“I felt like I had to be part of the solution after Columbine,” explains Franco, who, at 16, successfully ran the campaign of the mayor of Lakewood, CO, and did the same at 17 for a state representative. He says he’s had the political bug ever since.

The congenial Franco grew up on a horse farm and was named “One of 20 Teens Who Will Change the World” by Teen People Magazine in 2001. 

Prior to joining LeadingAge, he honed his skills in grassroots lobbying for various groups, including the Alzheimer’s Association and American Diabetes Association. As a grassroots lobbyist, he works to help constituents tell their stories, which he calls “the secret sauce” in loosening tight political logjams in Congress.

Among his accomplishments in the two years he has been with LeadingAge is the launch of Advocacy Champions, which offers simple tools and ideas to help members advocate on behalf of aging services and work with local officials to make change happen.

There’s also Coffee Chats With Congress, a campaign that encourages members to set up informal conversations with lawmakers. After all, “Who can say no to coffee and cookies?” he points out.

This advocacy effort, he is pleased to note, recently resulted in Sen. Mark Warner (D-VA) sponsoring a bill that would repeal current certified nursing aide training lockouts.

His success at LeadingAge has not gone unnoticed. Late last year, The Hill newspaper recognized him as a top lobbyist in the “Grassroots” division of its annual “honor roll.”

 “I think Joe takes a very complicated process and makes it very user-friendly,” observes Dana Parsons, vice president and legislative counsel at LeadingAge Virginia.

Ginny Helms, president and CEO of LeadingAge Georgia, who worked with Franco on public policy at the Alzheimer’s Association, agrees: “He has a great mind, great insight and knows how to be effective in advocacy and public policy.”

Franco, who has discovered through his day job that he loves being a teacher, firmly believes that anyone can participate in the political process. It is not a surprise that one of his heroes is President Franklin Roosevelt, who fought for everyday Americans and believed in the ideals of the United States during one of the country’s darkest times.

When he is not working the advocacy channels, Franco enjoys reading about and watching politics (his favorite book is “Amazing Grace” by Jonathan Kozol and he’s a fan of Netflix’s “The Crown”). His other passions include being a dad to infant son Daniel and traveling. He and wife Amanda took particular delight in taking baby Daniel to Costa Rica. 

At work, he’s looking forward to helping inform more advocates about the political process and how they fit into it. 

“I’m really excited because of the election and educating members about the important voice they have in the discussion and getting big issues across the finish line,” he says.

Resume: 2004, Receives B.A. in political science from the University of Colorado at Boulder; 2010, Earns master of professional studies in political management degree from George Washington University; 2010, Named associate director of advocacy for the Alzheimer’s Association; 2013, Becomes manager of grassroots for Blue Cross and Blue Shield Association; 2014, Begins as vice president of grassroots and internal advocacy for the American Diabetes Association; 2017, Joins LeadingAge as vice president of grassroots affairs; 2019, The Hill newspaper names Franco as a Top Lobbyist.

McGuffey Healthcare & Rehab First, a 209-bed facility in Gadsden, AL, celebrated its longest-serving employee after she officially retired in mid-January. Garrett’s career in long-term healthcare started in June 1965 after being encouraged by a family member. She started as a certified nursing assistant before becoming a licensed practical nurse in October of 1966. She has also served as a charge nurse, nursing supervisor and clinical nurse manager. 

Garrett said she’s enjoyed working with fellow staff members and bonding with residents over the years.

“I really enjoyed the patients,” Garrett told McKnight’s. “They appreciate you and know that there’s someone there that loves and cares for them.”

Garrett’s leadership will be hard to replace, Administrator April Conley said. 

“She’s a great leader and good mentor for the staff that comes on board with us. The love and the affection that she shows our residents [is amazing]. She’s a hardworking, dedicated professional employee and her absence will definitely be felt.” 

