1. Administrators would do well to heed the advice…

of busy designers, who say timing is as critical as any other aspect of a redesign or new project. “If the work is an interior refresh, it can be helpful to consider the current use of the space and how other areas could temporarily accommodate that use,” says Melissa Destout, associate principal and senior living practice leader at Perkins Eastman. “Obviously, it is also smart to avoid major holidays and periods of historically high move-ins.”

Timing the renovations so that any shutdowns occur during the spring or fall seasons also will minimize disruption to building occupants.

Top priority goes to any renovation issues that are critical to meeting the immediate safety or needs of current residents or staff, stresses Gaurie Rodman, senior director of real estate strategy and development for Aptura. These include building systems or equipment issues. “Renovations that would allow you to better serve the needs of current residents and staff should be the next consideration,” Rodman says. “Finally, renovations, best determined to allow you to reposition the community to better serve current and future market needs, should be first done with careful planning — and optimal project times.” For example, time renovations well before or after flu seaso or year-end surgical trends, whever possible.

2. Prioritize every project, big or small.

This is especially critical in times of ultra-tight budgets.

Destout often advises organizations to focus on the spaces that have the biggest impact on resident wellness and quality of life.

Nurses’ stations are very popular renovation candidates for facilities that primarily support institutional care because they are often at the center of a neighborhood or wing, with living, dining and open kitchen implications, she adds. “This symbolically and literally puts living at the center of long-term care and often helps improve culture and community.”

Another highly critical renovation target is resident rooms. Key design considerations include adding bath lifts and storage, opportunities for resident personalization, and efficiencies and safety features for staff.

“Many facilities now are consciously using materials and fabrics that play a role in infection control,” adds Elizabeth Donicht, director of business development and senior living sales for Kwalu.

3. Choose upgrades that please residents and their families. 

The upgrades should be visibly deliberate and intentional.

“Adding a destination such as a small café or grab-and-go food area that allows residents and families to share a casual meal clearly communicates that your organization values social interaction and supports residents’ continued quality of life,” says Destout.

“Families look at furnishings themselves as an integral part of overall design,” adds Randy Schellenberg, president of ComforTek Seating, recalling how a cantankerous resident was soothed after the facility installed updated chairs with high-tech mobility features in the dining room and other places.

4. Budgets these days can be tight…

so it’s vital to first ensure that your design project is affordable.

“When considering renovations in a long-term care facility, planning for the future is both complex and critical,” says Destout. Designs that allow for small groups of resident rooms to flexibly provide differing levels of specialty care will help position an organization to meet market needs as they evolve. 

Balancing all the various needs of an average facility isn’t for the faint of heart, as Rodman has learned. Understanding how a renovation can drive net operating income is important.

“As an industry, we don’t have the luxury of making mistakes in our capital investments on facilities,” she says. “Therefore, careful planning, consideration and alignment on anticipated project outcomes, cost and timing are critical to obtaining funding.”

But telehealth continues to earn accolades for promoting greater access to doctors and improving outcomes and patient satisfaction for everything from stroke rehab to dementia care.

“The kind of services telehealth provides to patients are limitless,” said Kyle Zebley, senior vice president of the American Telemedicine Association, noting its use in therapy, diagnostics and even dialysis.

One promising application caught the interest of David Chess, MD, founder and chief health and public policy officer of Tapestry Health, which generated buzz by integrating a network of practitioners to support its freestanding telemedicine hardware inside nursing homes.

“We believe that passive vitals monitoring can be a real game changer, allowing us to pick up changes in condition and early disease process to intervene and prevent disability and hospitalization,” said Chess.

There’s also plenty of interest in telehealth’s potential to help fill the vacuum created by workforce shortages.

Despite the industry’s hangover from the 2020 surge, Chess said he remains optimistic about behavioral and after-hours interventions for facilities, and the current pace of innovation in optics and embedded technologies. Still, challenges remain.

“Many providers, clinicians and residents and their families are not yet ready for virtual care,” said Allison Rainey, MatrixCare’s head of nursing and clinical informatics. “The general culture still promotes a more traditional care model.”

Zebley said hurdles include needed investment, required education and looming questions over standards of care. There also are thorny public policy issues to navigate and outdated laws and regulations to overcome.

At press time, Medicare had announced plans to finalize expanded coverage for telehealth services in 2024.

K. pneumonia most commonly leads to pneumonia, but the pathogen also causes meningitis and infections in the bloodstream, wound or surgical sites and urinary tract infections.

