Pivoting providers: SNFs focusing on transitional care and rehab welcome COVID-19 patients

Before the COVID-19 crisis, Allaire Health Services served a mix of rehab patients, individuals with medically complex conditions ranging from traumatic brain injury to congestive heart failure, and long-term care residents.

Four facilities in New Jersey and Pennsylvania featured amenities such as private suites, gleaming rehab gyms and spaces dedicated to relearning activities of daily living. Respiratory therapists and wound care specialists directed therapies using equipment more commonplace in hospitals.

Over the last year, the upscale chain’s emphasis on clinical staffing and subacute recovery became lifesavers — both for patients who would continue to fill beds throughout much of the last year and for the business itself.

“Change is the one thing that’s consistent in healthcare,” CEO and Founder Ben Kurland said. “We try to gear everything that we do in our centers to the population that we’re dealing with, and we work with our local community, our local hospitals, to see what they need from us.”

For Allaire, existing relationships and new collaborations led to significant growth despite COVID-19. By early this year, the chain had nearly doubled in size, adding a facility each in New Jersey, New York and Vermont. Pennsylvania health officials also tapped Allaire to run a facility overrun by COVID-19.

While much of the industry found itself hobbled by low occupancy and sustained consumer fears, providers focused on intense rehabilitation and transitional care were typically better prepared to pivot. That’s largely because they were able to demonstrate their value to upstream providers in need of reliable outlets for step-down patients.

“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.”

While the trend toward targeting clinically complex patients is nothing new, observers like Kramer say the continued push toward payment incentives that unite payers and providers around risk and ongoing, specific needs related to COVID-19 have hastened the transformation.

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.

Putting procedures in place

Like Allaire, Kansas City-based Ignite Medical Resorts grew significantly during 2020. Much of that expansion was anticipated due to new partnerships with LTC Properties and Sabra Health Care real estate investment trusts.

But CEO and co-founder Tim Fields also struck a deal to run a new Milwaukee location in conjunction with NHI and acquired two additional Kansas City properties from Ascension in November. Ignite will break ground on an 11th location later 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 decided late last March that Ignite would stand up dedicated COVID-19 units to reinforce relationships with key acute partners.

“We realized strategically we needed to flip the switch,” he 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.”

Buildings that typically filled 90% of beds with traditional rehab patients could have 75%  COVID-19-positive patients and 25% rehab patients without COVID-19. After June, the mix fluctuated but census held steady.

“We were very communicative about how we could admit both patients,” Fields said. “Whether you’re doing broken hips, pneumonia, wound care or COVID, it’s about putting the right procedures in place.”

Allaire also created COVID-19 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 access to PPE.

“I personally was on the phone sometimes several times a day with the hospitals,” Kurland said. “What do you need? How do we get it? What could we do? There’s a high level for collaboration. I think when they saw how engaged we were, their confidence really went up. They said, ‘You know what? We could send these patients there.’”

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.

Kramer noted that select SNFs can rival capabilities offered in long-term acute-care hospitals or inpatient rehabilitation facilities, but at lower prices. Demonstrating that they don’t send patients back to the hospital — a pain point for home health — also sweetens the deal, especially for partners in incentive 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

Allaire’s data sharing, infection prevention success and willingness to pay for additional staff caught the eye of Pennsylvania officials. In May, they offered Allaire a contract to manage Brighton Rehabilitation and Wellness Center, where 73 residents and a housekeeper died during COVID-19’s peak.

The building’s first temporary manager lasted only a week. Allaire’s contract was extended last summer and, at press time, was ongoing — providing an additional source of income.

In some cases, Kurland hired new staff for the communities Allaire took over. He reassigned workers if they were willing and relied on an existing program that uses hospital nurses to train nursing home staff on caring for complex patients.

Knowledgeable workers were key to securing COVID-19 partnerships with hospitals, said Mark Fritz, president of Bridgemoor Transitional Care and its four Texas locations. Three of his facilities have full-time respiratory therapists, and Bridgemoor also employs infusion-trained nurses.

“Our teams are used to working in higher acuity so it wasn’t as hard for us to make changes,” Fritz said . “Those things were not something we had to re-tool for.”

Bridgemoor experienced a “shocking” occupancy drop of about 50% after Texas officials stopped elective surgeries.

Like many providers, Bridgemoor worked with its real estate partner, Invesque, for a short-term reprieve. Invesque leaders acknowledged during a recent earnings call that they did not receive revenue from Bridgemoor during the fourth quarter of 2020. The real estate investor said February’s harsh winter weather compounded the region’s COVID-19 stress to put Bridgemoor in the “proverbial eye of the storm.”

But in March, Fritz struck a more optimistic tone, buoyed by an ongoing relationship with a hospital that used his facilities to offload some COVID-19 cases.

“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, however, did not fill as many beds with COVID-19 patients as others. At times, staffing was so challenging the operator could not admit new patients.

In the end, Fritz said, it was the state’s periodic resumptions of elective surgeries that kept his company afloat. 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.

Be an asset when needed

Its relationships strengthened, Bridgemoor is preparing to pilot specialty programs in congestive heart failure and COPD starting this spring. Those patients may help balance occupancy into the future, even as hospitals continue sending more orthopedic patients home to recover.

“Our industry is changing, and this is just going to be part of it,” Fritz said, noting safety is as important to consumers as it is to his managed care partners. “However you do it, everyone is going to have to get to more private rooms and more physician involvement.”

Of course, leveling up skilled care requires capital. Not everyone can convert to single beds and take revenue offline when occupancy remains at record lows.

For providers without deep pockets, like those with majority-Medicaid clients, 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-19 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.”