— Danielle Brown

Under the Patient Driven Payment Model, nursing homes have a relatively short window to get everything right, and it’s more important than ever to do it right the first time. The diagnosis — and prescribed medications associated with it — must be correct and consistent. If the information is coded wrong, it could put payment, quality and compliance at great risk, experts emphasize. A botched ICD-10 coding means a facility could be stuck with a CMS-assigned default payment rate that could cost the facility over $300 per day in lost revenue.

Through the lens of medication management, diagnoses have not been assigned such a level of criticality as they are now. 

“They’ve emerged as the red-headed stepchild,” acknowledges Marti Wdowicki, PharmD, director of clinical operations for PharMerica, a long-term care pharmacy services company. 

“Prescribers didn’t pay as much attention to diagnoses in the past. It was more a nice thing to have, but optional. There is no real repository accurately linking drugs to diagnoses. And while PDPM underscores the importance of both, we haven’t moved technology along to match it. Now there’s a gap.”

Consequently, problems are resolved retroactively, “but it becomes like a game of whack-a-mole,” Wdowicki adds. “Next time they may know they’re missing diagnoses on transplant patients because they didn’t properly identify transplant medication in time.”

Facilities will need to work more closely with prescribers and pharmacists.“If nursing homes can get more familiar and their prescribers can get more accustomed to providing a diagnosis code when they’re prescribing, then downstream, it makes a lot of things easier for them,” says Stephen Creasy, PharmD., director of clinical services for PharMerica.

Meanwhile, Erin Marriott, RPh, of Guardian Pharmacy Services, believes “a deeper and more efficient medication reconciliation process will be a higher priority over the coming months.” 

As if that weren’t enough, providers now find themselves monitoring critical public policy issues on numerous fronts.

In some respects, these are atypical times on the finance front for the country’s 15,000-plus skilled nursing facilities.

Pressing for most providers is the specter of sweeping oversight legislation that could be enacted before year’s end. Sponsored by Senate Finance Chair Charles Grassley (R-IA), the package reportedly calls for heightened nursing home scrutiny, including more muscle in the survey enforcement efforts.

Grassley acknowledged part of the motivation to ratchet up oversight is driven by ongoing quality issues in the nation’s nursing homes, citing a recent Government of Accountability report of a doubling of elder abuse deficiencies between 2013 and 2017.

These and other developments spurred LeadingAge President and CEO Katie Smith Sloan to warn lawmakers about larger-than-normal numbers of Medicaid shortfalls and facility closures. In a Dec. 6, 2019, letter to Grassley and Sen. Ron Wyden (D-OR, pictured above), she said such developments “threaten the survival of … providers, truly the ‘safety net’ for people who need long-term care.”

More than 500 homes have shuttered over the past five years, including record numbers of rural facilities.

Among Smith Sloan’s recommendations: Allowing SNFs to explore alternative quality assurance measures, including reduced penalties for self-reported deficiencies and more stringent surveyor qualifications and vetting.

Also in late 2019, the provider community learned that a Trump administration rule would endanger Medicaid supplemental payments, which facilities traditionally depend on to shore up financing gaps. The Medicaid Fiscal Accountability Rule would crack down on so-called “impermissible financing arrangements.”

AHCA President and CEO Mark Parkinson said “provider taxes and supplemental payment arrangements both have become very important financing sources for long-term care providers.”

Greystone, a leading national commercial real estate lending, investment and advisory company, has provided a $71.3 million Department of Housing and Urban Development-insured loan to refinance Massapequa Center Rehabilitation & Nursing, a 320-bed skilled nursing facility in Long Island, NY. 

The $71,280,000 permanent Federal Housing Administration financing deal carries a 30-year term and 30-year amortization along with a low, fixed rate. The refinancing enables the borrower to exit initial bridge financing used for the purchase in November 2017, and to continue with large-scale renovations at the facility.

»Berkadia secures over $57 million in SNF financings

Berkadia’s Seniors Housing & Healthcare group announced at press time $57.2 million of loan closings in December for skilled nursing facilities located in Alabama, Illinois, New Jersey, Maryland and Washington.