Multidrug-resistant organisms “continue to pose a significant threat to nursing homes, particularly in close living quarters and among those with weakened immune systems,” according to Heather Hutson, RN, founder of Prevention ID.

“The epidemiology of K. pneumoniae is changing and it’s highly concerning,” added Doe Kley, RN, infection prevention fellow for Clorox Professional. “We’ve seen a lot of drug resistance with this and other emerging pathogens.”

Compounding matters is the fact that new kinds of antimicrobials quickly become obsolete, which has led to weakened incentives for pharmaceutical companies to develop new drugs, Kley added.

“The real threat nursing homes face is a lack of preparedness for whatever may be around the corner, whether that is another emerging pathogen or a geographic catastrophe,” said Evelyn Cook, associate director, Statewide Program for Infection Control and Epidemiology at the University of North Carolina at Chapel Hill.

Some infection preventionists believe COVID distracted providers from managing disease transmission. Kley supports a horizontal approach to infection control.

“During the last several years, our attention has been on a single pathogen,” she said. “When we do this, other pathogens — like C. auris — can proliferate in the background.

“The good news is that infection control measures work,” Kley added. “This includes things like antimicrobial stewardship, standard precautions, transmission-based precautions (when indicated), hand hygiene and environmental cleaning and disinfection.”

According to the NIH, a vaccine approach for prevention/treatment of [future] K. pneumoniae infections is feasible. 

1. Educate yourself and your staff.

A simple query to the popular app ChatGPT yields bountiful advice on various situations staff might encounter in their roles, from performing routine tasks like medication reminders to helping with remote consultations and providing mental health support.

“Skilled nursing facilities have an unprecedented amount of access to tools, including artificial intelligence, to increase efficiency and assist with caregiver workload,” said LeaderStat’s Liz Wheeler, a registered nurse consultant. “Some increase provider accessibility and information systems can assist with data analytics.”

Brandi Kurtyka, CEO of MissionCare Collective, which includes MyCNAJobs, said her company has actually “baked AI” into its employee engagement and retention tool to help companies leverage data to stabilize their workforce.

While employees get more engaged, nursing facilities get access to powerful algorithms to see who’s a “flight risk” for turnover, Kurtyka added.

Staffing firm KARE uses AI to offload repetitive tasks and standardized operations, said Lindsay Evans, the company’s vice president of product. Evans said so-called “chatbots” provide her company with a variety of tools that streamline billing and planning residents’ daily activities.

2. Still, don’t take your eye off the more “conventional” solutions, experts advise.

Through ShiftKey’s strategic investment in OnShift, the company implemented Schedule Automation Marketplace Integration with “incredible results” after launching it earlier this year, said CEO Brandon Tappan. ShiftKey uses other integrated technology solutions to identify patterns in scheduling, demand, available providers, and more to equip facilities with the data and insights to make strategic workforce decisions.

Kurtyka said automation is behind a variety of new applications such as virtual assistants and social engagement tools like virtual reality and digital social platforms. 

Wheeler said robotics are being utilized to increase provider accessibility in some areas, which can assist with assessment during off hours or emergent situations. “Ultimately, this will have an impact on rehospitalizations and lead to more positive outcomes,” she added.

3. For now, workforce providers and others caution against overreliance on AI.

Evans believes there is a risk of being “too confident in AI’s output. AI is driven by human-programmed rules and requests and is not meant to fully replace the physical caregiver,” she observed.

“The adoption of new technology in the healthcare space will never replace the care and expertise provided by licensed and certified professionals, but technology can provide facilities and teams with new efficiencies that preserve essential, person-centered care with more limited resources,” said Tappan.

Kurtyka, meanwhile, urged a more measured approach.

“There’s no reason for administrators and nursing managers to fear the incorporation of new technologies like artificial intelligence,” she said. “The best care is the intersection of where humans and technology meet. Better care can be achieved by empowering nursing staff with the right technology.”

4. Even the most ardent supporters of non-human intelligence recognize its limits.

“AI is only as good as the rules that a human programs and the dataset which is utilized,” Evans said. “Not only is it important to remove protected health and personal identifiable information from the dataset, but it’s also important to understand the problems you are trying to solve with AI. Are you aiming to be more efficient, more predictive, or more automated? Starting with the goal and determining the data and processes needed to achieve that goal is necessary to successfully deploy AI.”

