Kimberly D. Green, Chief Operating Officer, Diakonos Group

It’s not always easy for healthcare workers to continually walk in the proverbial shoes of the resident. But for Kimberly D. Green, losing sight of the resident is an outright impossibility.

She’s a medical speech language pathologist and Medicare and reimbursement specialist who also has more than 30 years of experience in other healthcare roles, from nursing assistant to provider to contractor to corporate executive.

On March 15, 2011, a horrific car crash landed Green in the role of patient. On the way home from a family vacation, a tractor trailer collided with the truck she was traveling in with her two school-age daughters and her then fiancé.

To the amazement of Oklahoma highway emergency crews, her family escaped the accident virtually unharmed, but Green suffered life-threatening injuries: a femur and pelvis fractured in three places, a hip broken in two places, a broken sternum and hand, fractures to every rib, a lacerated liver and collapsed lung, a cut cornea, third degree burns over nearly half her body, and a traumatic brain injury.

The odds weren’t in her favor and her grueling recovery involved a 10-day intensive care unit stay, numerous surgeries, five months of daily deep wound care to save her arm, and countless hours of therapy.

“Aside from being in the worst pain of my life, I was grieving my loss of independence,” recalls Green.

The brain injury caused aphasia for a period and took her longer to process thoughts and responses. “I saw how uncomfortable some people become when you don’t respond correctly or [in a normal timeframe]. They smile, politely touch your arm and say, ‘Good to see you,’ before walking away. I felt like the world was leaving me behind, and that’s how many of our patients feel every day.”

Pain as a teacher

Following her hospital stay, Green spent a month in an in-patient rehabilitation facility. She experienced firsthand the challenges of being on the receiving end of therapy and how it seemed easier some days to throw in the towel than experience the physical and emotional pain, exhaustion and frustration.

“I thought of the therapy patients we worked with who were in terrible pain and I realized my perspective as a patient would make me better professionally.”

Following her rehab hospital stay, Green was sent home with what amounted to a single home health rehabilitation visit. “They said I was young and had family to support me, so they left my fiancé with a packet of exercises and never returned,” she recalls. “It was absolutely terrifying. I was non-weight bearing on my upper and lower body for five months.” She relied on her fiancé for help with virtually every physical task.

She also leaned on her therapist friends who helped with electrical stimulation, gait training, ultrasound and more. It was nearly a year before she could walk without an assistive device and perform other activities of daily living without help, such as showering, dressing and toileting.

Therapy continues today, as needed. The corneal injury left her legally blind in her right eye and she still experiences short-term memory loss, which she manages well with compensatory strategies.

New beginnings

On March 30, 2013, one year and 15 days after the accident, she and her fiancé married, and the following year, Green gave birth to another healthy daughter, despite being told she would never be able to carry another child due to her accident injuries.

Her other “baby,” her beloved career as an educator and consultant, kept her ingrained in the profession she loved. Then a visit from Scott Pilgrim, owner and CEO of Diakonos Group LLC, while Green was on maternity leave led to an offer she couldn’t refuse: serving as the company’s chief operating officer.

Today, in addition to managing operations for the company’s 20 buildings, she also runs Diakonos Group’s consulting division, Senior Health Strategies, where she consults and educates on Medicare, RAC, RUG-IV/MDS 3.0, restorative nursing, dementia management, rehabilitation, senior mental health and long-term care.

“Kimberly is absolutely dedicated to improving our profession. She could have easily stayed in her path as a consultant, telling others what they should do … but she chose the far more difficult path of becoming engaged in actual operations,” says Pilgrim. “She invests herself personally in improving the lives of our direct care staff.

Green is actively involved in healthcare associations in her home state of Oklahoma. She currently serves on the board of the Oklahoma Health Care Association and the Mental Health Association of Oklahoma, and on the Housing Committee, Aging Taskforce and the Board Development Committee for the Mental Health Association of Oklahoma.

She wrote a restorative training program and manual for Oklahoma, Georgia and Nebraska healthcare associations, and continues to teach restorative classes for the three states. Beyond that, she passionately advocates for the profession at the national and state level, speaking with legislators on the needs and funding for geriatrics and mental health.

“Kimberly is a visionary and her steadfast devotion to long-term care is extraordinary. She always had this tremendous talent and persistent desire to touch everyone in our industry through her inspirational stories of courage and leadership,” says Mendee Rock, vice president of membership services for the Georgia Health Care Association. “Kimberly has taken her own story of her remarkable journey of recovery and all the people who tirelessly cared for her along the way to affirm that we all possess within ourselves the ability to choose to step forward, embrace challenges and make a significant difference in the lives of our residents and colleagues.”