The company refinanced a portfolio of three skilled nursing facilities in Washington state for $26.2 million, and secured a loan for a 146-bed SNF in western Maryland, utilizing HUD’s 232/223(f) program. 

The third transaction was a $15 million 12-month bridge loan for a portfolio of three skilled nursing facilities in Alabama, Illinois and New Jersey, using its Bridge Lending Program.

»Lancaster Pollard helps SNF obtain permanent financing

Lancaster Pollard, a division of ORIX Real Estate Capital, LLC, reports that it recently assisted Totally Kids Specialty Healthcare to obtain permanent financing for its 56-bed skilled nursing facility in Loma Linda, Calif.

The campus in Loma Linda includes a skilled nursing facility, 25-bed pediatric acute care hospital, intermediate care facility and pediatric day care facility. The organization was seeking long-term financing for the skilled nursing facility component of the campus after completing a bridge loan to acquire the real estate.

»Remedi SeniorCare to open two new facilities in early 2020

Baltimore-based Remedi SeniorCare recently opened its 12th 24-hour, unit-dose medication management pharmacy in Chicago. The 50,000-square-foot pharmacy will employ Remedi’s proprietary dispensing system PAXIT^® and eventually employ more than 200 individuals.

In other news, the company named Michael Hovis, PharmD, as general manager of the company’s Huntsville (AL) Pharmacy as development progresses on the company’s thirteenth location. The 36,000-square-foot facility is scheduled to open in the first quarter of 2020.

»First meds delivered by drone

A retirement community resident recently became part of history as one of the first people in the United States to receive a medical prescription by drone under a program approved by the Federal Aviation Administration.

The resident’s delivery, in North Carolina, was the second revenue-generating drone delivery of a medical prescription from a CVS pharmacy directly to a consumer’s home.

»Seniors use Amazon AI device to manage meds

Some senior living residents and other users of Amazon’s Alexa virtual assistant are now able to review prescriptions and set medication reminders by using their pharmacy prescription information, as well as request prescription refills by voice command, using a new feature the company announced in partnership with Omnicell in late December.

Customers in 229 grocery pharmacies in five states are now using the service.

»‘Dump the fax’: EHR solutions provider

GPM Corp. is appealing to nursing homes to cease the arcane practice of faxing orders.

The company pointed to such wasteful practices as paper, time and maintenance. While a “technically HIPAA-compliant” means of transmitting sensitive information, faxes can and have wound up in the wrong hands, compromising privacy. 

There has been much speculation about how the new system, considered the biggest change for nursing homes since the onset of the Prospective Payment System in 1998, is working, who it is hurting and helping and, ultimately, what the impact is on residents.   

Five months into the program, most consultants and industry leaders were still hesitant to draw conclusions about its success, as of press time. They’re interested in concrete data. 

But they have identified unmistakable signs of success for the nascent program, as well as areas of improvement for providers going forward.

They also offered plenty of educated guesses on how the Centers for Medicare & Medicaid Services might tweak the program in the days and months ahead.

What’s to come 

One of the biggest questions in the first quarter of 2020 is what will CMS do next? The agency aimed for the program to be budget-neutral. If providers end up billing more than CMS anticipated, then a rate recalibration could be in order.

The agency has turned its razor-sharp gaze to how much therapy providers are giving under the new system. 

“CMS is monitoring the implementation of the PDPM, including the therapy service provision, as compared to RUG-IV, at the national, regional, state and facility level,” an agency spokeswoman said. “Significant changes in the amount of therapy provided to SNF patients/residents under PDPM, as compared to RUG-IV, or the manner in which it is delivered, may trigger additional program reviews and potential policy changes.”

CMS already has given providers a head start on what is to come with its first draft of the 2020 MDS item sets released at the end of 2019. In this draft, it eliminated Section G of the MDS, which essentially is a duplicate of the newer Section GG. Both measure the functional abilities of the resident, specifically in the areas of self-care and mobility. The draft is set to become effective Oct. 1, 2020.