“Education and stressing the importance of responsible use is imperative to prevent over-reliance and adverse outcomes,” said Wheeler. “Ensuring all team members are aware of the intent and process of any new technology will help minimize confusion or inappropriate use.”

“Nurses who are certified to care for wounds and ostomies are in short supply, at Kaiser Permanente and all over the country. And many are set to retire soon,” said Laureen Lazarovici, a writer for Labor Management Partnership, a joint effort by Kaiser Permanente and labor unions.

“Exquisitely acute” is how Christy Recke, a long-term care wound care specialist for Essity, describes the situation. She says high turnover among active wound and ostomy nurses is partially attributable to “lack of education or comfort in their role.”

The situation is alarming to many.

Amin Setoodeh, RN, senior vice president of Skin Health and Clinical Services for Medline, says he has seen a spike in skin injuries  such as incontinence-associated dermatitis, skin tears and pressure injuries.

“The industry is truly struggling to meet standards of care with very limited resources and funding from the government,” Setoodeh says, adding that the nursing shortage also puts some patients at higher risk for developing skin breakdown or multiple wounds. The ratio of certified wound care clinicians with expertise to the number of patients with wounds [also] continues to decrease.

“The issue we are facing today is a national crisis and it will require several specific strategies to overcome potential risk factors related to wound care management,” Setoodeh says. This includes thorough assessments of the skin and wound care programs and developing an interdisciplinary prevention approach, he adds.

While acknowledging the severity of shortages varies geographically, Dea Kent, immediate past president of the Wound, Ostomy, and Continence Nurses Society, says “in some cases, patient care is likely suffering and staff are very, very thin.”

Complicating matters is a reduction of ostomy caregivers.

“Ostomy patients usually still fall into the nursing purview, so unless there is another professional in the building who is interested, there is no other help,” she says.“WOCN supports efforts by nursing organizations to reverse these trends. The outlook is uncertain. But we have a lot of hope.”

But on the flip side has been a devastating spate of nursing home closures and an administration dead set on a staffing rule, prompting the Iowa Health Care Association to admonish the government for “mandating the hiring of people who do not exist to care for people who do.”

While some investors believe that has taken the shine off the current SNF environment, some silver linings remain.

“The nursing home market is still dominated by sales of moderately to severely distressed facilities, both of which are very difficult to finance,” said Jeff Binder, managing director at Senior Living Brokerage.

Yet, many experts are bullish on the fate of this shell-shocked industry.

“I would characterize the skilled nursing housing climate as slowly continuing to improve,” said Michael Gehl, chief investment officer, FHA Lending for Newpoint Real Estate Capital, LLC.

While occupancy is still 9% below pre-pandemic levels, the industry has rebounded by more than 100,000 new residents since its nadir in January 2021.

But Gehl warned of more closures and reductions of capacity if current industry trends continue into 2024.

“On the seller side, the current period is generally characterized by those that have to sell rather than those who want to sell,” added Brian Jurutka, vice president, senior housing for IMA Financial Group. 

“Buyers in this market are likely thinking of skilled nursing as a beachhead to a broader suite of services offered to the residents of the property or portfolio being acquired, rather than thinking of SNFs as a stand-alone investment,” he continued. “This last dynamic likely makes traditional financing more challenging.”

The wild card to many observers will be the fallout from any administration staffing mandate eventually finalized. In the meantime, Gehl predicted the skilled care industry will continue a slow and steady recovery and return to pre-pandemic occupancy and staffing levels by the end of 2025.

1. Understanding how the easing of the pandemic positively changed rehab care is an important first step.

The challenges of COVID and then-new PDPM rules forced therapists to look at different ways to provide high-quality therapy outside of the usual rehab gym setting, observed Karen Welsh, vice president of clinical and reimbursement excellence for Functional Pathways Rehab.

That was an eye-opening period that will have a lasting, creative impact.

But treatment interventions outside of the patient’s room have returned to near pre-pandemic levels and therapy teams can now resume group activities to allow patients to offer support and suggestions to their rehab peers, said John Pauley, northwest regional vice president for Consonus Healthcare. 

“In a sense, the human connection between therapist and resident has been restored, with changes in masking and isolation policies,” he said. 

2. Therapists can play important roles mitigating the impact of workforce issues.

“As we work together for continued industry stabilization, contract physical therapy companies and skilled nursing providers can efficiently improve patient outcomes and foster a positive and collaborative environment to increase facilities’ marketability for more effective community partnerships and increased census,” said Stephanie Parks, chief development officer for Reliant Rehabilitation. “Work together to develop personalized treatment plans for each patient. Encourage input from the contract physical therapy company and the skilled nursing provider to ensure a comprehensive approach considering the patient’s needs, preferences, and overall care plan.”