Alive Day

Green calls the day of her accident her “Alive Day” and openly reflects on it each year. She does this not to relive the painful details of the accident but to remind herself of all the blessings from that day – from surviving what many would consider an unsurvivable accident to the enlightenment and perspective gained from becoming the patient and experiencing firsthand the challenges, frustrations and growth that can be associated with it.

She credits seatbelts for saving her and her family’s lives. She adds that her Christian faith and the love and support she received throughout her recovery helped her see the bigger picture: how beauty and unique perspective can come from life’s most difficult experiences.

“I’ve been on so many sides and have gained so many different perspectives,” she says — from nursing assistant to therapist to consultant/educator to executive and, of course, patient.

“I always wanted to be a positive change agent and that desire is even more intense today. I have all these different perspectives that have made me better, and I can use that to make a positive difference.”

Resume

1994

Completes Bachelor of Science degree in medical speech language pathology from Northeastern State University in Oklahoma

1995

Earns Master of Education degree in medical speech language pathology from NSU

1995

Serves as a clinical specialist for Rehabworks 

2003

Joins Peak Medical Corp. as VP of rehabilitation services 

2005

Becomes COO of Summit Rehab LLC

2008

Serves as CEO/owner of Eli Healthcare Consulting until 2013

2009

Joins Kissito Healthcare Corp. as SVP of post-acute services 

2013

Becomes COO of Diakonos Group LLC

2016

Earns Tulsa’s Women of Distinction award 

2019

Appointed to the Long Term Care Advisory Group by the Oklahoma Speaker of the House 

 Last summer, the Friendly Painters group was having a hard time finding subjects to practice its portrait painting. Marian Neumann — the mother of one of the organizers and a resident at Friendship Village — suggested they use residents at the Schaumburg, IL, community as their subjects.

 “She said it would be an opportunity for them to do something fun that they’ve maybe never done before while earning a little bit of cash,” says Kathy Smith, Neumann’s daughter.

 The partnership has flourished. Each week, Friendly Painters visits the continuing care retirement community to paint a new resident. They’ve depicted more than 20 so far, paying each model $30 for around three hours of his or her time.  

 Each subject sets up in the community’s perfectly lit Wintergarden room, situated off the main lobby. Often, curious onlookers will pass by and end up volunteering for a future session.  Donna Brown, lifestyles activity manager for Friendship Village, says the partnership has been a big hit thus far.

 “It makes the residents feel special and like they’re one of a kind,” she told McKnight’s. “It’s fun to be immortalized.” 

RUG-IV mandated at least five assessments over a 90-day stay, but under PDPM many patients will need just two: an initial MDS completed within eight days of admission and a resident discharge assessment tied to the last day of stay.

“Under RUG, it was a lot of work,” says Elisa Bovee, vice president of clinical strategies for HealthPRO Heritage. “It’s intensive, and payment could be adjusted at those pre-set times based on therapy minutes or therapy type changing. Now, looking at skilled nursing, it makes more sense to provide a consistent rate that recognizes the level of skilled care and the consistency with which it is provided throughout the stay.”

It’s a logical shift when considering industry-wide pressure to decrease lengths of stay and the Centers for Medicare & Medicaid Services’ own proclamation that PDPM will improve the appropriateness of payments and reduce administrative burden.

While it may seem there’s less data to be collected, the opposite may be true.

Providers must be more accurate with the patient information they collect in the initial MDS and the medical record; more intentional about monitoring it internally; and more in-tune to changes that could precipitate additional communication with CMS to earn appropriate reimbursement.

“MDS now is going to basically allow you to paint a picture of the patient from a clinical perspective,” says Sherri Robbins, senior managing consultant with BKD’s healthcare group. “Every part is going to be more important than before, not just for Medicare reimbursement but for clinical outcomes. Under PDPM, leaving one thing off Section K or Section I, for example, it can really impact your ability to care for the patient.”

First look is key

The initial five-day assessment still hinges on the MDS, but providers who view the assessment tool the same as in the past are taking a risk.

“We have to step back,” says Mike Capstick, founder of Select Rehabilitation. “For 90 percent of patients, it’s been Section O or Section G that have driven payment … We’re going from roughly two sections to 11 or more.”

New MDS items under PDPM will include Section I for a primary SNF diagnosis, Section J for surgical history and a new column in Section GG to track interim performance. Other MDS items link specifically to payment for the first time, including Section K for swallowing disorders and other speech-related services and Section I’s addition of ulcerative colitis, Crohn’s and inflammatory bowel disease.