“They gave us a heads-up with a lot of lead time,” said Cynthia Morton, executive vice president of the National Association for the Support of Long-Term Care. “It was a little bit of a gift that they went and signaled that.”

Experts anticipate other tweaks to the program, such as fixing some gaps between ICD-10 and PDPM language. 

‘Most important data set’

Beyond regulatory changes, leaders in the industry were waiting for other types of information to gauge the new program: earnings reports from publicly traded companies and patient outcome data. The latter will reveal how successful the program really is, they say.

“That’s the most important data set,” said Mark Parkinson, president and CEO of the American Health Care Association, who has praised CMS for the policy underpinnings of PDPM and the rollout. “If CMS needs to make changes on the revenue or other side, we’ve got to have patient outcome data to know what the logical changes will be. We’re going to have to be patient.” 

Morton agreed: “What’s most important to me is how the patients are faring under PDPM. Let’s keep the patient foremost here. That’s really why we changed to PDPM.”

A new world order

PDPM, which replaces the RUG-IV case-mix classification system, not only has offered a different payment system for nursing homes regarding Medicare Part A residents but also has ushered in a new approach to residents’ clinical needs. The old system tied therapy volume to payment, incentivizing providers to provide as much therapy as possible. The new system throws out the volume threshold and instead links payment to specific patient characteristics, elevating nursing to a new level. It also calls for fewer resident assessments in an effort to decrease the administrative burden on nursing homes.

Education has been the key to success under this new model, experts maintained. “I certainly think the folks who were able to think through training, education and operational workflow within their organization are well-prepared,” noted Tim Ashe, chief clinical officer of WellSky, a post-acute and community care technology company based in Overland Park, KS.

This new worldview represents the continued push by CMS toward a holistic, versus a siloed, approach to care, according to Renee Kinder, MS, CCC-SLP, RAC-CT, vice president of clinical services for Broad River Rehab,  Asheville, NC. Those facilities that adapted to this perspective have adjusted better to PDPM, she said.

“It moves to a payment system that looks at the person or beneficiary and their clinical presentation,” she said. “It’s been an overarching cultural change.”

NASL’s Morton echoed that idea. “Therapy and nursing have to further work together and talk to each other,” she said.

Prior to PDPM, the two clinical areas were separate domains. “Nursing has had to step up a little bit under PDPM,” she noted. “There is more ability to skill the patient from a nursing point of view.”

The move to PDPM has been a learning curve for many providers, asserted Ron Orth, RN, CMAC, CHC, post-acute care curriculum designer for Relias, a healthcare education firm. Specifically, people are having a hard time adapting from the RUG rules, which were the law of the land for more than 20 years.

Among the major adjustments under PDPM: fewer resident assessments. “I think people struggle [with the fact] that the IPA [interim payment assessment] is an optional assessment,” he said. “They are so used to doing an assessment when there is a change in therapy. It’s like, no, you don’t have to schedule an IPA. You may just do one assessment for your entire stay, and that’s OK.”

Reimbursement concerns

The new system is an improvement over RUG-IV because it puts the resident, versus therapy, back at the focus of reimbursement, Orth observed. Under the old system, two residents who came in with hip fractures might qualify a facility for the same reimbursement. Not so under PDPM, which looks at more clinical factors about these two residents and how a facility may be expending more resources on one resident compared to the other based on these clinical factors.

“This is the beauty of this new payment system,” he said. “It really does take into account resident characteristics that increase resource consumptions.”

As a result, an understanding of the resident’s clinical profile is imperative from a reimbursement perspective. 

“Facilities that will fare better under the new system are getting all the appropriate documentation from the hospital or even from the primary care provider, as far as what are all the medical conditions that his resident has,” Orth said. “What has their history been? Those comorbidities can certainly lead to better NTA [non-therapy ancillary] scores, which equate to higher reimbursement.”