Kristin Hoffman, senior customer onboarding specialist for iN2L, suggests scheduling group therapy sessions with activities staff or volunteers if there are caregiver shortages. 

“This can help therapists see a broader range of abilities of their residents’ physical and cognitive abilities without having them on caseload, maybe sparking a need for an eval while still completing their group therapy session,” she said.

3. Develop mechanisms to help staff adapt to  changes that make them better at what they do.

“Facility team members are still adapting to changes from the pandemic,” Pauley said. “It’s important to use clear communication for the reasons behind the changes — and how the changes will be implemented to minimize any concern among staff.”

Added Shelley Horst, director of strategic partnerships for Reliant Rehabilitation: “Addressing staffing shortages in therapy within skilled nursing centers is crucial for providing optimal care to residents.”

4. Many agree that therapists can benefit from understanding how and why workforce shortages are not only affecting the business of long-term care, but also the way they approach their work.

“The key to success with the workforce crisis for therapy and nursing is the ability for the interdisciplinary team to support one another and place the patient’s goals at the center of decision making,” explained Pauley. He noted that therapists are skilled in their ability to assess a patient’s environment, promote needed body positioning and transfers, and provide recommendations that  can reduce caregiver burden. 

5. Though it may seem obvious, experts advise tackling the biggest challenges first.

“Therapists are perfectly positioned to help nursing home caregivers provide the necessary functional tasks by ensuring treatment is delivered during times when it is needed the most — early morning or evening ADLs, all meal times, activities and weekends,” said Welsh. “It’s important for each therapy director to work closely with the leadership team and determine the best way to incorporate therapy into the daily schedule to assist at those times when it’s needed most for patient care.”

Hoffman believes giving patients increased independence by the end of the treatment sessions is another way therapists help reduce caregiver shortages. “The more a patient can do for themselves, the less assistance they will need,” she added.

“Something new this year is that two new vaccines were recently approved by the FDA to protect against pneumonia due to respiratory syncytial virus (RSV) in adults age 60 and over,” said Erica Johnson, chair of the Infectious Disease Board of the American Board of Internal Medicine. 

“While there has been a fair amount of media attention surrounding the new vaccine [for seniors], it may prove to be a bit more challenging to incorporate into the core group of routine vaccines we are accustomed to,” warned Erin Marriott, RPh, director of clinical and regulatory support at Guardian Pharmacy Services.

Erin Donatelli, PharmD, vice president of clinical and consulting services for Remedi SeniorCare, stressed that treatment options and outbreak procedures for COVID and flu should follow a tight timeline after symptoms or a positive test.

Pharmacists and others expressed confidence in the preparation and efficacy of new COVID boosters and vaccines. Still, work remains to be done..

“As a country, we are still dealing with misinformation, mandates and some poor communications from government leaders,” said Chad Worz, PharmD, chief executive of the American Society of Consultant Pharmacists. “It will take a huge effort by doctors, nurses and pharmacists to rebuild confidence in vaccines.”

Meanwhile, experts are mixed about a repeat of drug shortages. Andrew Agan, a spokesperson for Guardian Pharmacy Services, said “drug shortages remain a huge issue impacting skilled nursing. From atropine to lidocaine, there’s a large list of drugs currently in shortage.”

As for parting advice, experts have plenty.

“Get ahead of potential outbreaks,” said Worz. Vaccinate and evaluate residents in anticipation of needed antiviral treatments that could involve possible interactions with other medications.

And finally, “work collaboratively with your pharmacy partner on securing access to any of the needed vaccines,” said Marriott.

AI technology promises to create untold efficiencies and, in turn, solutions to so many of the thorny issues of workforce, care, operations and more. 

Still, caution with this emerging tool is advised, experts say.

“AI is not new,” says Majd Alwan, PhD, chief strategy and growth officer for ThriveWell Tech. “Alan Turing, a computer scientist who is considered the ‘godfather’ of AI, devised what is known as the Turing Test in 1950, which asks, ‘Can a computer convince a human they’re communicating with another human?’”

Recent examples of innovation at work:

• Certainty-based location visibility, which Deric Blattenberger, general manager, Senior Care, CenTrak, describes as “enterprise visibility with location certainty,” supported by Real-Time Location Systems (RTLS) through wearable pendants.