Staff also will need to be keyed into all the comorbidities and services that determine an individual’s case-mix. Once it’s set, there’s no way to add or adjust resident characteristics unless a resident has a significant change in status.

“Everybody agrees you will have to take your time, ensure that you have researched all diagnoses, all conditions, and be assured that the MDS is scored appropriately to ensure you get those monies that are due to you based on the services you will be providing,” says Nancy Losben, R.Ph., Omnicare’s senior director of quality.

Capturing the primary diagnosis likely will be difficult for many facilities, says Rosanna Benbow, RN, owner of Leading Transitions Post Acute Care Consultation and Staffing.

“Getting a comprehensive background on a patient is going to be the hardest part,” she says. “I think a lot of providers need to shift their pre-admission assessment process to clarify what they’ll be doing and who will be communicating with the hospital or the community physician.”

In some cases, two conditions, such as an elective knee surgery and an infectious complication,  may compete for the primary ICD-10 code. Working as a team, staff will have to determine which of those diagnoses would most accurately reflect the services needed by that resident and the resources that he or she will require.

Although CMS estimated in its proposed rule that a provider would save 183 MDS hours annually with fewer assessments, most MDS experts will take on new responsibilities, experts predict.

In addition to becoming puzzle-solvers, MDS coordinators could be assigned more time working directly with residents in a clinical capacity. Benbow predicts many buildings will ask MDS nurses and unit managers to perform hands-on assessments regularly, and some larger buildings should consider scheduling changes to ensure more MDS coverage.

“We’ve seen lost reimbursement before with agency nurses because of staffing shortages,” Benbow says. “Providers need to figure out now who is going to be doing all of the information gathering, coordinating with physicians to spot infection and hypertension issues, and making sure the coding and the documentation match.”

Interim opps

The Interim Payment Assessment remains the least understood new patient measure. Many providers said they were hoping the new Resident Assessment Instrument, expected by May, would put specific parameters around “optional” submissions.

“The premise of doing a significant change is a review of the patient because medically, something has happened, so they would have additional need for therapy,” Bovee says. “The trick of it comes into play when talking about who is monitoring patient information and how the case-mix works as far as using nursing and NTA [non-therapy ancillary] services.”

For now, providers are split on whether a status change will be tied to a resident’s primary diagnosis or whether the IPA could be completed if a resident needs more assistance with ADLs or new therapies.

Current language also doesn’t make clear whether providers should file for significant improvements in a resident’s condition.

“The word ‘optional’ from CMS always concerns me,” Capstick says.

He notes that under the RUG Change of Therapy policy, facilities that failed to report changes for patients not classified in a RUG-IV therapy group — a supposedly optional window — still sometimes found themselves paying back Medicare.

Staff given the responsibility to order IPAs need to know when they would be advantageous and to make sure any observed change in status is reflected on the corresponding MDS.

Although no one is certain how often IPAs will be justified, Benbow predicts filing more than the industry norm will bring scrutiny.

Discharge data

The fact that discharge assessments aren’t tied directly to payment shouldn’t influence how they are handled. Data will drive quality-reporting metrics and Five-Star ratings, and it will provide another opportunity for self-measurement.

Capturing how well your patients do — including functional and cognitive improvements and the prevention of decline for complex patients — will offer a competitive boon and be a tool for partners.

“PDPM doesn’t just exist in a vacuum,” says Scott Rifkin, owner of Real Time Medical Systems. “There are all of these market forces that hospitals are bringing to bear on every provider now.”

Discharge data also could eventually be used to inform a unified payment system. For the industry’s sake as well as that of individual operators, it’s important that providers accurately capture what works and what doesn’t.

“We want to make sure CMS has an accurate picture of what patients are doing and how we’re serving them,” Capstick said.

IS SOFTWARE THE ANSWER?

In response to the question posed in the title above, there is clearly a camp that says yes.

“There will be much greater pressure on providers to collaborate sooner about a patient’s needs and establish the care plan correctly from the start,” says Rita Cole, Optima Healthcare Solutions’ clinical director. “This will require software resources and business intelligence tools that can support greater communication between multidisciplinary team members and suggest the appropriate care plan for each individual patient.” 

Analytics will be increasingly important as SNFs try to spot diagnostic oversights, track patient conditions and attract new partners under PDPM.

“In the past, there was critical information in the medical chart that did not make it into the MDS,” says Mike Capstick, whose Select Rehabilitation has developed an online portal with optical scanning technology to read hospital, facility and therapy documentation to assist the MDS coordinator under PDPM. 

