Most of long-term care has found itself hobbled by low occupancy and consumers’ sustained fears during the pandemic, but one group has generally fared much better than the others: Providers focusing on intense rehabilitation and transitional care.
That’s largely because they were able to demonstrate their value to upstream providers in need of reliable outlets for step-down patients.
The trend toward targeting clinically complex patients is nothing new, but observers say the continued push toward payment incentives that unite payers and providers around risk — plus ongoing, specific needs related to COVID-19 — have hastened the transformation.
“There’s no question,” said Bob Kramer, co-founder and former CEO of the National Investment Center for Seniors Housing & Care. “Specialized clinical programs working in conjunction with health systems … are seeing real pick-up and real demand of a sort they weren’t before.”
Kramer, who last year founded Nexus Insights to help develop new aging services models, calls this sub-sector “peri-acute” care, likening it to a protective moat around the castle that is acute care.
Just before COVID-19, Allaire Health Services served a mix of rehab patients, medically complex conditions ranging from traumatic brain injury to congestive heart failure and long-term care residents at four facilities in New Jersey and Pennsylvania. Amenities include private suites and gleaming rehab gyms. Respiratory therapists and wound care specialists direct therapies using equipment more commonplace in hospitals.
Over the last year, Allaire’s emphasis on clinical staffing and subacute recovery became a lifesaver — both for patients who would continue to fill beds throughout much of the last year and for the business itself. By early this year, Allaire had added a facility each in New Jersey, New York and Vermont. Pennsylvania health officials also tapped Allaire to run a facility overrun by COVID-19.
Putting procedures in place
Like Allaire, Ignite Medical Resorts grew significantly during 2020. Much of that expansion was anticipated due to new partnerships with LTC Properties and Sabra Health Care. But CEO and co-founder Tim Fields also struck a deal to run a new Milwaukee location in conjunction with NHI and also acquired two Ascension properties in the Kansas City market. Ignite plans to break ground on an 11th location late this year.
Fields said navigating the pandemic while on a growth trajectory required nimble leadership and an ability to frequently repurpose people and equipment. He created dedicated COVID-19 units to reinforce relationships with key acute partners and took in an estimated 1,200 patients.
“We realized strategically we needed to flip the switch,” Fields said. “We get 98 to 99% of our business from the hospitals. We have to have the pulse all the time. We saw this as an opportunity to be part of the solution.”
With a high nurse-to-patient ratio, in-house therapy and medical equipment already in place, the company used technology to remotely monitor heart rates and oxygen saturation and safely deliver therapy to promote strength gains. Buildings that typically filled 90% of beds with rehab patients at one point might have had 75% of beds filled by COVID-19 referrals. After June, the mix fluctuated but census held steady, Fields said.
Allaire also created COVID units, starting with a floor at its Morristown facility. Careful attention was given to isolation precautions — including visitor restrictions that predated state and federal mandates — use of private rooms, and ongoing access to PPE.
“I personally was on the phone sometimes several times a day with the hospitals,” said Allaire CEO Ben Kurland. “What do you need? How do we get it? What could we do? There’s a high level for collaboration.”
The idea that these conversations were taking place with both upstream and downstream partners — and sometimes in group chats with peers in the same region — isn’t surprising given the pressures coming from managed care and incentive-based payment models.
“If you’re a payer, you do everything you can to keep a patient from a hospital stay,” he said. “Whoever’s holding the dollar risk, clearly you’re going to like dealing with a facility that’s new, that has brand new equipment and higher staffing ratios.”
Proving their worth
In Texas, Bridgemoor Transitional Care experienced a “shocking” occupancy drop of about 50% occupancy after the state stopped elective surgeries.
Like many providers, Bridgemoor worked with its real estate partner, Invesque, for a short-term debt reprieve. Invesque leaders acknowledged during a recent earnings call that they did not receive revenue from Bridgemoor during the fourth quarter of 2020.
But in an interview earlier this month, President Mark Fritz struck a more optimistic tone, buoyed by an ongoing relationship with a hospital that called on his facilities to offload some of its COVID-19 patients.
“One of the reasons was the relationship we had with them and being able to take more medically complex patients,” Fritz said. “The private rooms, that was a big factor.”
Bridgemoor had zero in-house acquired COVID-19 cases until a four-patient outbreak in February, a fact that it could tout when hospitals were ready to send out surgical patients.
Its relationships strengthened, Bridgemoor is preparing to pilot specialty programs in congestive heart failure and COPD starting this spring.
“Our industry is changing, and this is just going to be part of it,” Fritz said.. “However you do it, everyone is going to have to get to more private rooms and more physician involvement.”
Be an asset when needed
Of course, not all providers have the capital to convert to single beds or take revenue offline when occupancy remains at record lows. When census mix depends on Medicare referrals to balance a majority-Medicaid clientele, a small bite at the apple might provide needed gains.
“If there’s a specific need in your market, specialize in that,” Kramer said. “Find out, what’s the dollar cost for this specialized type of care? Build your reputation around it. Demonstrate to your health systems, ‘You can trust us on this condition. And we’re really good at keeping people out of the hospital.’”
Fields expects sharing Ignite’s COVID-19 success will build confidence in programs dedicated to dialysis and pulmonary rehab — potentially critical for COVID long-haulers with fibrosis.
And Kurland predicts those who proved their worth during the pandemic will be a well that providers return to in the future.
“It makes us an asset to them when they have needs,” he said. “Today it was COVID, tomorrow, it will be something else.”