• CarePredict has developed a continuous activity and behavior observation platform that uses AI to learn correlations between particular changes in activity and behaviors and labeled health events, says Satish Movva, CEO and founder of CarePredict.

Alwan asserts that the “deep learning” promises of AI in long-term care seem endless — everything from fall detection and medication management to early detection of pressure ulcers.

“AI can play a significant role in early identification of risk,” notes TK King, vice president of healthcare strategy for Accushield. “Its ability to scan data, search for keywords, and evaluate trends means it can pinpoint staffing needs and resident risks.”

Still, healthcare experts agree many issues surrounding risk need to be tested.

Movva urges early adopters to be mindful of privacy and security concerns. And Blattenberger warns of a risky upcoming phase that introduces virtual caregivers and “approximate” outcomes.

Alwan describes current efforts as a significantly acceleration and competitive “race,” and warns adopters to protect data from corruption or premature release.

He’s also adamant about ensuring that humans remain in charge of testing and evaluation.

1. Be constantly vigilant of the top bath safety hotspots.

Dangers can lurk in plain sight in even the cleanest and neatest bathing areas. There are core issues that guide safety-mindedness.

“Many safety concerns exist when environments are not built with optimal ergonomics and accessibility in mind,” states Jaime Stoffer, PT, DPT, director of clinical programs for rehab and fall prevention for Medline.

Supporting proper body mechanics is key. 

“Slips and falls increase when a facility is not equipped with bathroom modifications for stability and safety,” adds Stoffer. 

Inadequate bathing spaces are another concern, according to Karen Lerner, RN, MSN, ATP, CWS, the clinical vice president of Drive DeVilbiss Healthcare. Such lapses can increase risks of slips and falls, poor hygiene and infection control. 

A patient-centric approach is needed, adds Patricia Howell, RN, BSN, WCC, CFCS, clinical support manager, clinical resource team for McKesson Medical-Surgical Extended Care. 

“The first step in patient safety and better experience in bathing is to know your patient,” says Howell.

She urges caregivers to be mindful of residents’ individual impairments, such as partial blindness, deafness or left- or right-sided weakness.

2. Don’t take safety issues for granted.

Even seemingly minor issues can quickly escalate in the bathing environment.

Stoffer warns against treating actions independently and prefers taking a broad view, focusing on the frequency of bathing routines and bathing facilities. 

“One instance of lifting may not be extremely risky,” she says. “When you look at the big picture, lifting weight several times a day in a wet, cramped environment creates a whole new set of risks and challenges.” 

The same principle applies when evaluating bathing implements and facility cleanliness. Caregivers are also advised to not ignore small areas where mold appears.

“Healthcare-associated infections remain one of the leading causes of increased morbidity and mortality among health care consumers,” Lerner says. “Even visibly clean surfaces may be microbiologically contaminated and constitute a reservoir of infectious agents.”

The simplest hazards can be easily overlooked. 

Howell warns caregivers to ensure adequate lighting, easy-to-reach fixtures and grab bars, non-slip surfaces and that water is at a safe temperature before allowing elderly residents, especially those who are prone to falling, to dip their toes.

3. Take steps quickly to mitigate problems and prevent small issues from getting out of hand.

“It’s important that a facility does not wait until after a fall happens to implement safety standards,” according to
Stoffer. “Consider every potential safety issue, then evaluate the equipment that is being used and consider whether it fits the space appropriately and whether it aligns with your patients’ physical abilities.” 

Howell reminds all caregivers to be as mindful entering and leaving a resident room as they are when touching residents.

“Hand washing continues to be the best way to stop the spread of infection,” she notes. 

4. Be mindful of best practices when it comes to addressing safety lapses in bathing areas.

“Some of the immediate fixes that can make a big difference are small,” says Stoffer. Examples include removing tripping hazards such as rugs, properly directing water flow to prevent slipping, and providing ample-sized sitting surfaces, transfer benches and shower chairs. “If the space allows, transfer aids such as lifts can be useful,” she adds.

For more independent residents, Lerner encourages walk-in tubs, while cautioning facilities to “consider the whole suite, and discuss dignified bathroom management instead of just products and a price. 

“Rehab-style commode chairs can permit a dignified and safe transfer in the resident’s room,” she adds. “These chairs back up over toilets and can be wheeled right into zero threshold showers. Not only are these much safer for residents, but they are also easier for staff, too.” n