But how much of a voice should it be given in helping with actual MDS coding?

“Software can be useful in making sure an ICD-10 maps to a clinical category rather than return to provider,” says Sherri Robbins of BKD’s healthcare group. “That being said, the staff at the facility level are going to need to learn to code to the highest level of specificity for success under PDPM.”

As a one-time medical director and former owner of 21 skilled nursing centers, Scott Rifkin notes people play a powerful role in making software helpful. Make arrangements now to get physicians more involved so that they too can spot pathways to disease and add notes that other clinical staff might miss, he adds.

“If you can team them up with good data, mining the charts and the MDS, then you’ll be successful,” he explains. “It will pay for itself.”

Rifkin, owner of Real Time Medical Systems, says electronic medical systems and analytic capabilities will become more important once 14-, 30- and 60-day assessments end. Real Time, a Medline partner, runs automated keyword searches three times a day to warn of changes in status that could follow on the heels of chest pain or diarrhea.

“If you’re just using MDS-based data, and not accessing the data in your EMR, you’re literally leaving tens of thousands of dollars a month on the table,” Rifkin says.

And no wonder. Data and everything it represents affects and controls virtually every input and output inside a facility.

Nursing homes acknowledge the power of that information and the responsibility they have to manage it well so everything from rehospitalization rates to receivables stay low and Five-Star ratings and lengths of stay remain appropriately high. The tasks of herding and analyzing all of that data and working with IT partners, therefore, are as critical as ever.

Culture shift

The digitization of data may have occurred years ago, but only recently have nursing facilities begun to truly grasp its importance.

“Post-acute care has come a bit late to the data gathering and analytics party and [we] are only in the early stages of learning how to use our data to create value,” says David Carter, post-acute care advisor to the Stratus Interoperable board of directors. “All roles are changing across the organization — a kind of cultural shift that will enable everyone to use data to drive better performance.”

Experts agree the size of a skilled nursing facility, the depth of its staff and whether it can tap into the vast resources of a chain usually determine how data is managed internally.

Whatever the internal structure, Carter believes coordination is key. “It’s going to take an ‘all-hands-on-deck’ and an aligned effort across all financial, clinical, operations and technical stakeholders to make the shift from volume to value,” he adds. “Senior teams must move quickly to ensure the organization as a whole works as a cohesive unit to facilitate the transition to data-driven performance.”

Here’s how experts view key internal stakeholders’ roles.

Chief financial officer

As the title implies, CFOs are typically responsible for all things financial — from labor costs and their relation to scheduling, receivables, expenses, revenues and profits. CFOs also typically should sit on business intelligence committees to evaluate investment performance, observes Brian Dimit, vice president of professional services for CareServ. 

Chief operating officer

COOs are typically concerned with data related to regulations. For example, a COO may need to identify metrics within nursing and how they relate to government regulations such as census, per-patient days, scheduling, readmissions and hospital leaves, says James Stormoen, vice president of client solutions for vcpi. 

Their role is essential in ensuring the “stickiness” of data and analytics at the operational level, says Status Interoperable’s Carter, adding, “they need to make sure that data and analytics are ‘hardwired’ into the daily work flow and that team members are obsessed with moving the dial on the delivery and the quality of care every day.”

Chief executive officer

Two words: big picture. “They’re concerned with overall vision and strategic metrics such as trending, market and competition and how the data gets used,” says Stormoen.

Chief nursing officer

Some would argue that CNOs are rising figures in the internal data hierarchy — and for obvious reasons, around outcomes and quality. They also can play a vital role in business intelligence. 

As Dimit argues, “A CNO provides clear definitions of business rules for data and verifies any differences between facilities to ensure there is consistency in what is being measured.” 

Adds Jayne Warwick, director of market insights for PointClickCare, “The CNO aggregates clinical outcomes. Such data can speak to the effect of corporate policies and procedures on a facility’s clinical and financial performance.”

As critical as these roles are, some believe data management should not be concentrated solely in the C-suite.

“Data doesn’t just belong to the top tier, but all levels of care should be leveraging the power of data to affect change,” says Warwick. Rob Price, senior product manager for MatrixCare, agrees. “All levels of SNF leadership play a role in the successful creation and usage of analytics to help drive success in the organization.”

Multiple stakeholders have a shared interest in analytics and outcomes within the SNF, argues Kelton Swartz,  senior solution strategist, post-acute analytics and intelligence for Cerner.

“These and other interested parties should collectively review analytics daily and collaborate on areas where there are direct influences on the goals and thresholds that are either met or not met through the data,” Swartz says. 

