have a non-negotiable policy when it comes to any kind of hatred.”

As such, Principle has endorsed a policy of “kindness” under her leadership.

“I’ve always valued the criticism of other people, as long it is done in the spirit of improving the lives of others,” she adds. It’s helped form her worldview and humanitarian streak.

Lozama recognizes this strength: “She puts people first, and therefore people will go the extra mile because they feel appreciated.”

Resume: 1986, Earns nursing degree from University of Connecticut, followed by a healthcare administration certificate; 1986, Becomes director of admissions at Kimberly Hall North Skilled Nursing Facility in Windsor, CT; 1991, Joins HCR ManorCare as administrator in Florida; 1995, Promoted to regional director of a facilities group for ManorCare; 2007, Named general manager, divisional vice president for ManorCare; 2012, Wins President’s Choice Award from the Haitian American Nurses Association of Florida; 2015, Elected to Women of Excellence by Free Yourself Women Foundation, a nonprofit for victims of domestic violence; 2017, Becomes president and CEO of Principle LTC; 2019, Launches Principle Cares, a nonprofit fund providing crisis fund for employees; 2021, Elected into the McKnight’s Women of Distinction Hall of Honor

In fact, overall attitudes displayed have been nothing short of “astonishing,” said one expert examining results of the 2020 McKnight’s Mood of the Market Survey.

Slightly more than one-fifth (21%) of respondents said the coronavirus pandemic has “definitely” made them more likely to leave the profession, with another 8% saying “probably.” On the other end of the spectrum, however, 28% answered “no way” to the same question, while the most popular answer was “probably not” (29%).

“That means 57% of the people are liking this profession and feeling really tied to it. It really shows people like being in the long-term care industry,” observed Matt Leach, principal and senior consultant for Total Compensation Solutions of Armonk, NY. “They like helping the elderly — it’s why they’re there.”

Nearly 14% said they were “considering it, but not sure” when asked  if the pandemic made them more likely to leave the profession. 

“That means 70% might think about it but probably are staying,” Leach noted. “You have to figure these numbers are only going to come down when things come back to more normal conditions. They’ll probably never be higher than now. If they’re not leaving during a pandemic, they are going to be in this industry until they retire.”

The 2020 Mood of the Market Survey gathered attitudes of 381 long-term care administrators and nurse managers. They answered survey questions sent digitally over a week’s span, ending in early August. A similar survey was administered in 2019.

Like last year, respondents overwhelmingly found their work “very” (82%) or “somewhat” (16%) meaningful. It was the key to other sometimes surprisingly optimistic results, experts said.

Nursing homes have been the most common setting linked to deaths due to COVID-19, with some 40% of nearly 180,000 U.S. deaths (including many workers) attributed to such settings. That’s according to federal figures at press time, which were almost universally acknowledged as low due to confusion reporting deaths and infection rates.

Intent to stay or flee

When asked, “In the last three months, have you seriously considered quitting your job?” more than 44% of respondents said “yes” this year. That marked a seven percentage point (or 19% net) rise over 2019 results.

Yet job satisfaction levels, while slipping slightly from a year ago, remained remarkably high, observers pointed out. Nearly nine in 10 (87%) said they were either “very satisfied” (47%) or “somewhat satisfied” (41%) with their current job. That’s only slightly down from 91% recorded in the pre-pandemic Mood of the Market survey. This year, nurse managers (91%) registered slightly higher overall satisfaction levels than administrator (88%) respondents.

“I’m just astonished, quite honestly,” said compensation and benefits expert Mark Heston of Heston & Associates. “When you look at how satisfied they are after everything they’ve been through the last four to five months, we’re talking about chaotic, uncharted times and they’ve been at the forefront of it. It’s a true testament to the type of people in the industry. It speaks to selflessness and commitment. They’re focused on hunkering down and caring for residents.”

Leach agreed that environment is critical.

“What’s going on is how much these individuals like where they work and like the residents,” Leach said. “The fact that it’s only down that much tells us that it’s the culture that makes people do that, and that’s why they’re there.”

Heston cautioned, however, that such qualities shouldn’t be taken for granted.

“I know the workload has gone up significantly for all of these folks, which speaks volumes to the people they are,” he said. “But my concern is burnout. How long can they sustain that type of effort?”

Satisfaction with pay levels, perhaps not surprisingly, slipped markedly between the 2019 and 2020 surveys. Some 56% said they were “very well paid (21%) or “somewhat well paid” (35%), which was much lower compared to the 66% mark a year ago. Once again, nurses polled higher than administrators on this question (63% to 58%).

“They probably would say the pay has not kept up with the extra effort,” Heston noted. 

Here, too, is a danger, Leach noted.

“I can tell you from other downturns [in the economy] that the organization that has taken advantage of employees during downturns, those employees, once the market turns around, are not going to be very loyal soldiers,” he explained. “There’s a universal feeling if your company takes care of you but doesn’t take advantage of you during downturns, you’ll be a much happier employee and much more likely to stay during the good times.”

Leach also explained that long-term care managers may have more options to move than before. Several decades ago, they might have felt less inclined to bolt to other settings, but places such as hospitals, with more competitive pay and work schedules, could draw away talent.

Working too much?

One new question on this year’s survey slightly surprised the experts. Respondents were almost evenly split on whether they were asked to do too much work, though nurses  tilted much higher than the administrators on the feelings of burden.

Overall, 13% of respondents said “very much so, yes;” 36% said “generally yes;” 42% checked “generally no;” and 8% said “No, I don’t think that at all” about the “too much work” question.

“I would have thought it would have been higher (toward too much work),” Heston said. “Part of it might be the type of people and professionals you have here. They work hard and take the opinion, ‘We’re going to get done what has to get done.’ They’re used to this.”

Respondents reported feeling slightly less appreciated for the contributions at work this year. Overall, 81% said they felt their work was valued “a great deal” (45%) or “a moderate amount” (36%). In 2019, the overall level was noticeably higher at 88%.

The outlook for opportunities for advancement held steady from last year at about 60% positive overall, and were once again looked upon more favorably by nurses (61%) than administrators (57%).

“What is the one change that would most improve your job satisfaction?” showed that better salary and more staff (a new option in this year’s survey) led at 23.1% and 22.6% for the entire group. Better insurance or benefits (another new category) was next at 10.5% and was followed by more paid time off (9.7%) and training (8.1%). Last year, the top overall responses were more training (21%), higher salary (17%) and more paid time off (13%).

Broken down by vocational area in 2020, nurses’ top five changes that would lead to more job happiness were: higher salary and more staff (both 24%), better benefits and more training (both 9%) and more paid time off (7%). Administrators led with salary (23%), staff (22%), paid time off (12%), benefits (11%) and more flexible scheduling (8%).

Another notable survey finding: respondents’ confidence in their supervisor possibly helping them advance their career dropped from 74% in the more optimistic choice ranges in the 2019 survey to 68% in this year’s survey.