SEP 13-15, 2021

Beyond the Devastation: Bringing Quality and Financial Viability to

Long-Term CareM I C H A E L R . W A S S E R M A N , M D , C M D

C H A I R , P U B L I C P O L I C Y C O M M I T T E E

C A L I F O R N I A A S S O C I A T I O N O F L O N G - T E R M C A R E M E D I C I N E

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Disclosures

• Board of Directors, Sanolla

• Editorial Board, The Merck Manual

• Board of Directors, Wish of a Lifetime-from AARP

• Board of Directors, California Association of Long-Term Care Medicine (CALTCM)

• Board of Directors, Health in Aging Foundation

I also have a strong bias against ageism, which I will never remain quiet about!

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COVID-19 Impact on Long-Term Care

• ~200,000 deaths (lots of variability around actual number)◦ No real data prior to May 2020

◦ Lack of truly audited data

• Staff deaths ~2,000 (similar accuracy issues)

• Lack of PPE

• Staffing crises

• SOCIAL ISOLATION

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COVID-19 has “Unmasked” Underlying Issues in Long Term Care• Is there enough money in long term care?

◦ Operations

◦ Real estate

◦ Related parties

• Are there enough trained staff?◦ Wages and Benefits

◦ Are staff valued, respected and treated honorably?

◦ Is training sufficient?

• Who is responsible and accountable for quality?◦ Operators

◦ Consultants/Managers

◦ Real estate owners

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Bringing Quality and Financial Viability to Long Term Care

• Addressing COVID-19 specific issues is critical

• Must understand these issues in the context of underlying clinical, operational and financial weaknesses

• We actually have a roadmap already◦ Coronavirus Commission on Safety and Quality in Nursing Homes

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CALTCM’s Long Term Care Quadruple Aim For COVID-19 Response• Abundant PPE

◦ Pandemic supply chain challenges

◦ Ongoing needs in post-COVID world

• Readily Available Testing◦ Need to detect asymptomatic and presymptomatic

◦ Still important due to emergence of highly contagious variants such as Delta

• Stellar Infection Control◦ Need for Full-time Infection Preventionist

◦ Engagement of medical director and clinical experts

• Facility working under Emergency Preparedness/Pandemic Plan◦ Proxy for excellent leadership

◦ Need to focus on the facility leadership team

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5th Element: COVID-19 Vaccine

• Evidence in older adults very positive

◦ Albeit still no published clinical trials in nursing home residents

◦ Would have been an excellent opportunity to perform clinical trials in nursing homes and assisted living facilities

• Opportunity to reduce disease in staff

• Potential to reduce spread amongst staff

• Potential to reduce transmission to residents

◦ Need for mandates

◦ Vaccines work!

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What’s Next with the Vaccine?• Need to assure that resident and staff vaccination rates remain high

◦ Hospital vaccination for new admits

◦ LTC pharmacy engagement for staff and residents

◦ Mandates

• Will possibly need booster shots◦ 8-12 months after initial vaccine

◦ Will depend on follow-up on initial studies

◦ Will require monitoring of long term care residents

◦ Ideally would have more data

• Needs systems to achieve

• Will need planning and coordination

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Theme 1: Testing & Screening

• Testing is still a critical issue, especially in regards to variants

◦ Aggressive sequencing to monitor variants

• Rapid Turnaround Pcr testing

◦ <24 hours

◦ Point of care (immediate turnaround ideal!)

• Antigen testing

◦ Home testing (to reduce facility workflow issues)

◦ Frequent testing

◦ Need to reduce false positive & false negatives

• Massive Effort still needs to be directed at this issue!

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Theme 2: Equipment and PPE

• Every nursing home in the country MUST have an abundant supply of PPE

◦ N95s are essential

◦ Should be no risk of running out

• Need to address supply chain issues

• Need to assure that federal financial support is effectively put towards PPE and testing equipment

• Related parties should not be profiting from this critical need!

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Theme 3: Cohorting

• Balance resident and staff safety with infection prevention and control

◦ Waiving resident transfer and discharge requirements had and have unintended consequences

• Evidence and science should drive cohorting guidance

• Must incorporate issues related to social isolation!

• We need care setting specific studies and data!

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Theme 4: Visitation

• Allowing visits to and from friends and family

◦ Vital resident right!