“While the CNO may focus on referrals and key clinical outcomes, the CFO may have a vested interest in assessing the cost of care. Yet, both want to know how one impacts the other so that these outcomes can also be shared externally.”

Make sure that there’s a high-quality framework for data collection and dispersal, advises Netsmart’s Dawn Iddings, the senior vice president and general manager for post-acute.

“A data collection and presentation process that lacks structure will result in inconsistent values and interpretations,” she explains

Nurse leaders also may want to invest in real-time data platforms to improve quality measures. That also allows more flexibility to zero in on a particular issue, and discuss whether practical interventions are successful.

Who owns analytics?

Solid arguments are made about the division of labor when it comes to managing data internally. Still more are made about the need for a point person.

In smaller facilities, the job often falls on the shoulders of the one individual “who’s most proficient with Microsoft Excel,” observes Price. 

“For multi-facility operations then, the ugly job of compiling that data into something usable across the organization begins, as the data is mashed up and summarized, perhaps with a visualization that helps important trends stand out,” he says. “This process is laborious, prone to human error and difficult to repeat on a frequency greater than a few times per month.”

“You could draw a graph about anything but that doesn’t make it meaningful,” says Cheryl Field, chief product officer for PrimeCare Technologies. “Of course, an analytics person helps to visualize the data and bring it to life and tell a story.”

No doubt a skillful analytics person is invaluable. But consider the role of a chief information officer. Likely the closest any “C” title comes to being the “Big Kahuna” of data, the CIO corrals, or aggregates facility-wide data, and in general, is responsible for coordinating and disseminating, says Stormoen. CIOs also are likely to know more about the right platforms and the various inputs and outputs of applications.

Whoever wears the title, “when multiple functions are using the same data, an organization needs a ‘data quarterback,’” says Justin Silver, executive vice president of corporate development for ABILITY Network. This role ensures that data is aggregated and organized so that it can be analyzed and deployed in a meaningful way across areas where action is taken based on these insights, such as clinical and finance, he adds.

Price agrees. “The CIOs I’ve spoken with are the primary stakeholders who rely upon the analytics and data access services that we provide,” he says. “They are managing inbound requests for information that spans the enterprise and must be aware of which vendor or internal tools to deploy for an answer.” The CFO, CNO, DON and other leaders in the SNF, meanwhile, all contribute to the stream of needs that are serviced by the CIO’s ability to deliver information at the right level of detail, in the right format and at the right time.

A group effort?

This speaks to what all IT vendors believe: Ownership is one thing, but the management and use of data is a group effort.

“Everyone is using data today to drive decisions and nursing home staff continue to struggle with just the language of analytics,” says Field. 

With so much emphasis today on outcomes and resident care, quality assurance committees are a logical place for control to be centered, she adds. 

“There is accountability for outcomes, measurements, acknowledging and going through the steps around QAPI,” she explains. “An organization is always looking at outcomes and ways to improve in the future. This is the stuff so many internal metrics people use.”

Silver also believes analytics can thrive as a group effort.

“Leadership must play a key role in setting the overall analytics strategy and prioritizing the area within an organization, but analytics needs to be owned where the insight will drive the action,” he says. “For example, clinical leadership should own quality analytics to drive improvements in quality of care, finance should own analytics to drive revenue cycle improvements and business development should own comparative analytics for marketing insight.” 

Point person with vendors

When it’s time to go out and find the right data analytics partner, who should take the lead with vendors when it’s time to “talk shop,” or make purchases?

Some say it’s the same individual many identified as the “owner” of analytics.

“Finding a data analytics partner should be led by the information technology staff, since the nature of this process is the purchase of technology,” says Doron Gutkind, chief software architect for LINTECH. He adds, however, that clinical, financial and operational business users should be an integral part of the process because they can evaluate whether the technology fits or the partner has any experience with their line of business.

Still others favor the group approach.

“Avoid making a siloed decision,” counsels Iddings. “Ensure that a collective voice, including total consideration of meeting clinical, operational and financial requirements, is part of the final decision.”

I doubt the R in R.E.M. stands for rehab, but that rock band spoke truth with the song, “Everybody Hurts” in 1992. Experiencing physical pain is clearly disclosed in the fine print of being human, and I’m convinced understanding that is what makes a good therapist. 

A few months ago, a neck injury forced me into the ranks of those “everybodys.” Mine wasn’t the kind of pain that’s easily squashed with a couple of Advil. This was deep and soul-shaking, making me think back with bittersweet wonderment to the last day I spent without it. 