Zimmet Healthcare Services Group, a consulting firm for post-acute providers, was set to release its second analysis about PDPM as of press time. In its first analysis, released in November, it found that providers on the whole were collecting slightly higher reimbursements under the new system. 

But it also pointed out some areas where providers were missing out on reimbursements. Among them: accurately coding for swallowing disorders, shortness of breath, lying-flat assessments for COPD patients, and one-time revenue codes associated with NTA drivers. Another area where some facilities lost dollars, at least in October, was in coding for depression.  

Therapy in the spotlight

One of the major stories generated from the new payment model is CMS’s new treatment of therapy and therapists. CMS has granted providers increased clinical freedom around modes of treatment to increase efficiencies and reduce staffing. Because providers were planning to implement more group and concurrent therapy versus individualized therapy, word of therapist layoffs reverberated across the field. Genesis HealthCare, one of the country’s largest nursing home chains, confirmed that it eliminated 499 positions — not 585, as it initially said.

While the extent of the layoffs is still unclear, Morton, who believes some of the news reports regarding layoffs are exaggerated, argued that rehab is still an essential part of getting a resident well — and CMS knows that, too.

“Some of the CMS policy seemed to de-emphasize [individualized] therapy and more opportunity to provide group and concurrent therapy … but at the same time, CMS made it very clear that if a patient needed so many minutes under RUGs, CMS expected the same amount of care to be provided under PDPM and quality measures,” Morton said. 

That’s fantastic news, but it ignores one of my fundamental beliefs: that smartphone use is dementia, on a global scale. 

The irony is that our phone addiction is making us crazy as a civilization and species, but in our demented state, we think the disease is the cure.  

For instance, the mindfulness practices that are supposed to help us get off our smartphones and be truly present in the moment are delivered by, you guessed it, apps on our smartphones. 

That’s why whenever I walk into a nursing home and see staff bustling around, something feels oddly amiss. It takes a second, but then I remember what’s different: No one is on their phones.

They aren’t staring at their thumbs, scrolling their feeds, or taking Boomerangs of toasting wine glasses. No one is cackling at a meme, tapping the perfect emoji or pursing their lips into Instagram face. They’re simply doing their jobs and actually making eye contact with real people. It’s a little weird — and blissful. 

It makes me think maybe I should become a CNA, med aide or any direct care worker where phones are mostly required to stay out of sight. I’d actually like to be frisked at the door and have it forcibly removed, but I haven’t found a long-term care setting yet with a policy quite that idyllically draconian. 

As with anything important in life, it takes Mr. Rogers to cut right to the core of the problem and offer a solution. “I feel so strongly that deep and simple is far more essential than shallow and complex,” he was quoted in a recent documentary. 

Shallow and complex is the definition of our smartphone obsession. 

But whenever we can simply look up from our devices, we’ll notice, perhaps even deeply, that it really is a beautiful day in the neighborhood.

— Shilpi Chona, Administrator, The Grove of Evanston, Legacy Healthcare, Evanston, IL 

“CNAs. They are the backbone of the facility. They are the eyes and ears for the residents. Nurses cannot function without them. One week a year is not enough recognition (for CNAs). If families praise someone, we let them know. They’re there every day for the right reason.”

— Robin Lambert, Administrator, Johnson County Health and Rehab, Clarksville, AR

“In some ways, management. I can see it in survey on resident and employee satisfaction. There’s a lot of people who don’t understand what management does, nor how we do it. They think we sit in the office with our feet on our desk all day. I see it year after year on surveys. We need to do a better job of communicating what we do.”

— Michael O. Feltes, MA, LNHA, Executive Director of Support Services, Dow Rummel Village, Sioux Falls, SD

“IT tends to be in the background. We’ve accepted that. When we interact, there’s usually something wrong or they need something. Front line staff also are so needed. They have such a direct impact on results, so it’s good to focus on them and make their lives a little easier.”