• Vaccinations should be game changers!

• Person centered

◦ Risk:Benefit ratio MUST be fully addressed

• Isolating residents MUST be a LAST RESORT, not the first “go to” response!

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Visitation After Vaccination

• Important Issue

• Initial and ongoing CDC guidelines for vaccinated “people”

◦ Long term care residents are “people”

• Need to operationalize

• Vaccine passports and mandates

• We can’t just “lock up” LTC residents on a regular basis

• Need for essential visitors, at the very least!

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Theme 5: Communications

• Increase specificity and expand guidance on communications

• How CDC, CMS, FDA, FEMA communicate with each other and with facilities matters

◦ Interagency Task Force

• Expand on technological approaches

◦ Technology MUST facilitate change and quality improvement, not be a barrier or impediment

• Facilitate QIN-QIO efforts

◦ QIN-QIOs are a valuable resource

◦ Engagement should be required

◦ MUST incorporate expertise in geriatrics and long term care medicine

◦ Consequences for failure to engage

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Theme 6: Workforce Ecosystem

• 24/7 RN Staffing in all nursing homes

• 0.75 RN hprd

• One FTE Infection Preventionist (IP)/100 beds

◦ Minimum of one Full-time IP for >40 bed facility

• This DOES NOT require further “studies,” it needs to happen NOW!

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Theme 7: Workforce Systems• Catalyze interest in CNAs◦ Wage and Benefit reform

• Professionalize IPs◦ Requirements

◦ Certification

• Require certified medical directors◦ Nursing Homes need competent and engaged medical directors◦ Include a public facing medical director list for accountability

• Overhaul workforce ecosystem

• Convene LTC workforce commission and commit to ACTING on recommendations

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Theme 8: Technical Assistance & Quality Improvement

• Increase availability of onsite collaborative, data-driven support

• Eliminate need for QIN-QIOs to “recruit” nursing homes

• Reduce QIN-QIO administrative burden

• Bolster ”incentives” for nursing homes to work with QIN-QIOs

◦ Sharpen penalties

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Theme 9: Facilities

• Facility design enhancement

◦ Ventilation

◦ Space

◦ Capital incentives

◦ Green House

• Reevaluate SNF Virtual Command Center concept

◦ Each department mirrored in virtual command center

◦ Repository of best practices

◦ Rapid dissemination of information during crisis

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Theme 10: Nursing Home Data

• Retrospective COVID-19 Data is Needed

◦ Starting in January, 2020

◦ Deaths related to COVID-19 (residents and staff)◦ Regardless of location of death

◦ COVID-19 positive

◦ Presumed COVID-19 deaths

◦ Adverse events secondary to social isolation◦ Weight Loss

◦ Pressure Ulcers

◦ Behavioral symptoms

• Assisted Living & Group Home data also desperately needed

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Oversight & Accountability• Dissenting opinion from Commission member

• Survey process doesn’t work the way anyone wants it to◦ Are we capturing the important items that influence quality?

◦ Does the existing penalty structure and methodology work?

◦ Impact of survey on frontline staff

◦ Are we fully invested in oversight?

• Who is accountable?◦ Owners?

◦ Operators?

◦ Management companies?

• Lends itself to issue of financial viability

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Leadership as a Core Element to Effective Quality Improvement

• Consensus leadership style associated with better quality of care indicators in nursing homes

◦ >4,000 nursing homes in the U.S.

◦ NHAs

◦ DONs

◦ Nursing Home Compare Quality Metrics

◦ Restraint use

◦ Catheter use

◦ Inadequate pain management

◦ Two measures for pressure ulcers

• Nicholas G. Castle, PhD, MHA, AGSF, Frederic H. Decker, PhD, Top Management Leadership Style and Quality of Care in Nursing Homes, The Gerontologist, Volume 51, Issue 5, October 2011, Pages 630–642, https://doi.org/10.1093/geront/gnr064

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Leadership & Management Training

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Concept of Leadership Team!