After a gauntlet of tests, and being unsuccessfully stabbed, kneaded and twisted by an acupuncturist, masseuse and chiropractor, my ticket was finally punched for out-patient treatment in a post-acute rehab facility. 

It’s been a strange and sobering feeling to receive care alongside elderly long-term care residents. Once, as I lay face down and motionless, doing a neck stretch off the end of the therapy table, an anxious fellow patient asked in a shouted whisper, “Is he okay?” I twitched a leg to prove I wasn’t dead, and expressed appreciation for his concern. 

Over time, as my own pain has subsided, I’ve paid more attention to the far greater struggles of those around me — and especially to the empathic skills of their therapists. Though the therapy team is young compared to my fossilized self, they seem preternaturally blessed with deep compassion for what others feel. 

Maybe it’s simply the wisdom gained from working with different ages, conditions and levels of pain. But they always seem to know just the right approach, the right push here, the right pause there, to help these hurting people achieve far more than they think they can. And it all appears rooted in understanding the universal human experience.

The recognition that pain is something we all share allows therapists to connect and achieve something astounding and beautiful. Because everybody hurts. 

Therapists have been squirming plenty ever since the Patient-Driven Payment Model came out. Now comes research that adds a few more porcupine quills to the discomfort.

squirming plenty ever since the Patient-Driven Payment Model came out. Now comes research that adds a few more porcupine quills to the discomfort.

Scientists have released results questioning the use of productivity goals. The implications, to put it politely, are not good.

The major finding is that physical therapists whose employers emphasized productivity goals over evidence-based practice were six times more likely to report “high frequency of observed unethical behavior.”

Overall, 89% of the 3,400-plus respondents said they observed unethical behavior of some kind. On the plus side, most (69%) reported it happening “rarely” or “never.”

Skilled nursing respondents were the biggest sub-group (754) of respondents — and were worst in every category. Clinicians in SNF settings were four times more likely to report high frequencies of unethical behavior than all other settings, said lead researcher Justin E. Tammany, PT, DPT, SCD, MBA, an assistant professor of therapy at the Holland School of Mathematics and Sciences at Hardin-Simmons University.

Tammany said he hopes that shining a light on the results will help eradicate questionable practices.

“It’s kind of the dirty little secret that everybody knows is going on,” he told me. “But clinicians are feeling powerless to do anything about it. Maybe it will help with some data on it.”

Three-fourths (74%) of all respondents had a formal goal set by an employer. That meant measurements by units-per-billable hour for 85% of them. Moreover, 83% said that productivity goals influenced their clinical decision-making.

Tammany said he wanted to get findings out in the open before the Patient-Driven Payment Model goes into effect October 1. PDPM, of course, eliminates therapy being paid by the minute, something Tammany said has compelled a lot of bad behavior.

Heads must be nodding about the study throughout the halls of the Centers for Medicare & Medicaid Services.

“Part of the issue is anytime reimbursement changes, we come up with a new rate and fudge data or do a workaround to increase reimbursement,” Tammany explained. “It would be a great thing when that’s not an issue any more and there’s more of a push for quality-based reimbursement.”

The billionaire investor Warren Buffet famously refused to time the stock market. His rationale: Nobody really knows what the future will bring.

But that keen insight hardly keeps the rest of us from trying to handicap the road ahead.

Take the future of skilled care. These days, it appears both the optimists and naysayers are in ample supply.

Among the prosperity-is-just-around-the-corner crowd, several talking points are now in vogue. Among them: Skilled care’s limited supply makes it less vulnerable to the ugly downside of careless capital; operators are going to make a killing under the new Patient-Driven Payment Model; skilled care has always found a way to survive, if not thrive; and of course, the coming Silver Tsunami — which will harness the power of sheer numbers to help every facility succeed.

Then there are the downers. To say they are not bullish on skilled care is like saying Michael Cohen probably won’t be getting a holiday card from the White House this year.

Why are they so negative? Let me count (some of) the ways: Skilled care’s housing stock is aging and cumbersome; nobody wants to be placed in a skilled care facility; it relies too much on rehab; PDPM may actually reduce payments; and home care, assisted living and other alternatives will continue to degrade skilled care’s market share. And, by the way, good luck keeping any semblance of adequate staff in place.

So it’s probably safe to say that skilled care has its challenges and opportunities to look forward to.

Not that this is exactly what you’d call a new development. The field has always had its backers and skeptics. My guess is that neither group will be leaving the scene any time soon. That tends to be the reality in sectors where unpleasant work is in high demand.

As to whether the market will be better off or worse, in say, 10 years? I really have no idea.