— Dave Anderson, IT Director, AMFM, Charleston, WV

“In my building, my housekeeping department, day in, day out, is doing the brunt of the work, cleaning the filthiest of rooms, dealing with family members who come in yelling. A clean room is the first step in a resident’s journey to recovery and health.”

— Scott Morton, Administrator, The Grove, LaGrange Park, IL

“I always believe the activities director has a phenomenal ability to change the tone in a building beyond taking care of residents like doctors and nurses do. It can be massively impactful for employees, as well as residents. Employees like people being happy and not frustrated. Activities [employees] bleed into everything and can bring things up a notch.

Another one is the MDS coordinator. There are a tremendous number of nurses in the building who underestimate the work done by the MDS coordinator. Other nurses don’t always get that.”

— Kyle Romano, Administrator, Blair House, Milford, MA

“The man” — in this case Uncle Sam — often does come after you. Usually the reason given is it’s for the greater good. But sometimes credit must be given where credit is due.

The Patient Driven Payment Model has been an industry obsession for about two years, and rightfully so. Some good news is the Centers for Medicare & Medicaid Services got out in front of this potential mess and successfully educated providers. 

What ensued was largely another Y2K. In other words, no end of the world. In fact, with all due respect to some who saw their workloads lightened or even eliminated, the system seems to be working well overall. At least that’s a presumption from the lack of shrieking we’re hearing.

But the itch to fully evaluate it, even after about four months in play, still can’t be scratched, no matter how hard one wants to.

Sure, preliminary numbers looked good for many operators, but as of press time, we were all waiting to see what the big players would reveal at their quarterly earnings calls. 

Grandma could be doing well with solid clinical outcomes (undoubtedly the most important statistics), but if Nursing Home Inc. isn’t doing more than just staying afloat, nothing else matters. The second part of healthcare may be care, but the real first part is really “health of the business.” 

CMS met the PDPM challenge head-on and gave providers about as straight of language and instructions as can be expected from such a tentacled body. 

Opportunities have blossomed for proactive providers, and reimbursements have flowed accordingly. Operators have expanded care offerings in many instances. More segments of the LTC workforce are relishing their roles in helping determine their employer’s fate. Cue the slideshow about how more-engaged workforces are so desirable.

It’s not a one-size-fits-all approach that suits everyone perfectly, and there will be some payment take backs eventually, most analysts seem to agree.

But there also has to be agreement that CMS did an awful lot right this time.

Imagine if a person stopped you on the street and said this:

“I want to rob your house. The government says I can borrow your house keys, so hand them over.”

Forking over those keys would be just about the last thing any sane person would be inclined to do. But for the past five years, nursing home operators basically have had to do just that.

That’s because until the National Labor Relations Board came to its senses in December, operators (and all businesses, for that matter) were required to let employees use company email for union-related activities, including organizing. And no, I am not making this up.

There’s no need to cite the myriad reasons why a union shop is an undesirable thing from a management perspective. So I’ll just point out the most obvious one: It makes survival in a tough business that much more difficult.

Is politics involved in last week’s reversal? Of course. Republicans now control the NLRB. It’s no coincidence that the board has taken a pro-business stance since that happened. Just as the NLRB had a decidedly pro-labor bent when Democrats ruled the roost. So yeah, there’s that.

And to be clear, I grew up a child of immigrants. My father was a union guy to his core. His membership in the International Union of Operating Engineers was a major reason why he remained employed for most of his adult life. I don’t have a beef with unions. They have done and continue to do many noble things for workers.

But to me, this issue transcends a binary divide. It’s simply wrong to force a person or company to do something that might lead to ruination. And that is what a mandate to help unionization activities (by providing hardware and software that aids in the effort) has been accomplishing here.

Is my proud-to-be-a-union-member father spinning in his grave right now? I doubt it.

Yes, he believed in unions. But he also believed in common sense.

The provision in place for the past half decade served the former at the expense of the latter.

He might have agreed that the NLRB’s reversal on this issue was way overdue.