Recognizes complexity of nursing homes

Nursing Home Administrator

Director of Nursing

Medical Director

Director of Staff Development

Infection Preventionist

VALUE OF AN ENGAGED AND COMPETENT MEDICAL DIRECTOR

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AB 749: MEDICAL DIRECTOR CERTIFICATION

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Financial Viability• Without accountability and clear lines of responsibility it will be difficult to assure financial viability

• MUST address drivers of profit in the long term care industry

• Fully recognize the role of:◦ Real estate

◦ Related Parties

◦ Labyrinth of accountability reducing entities

◦ Management/consulting companies

◦ Real estate entities

◦ Operating entities

• There may already be enough $$ in the system, it just needs to be properly focused on resident care!

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Impact of Real Estate Ownership on Nursing Homes

• Lease and Triple Net (Real Estate Taxes, Insurance and Maintenance Costs)◦ Real estate owner collects their rent; operations pays for maintenance, property taxes and

insurance

• Appreciation◦ Real estate owner benefits from appreciation of property

• Leveraging of Assets◦ Real estate owner able to collateralize the asset to borrow money

◦ Borrowed money rarely spent on capital improvements

◦ Borrowed money almost never spent on quality improvement

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Examples of related parties that have an impact on nursing home finances

• Real estate

• Medical supplies

• Service providers

• Wound Care

• Construction

• Management

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Recommendations

• Create an HHS Interagency Task Force to identify, monitor and address situations in NHs that need more focused attention◦ Composed of CMS, HHS OIG, DOJ, CDC

◦ Provide ongoing analysis of NH owners and other individuals residing in PECOS, ◦ Incorporate staffing and medical director administrative time from the Payroll-Based

Journal (PBJ) database, data from the survey and certification inspection program, including complaints, and information from Medicare cost reports on spending patterns.

• Data-informed approach would provide a new lens on how ownership and financial investment in the nursing home sector impacts the quality of performance and the stability of individual facilities, chains, and groups of homes across the country.

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Recommendations

• Task force should focus federal oversight, coordinate monitoring across the federal government and with states, and report actionable recommendations – for example, whether “strike teams” may be needed if facilities are not able to assure resident safety, e.g., during emergencies.

• Augment PECOS reporting to include all parent, management, and property companies, and other related party entities and ensure enforcement of Sec. 6101 of the ACA, that companies provide a complete organizational chart.

◦ Failure to provide such complete and accurate data should result in specified financial penalties

• CMS should fine-tune its regulatory and enforcement approach to focus more attention on nursing home chains and groups, both within and across states. CMS’s “Care Compare” website should present information that is searchable not only for individual facilities but also by chain and common ownership, and publish an annual compendium on the quality of care in nursing home chains.

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Recommendations

• CMS should promulgate federal regulations that specify minimum criteria for the purchase (or change of ownership) or management of any nursing home. ◦ Prevent individual or corporate owners from purchasing, operating or managing additional

facilities if they have a history of owning or operating other facilities with chronically low staffing and poor quality care in any state.

◦ Companies with corporate settlements with State Attorneys General (AG) or DOJ should be barred from purchasing new nursing homes for a five-year time period.

◦ Establish an effective prior approval process for changes in ownership or management to ensure that the criteria are met in advance of approval.

◦ CMS establishing a centralized application unit for ownership and management evaluations, including processes to work with state agencies, state attorney generals and the Department of Justice.

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Recommendations• Cost report requirements should be amended to require each NH to provide annual consolidated

financial reports inclusive of data from operating entities (license holders) and all organizations and entities related by common ownership or control◦ Reports should provide flow charts of all related party entities including home offices, management

organizations, staffing, therapy, supply, pharmaceutical, consulting, insurance, banking and investment entities, parent companies, holding companies and sister organizations.

◦ Management companies and property companies that are not related by ownership should also be required to provide a full financial report annually. The CMS Medicare cost reports should be required to be prepared by a certified public accounting firm.

• A combined financial and oversight system should be established by CMS to conduct annual joint Medicare and Medicaid audits including home office and related party payer audits and penalties should be instituted for inaccurate cost data. ◦ CMS should be given full access to IRS filings of all the entities involved in the nursing home

operation.

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California Association of Long-Term Care Medicine

@CALTCM

#CALTCM

@Wassdoc

Check the CALTCM Website (CALTCM.org) ande-newsletter, the CALTCM Wave, for updates.

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Questions & AnswersP L E A S E U S E T H E Q & A B U T T O N T OS U B M I T Y O U R Q U E S T I O N S

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