But I do have some advice that could prove to be rather useful: Any time you talk to someone who insists he or she absolutely does know, try to do the following: Nod politely, avoid sudden moves and slowly back away.

(1) Remember: The basic necessities come first.It’s not unusual that providers should expect essential things such as clean kitchens, dining rooms and uniforms and  a kind, empathic and patient staff, as well as menu rotations that reflect the location and demographics in the community. So stick to your guns on them, says Ray Costello, founder of SimpleStays.

For Scott Shontz, director of dining services for Healthcare Services Group (HCSG), the best contracted food service comes down to the food itself. 

“A good partner will be able to provide a dining program that delivers culinary and service excellence, while ensuring regulatory compliance that results in positive survey outcomes,” Shontz says. 

The founder and CEO of the Senior Dining Association agrees.

“The most important point about food service is this: Having great food and great choice without increased costs,” says Harris Ader.

(2) Of course, that doesn’t mean one can’t ask their contracted vendor for special enhancements. On the contrary. Costello says it’s totally within reason to ask a vendor to install point-of-service terminals as one way to streamline ordering, for example.

Many facilities today are asking their contracted vendors to match the ambience of fine hotel dining.

“An opportunity to enhance the traditional SNF model would be to incorporate ‘restaurant-style’ service and delivery,” says Shontz. “Having residents greeted by a host upon arrival in the dining room, served by uniformed wait staff, a beverage service, and food delivered in courses can all enhance the overall experience.” 

Other tweaks might include weekly happy hours, exhibition cooking and themed meals. Pubs, bistros, coffee bars, healthy fast casual options, and to-go service are increasingly expected. Some other popular enhancements are special menus designed to satisfy vegans, or those with sensitive digestive tracts.

“One of our residents was on a special diet, needing softer, pureed food and also experiencing a declining appetite,” recalls Debbie Interrante, administrator at Frederick Living in Pennsylvania. “Our team devoted considerable effort to create ‘real’ looking food. Our fantastic chef even created the peas and carrots shaped to look like the real deal.” 

More providers want vendors that can “blend culinary artistry, clinical nutrition, and hospitality,” says Jack Silk, Area President – East, Unidine Lifestyles. 

It “isn’t just about early bird dinners – it’s about the experiential factor,” he explains. “From poolside cooking and hibachi grills to chef’s tasting menus and craft cocktails, discerning residents expect their communities to have multiple retail-style dining experiences beyond the traditional sit-down dining room.”

(3) Ader believes it’s not taboo to boldly ask your vendor for big things when negotiating a multi-year contract. This can include things like an investment to fund capital improvements for rehabbing a kitchen and dining room.

Costello believes vendors have a better appetite for such requests when RFPs are prepared or contracts negotiated. In the end, it’s important to involve the vendor as completely as possible. 

“Having an open dialogue with your food service company about your vision and the environment you are fostering for your residents is a great place to start,” says Shontz. 

“With a mutual understanding, you can then lean on their expertise to make recommendations on how to best utilize the products and services they offer to deliver on that vision.”

Ann Marks, vice president of health and wellness at Frederick Living, depends on her vendor for long-term dedicated support in “delivering training on how to serve food with respect, which protects the dignity of the guest.”

(4) For the roughly 85%  of skilled facilities that don’t use a contracted food service company, there’s plenty of advice on how to work toward delivering a world class program.

Many recommend having the mindset of a dedicated, outside food service vendor in areas such as the quality of service and food, as well as kitchen and dining room cleanliness.

To Ader, the two most critical decisions any facility makes in its food service program are the hiring of the right dining services director and chef. “Look for a chef with hotel experience, and a director who has worked in a nursing home before,” he advises. 

Ongoing training is also critical, “especially for communities with employees that have been around for 10, 15, 20 years,” says Costello. “And rotate these employees to new departments so they do not get complacent.”

Mistakes to avoid

—Failing to follow the ‘Golden Rule.’ Food service companies are universal in stressing treating residents like their own family when it comes to menu selections.

—Taking shortcuts in hiring key staff. Experts advise hiring chefs with hotel experience, and foodservice directors who are familiar with SNFs.

—Skipping big rehab opportunities. Done right, requests for vendors to kick in investments to upgrade kitchen and rehab dining areas are not out of the ordinary.

Skilled nursing facilities must demonstrate their new sites meet a need in specific locations, which the industry says keeps lower acuity seniors in their homes, rather than in a facility.

The Florida Health Care Association testified against the bill in early March. Eliminating the requirement for nursing homes to have a certificate of need “will most certainly result in unmanaged growth, low occupancy rates, inefficiencies in how buildings operate, and a reduction in the value of our state’s nursing centers,” FHCA Executive Director J. Emmett Reed said. 

“All of this could have a negative effect on the tremendous quality strides centers are making,” he added. “We will continue to work with legislators to help them understand the need to remove nursing centers from House Bill 21 and maintain our certificate of need process.”

The state’s House of Representatives voted to move forward with the bill on March 20.

SOUTHEAST

Glitch trips up provider

ALABAMA — A computer glitch that resulted in a payroll error has led to John Knox Manor paying more than $96,000 in back wages to 92 employees at its skilled nursing facility in Montgomery.

It appears to be a perfect example of an unsuspecting provider being undermined by an unexpected technology product flaw.

As a result, Manor violated Fair Labor regulations on overtime by not including employee shift differentials when computing overtime pay, the Department of Labor’s Wage and Hour Division said. The company’s system instead based overtime rates on base hourly pay, which resulted in lower rates than those required by law.

The company also violated FLSA’s recordkeeping requirements, DOL alleged.

But Terri Howell, administrator at John Knox Manor, told McKnight’s the facility successfully argued to DOL that no harm was meant, so no punitive fine was levied. The technology error, while “creating absolute havoc,” has been fixed, with checks sent out quickly to employees, she said.

Howell advised other administrators to check their payroll systems. “Otherwise, it could get somebody in a whole bunch of trouble.”

MIDWEST

Six charged with drug theft

IOWA — Six nursing home employees at as many locations were indicted in March for diverting a variety of prescription drugs from residents.

Two were accused of swiping oxycodone pills, while another is accused of removing fentanyl patches from residents. At other sites, individual nurses were charged with taking hydrocodone, oxycodone or tramadol pills.  

One, a licensed practicing nurse and one of the oxycodone suspects, had pleaded guilty as of press time. The Iowa Medicaid Fraud Control Unit investigated the cases.

SNF allocations improve

MINNESOTA  — Thirty nursing homes will receive $6.7 million in funding through the state’s Department of Human Services’ Performance-based Incentive Payment program. 

The PIP program lets nursing homes earn incentive payments by dedicating resources to quality improvement. The program provides up to 5% in additional operating payment funding to 74 nursing homes throughout the state. This is the 12th round of funding since the program began in 2006.

Selected projects include the Aftenro Home in Duluth developing and implementing an antibiotic stewardship program, and Inter-Faith Care Center in Carlton creating a program to lessen depressive symptoms in residents by increasing quality and quantity of resident-centered activity programing. Henning Rehab & Health Care Center in Henning will develop an “open breakfast program” to boost resident choice.

NORTHEAST

End-of-life bill passes

MARYLAND — The state House of Delegates passed the End-of-Life Option Act in March, drawing praise from some religious and senior-focused organizations.

The bipartisan legislation hopes to give mentally capable, terminally ill adults with less than six months to live the ability to obtain a doctor’s prescription for medication to end their lives.

More than two-thirds of Maryland residents support medical aid in dying, according to a Public Policy Poll released last month. United Seniors of Maryland, the ACLU and religious groups such as the Central Atlantic Conference of the United Church of Christ have lent their approval, and Compassion & Choices, which has been a prominent supporter, urged a Senate vote as soon as possible. 

The company is “aggressive” in increasing its width and depth, said CEO Bill Miller. The “width” reflects how WellSky understands patients are moving through different settings, Miller told McKnight’s. That means not only long-term care, but home health, hospice, transfusion centers, respiratory services and more. 

“HCS was really important and added the psychiatric piece that we had not necessarily touched,” he added. HCS Interactant^® is a platform for patients with complex needs, and HCS, based in New Jersey, has clients in long-term acute care hospitals and inpatient psychiatric facilities, as well as nursing homes and senior living. 

Providers also want systems to be able to provide more options, whether in compliance, security or additional data. Adding components that provide value for customers, such as revenue cycle, reflect having “analytics that are germane,” Miller said. 

WellSky, which bought Blue Strata EHR last year, understands that “skilled nursing is a hard business right now,” Miller said.

“We want to be a company that not only understands those business challenges, but in the development of our software show that we are anticipating how to make the right thing the easy thing to do,” he said. 

WellSky plans to continue making strategic acquisitions, Miller said, noting that in the past 18 months the company has doubled revenue and tripled its employees.

“I think the name of the game is to grow organically and really listen to our clients,” he added. “We intend to compete on price and value. We understand the cost pressures and compliance pressures.”