Abby Burns (00:23):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Abby Burns. If you've been paying attention on Radio Advisory, you know we've been talking about hospital throughput, health system growth, the patient journey across sites of care.

(00:41):
Well, I have to start this week's episode with a bit of a mea culpa, because there is an incredibly important subsector of the industry that has been all but absent from those conversations, post-acute care. And I'll be honest, this is an area of the industry that is often villainized and, on the whole, pretty poorly understood.

(01:01):
It's also the part of our industry that takes care of our family members who need long-term care, who aren't sick enough that they need to be in the hospital but are too sick or frail to go home, that provides home health when they can go home but still need extra care. We haven't been able to crack the code on hospitals and post-acute facilities working together effectively, and we want that to change.

(01:22):
So this week, I'm bringing on Monica Westhead from Advisory Board and Jennifer Skaggs from Optum Advisory. They're going to help us do two things. One, shed some light on the post-acute care landscape, and two, help us understand what effective collaboration between acute and post-acute care actually looks like. Monica, welcome back to Radio Advisory.

Monica Westhead (01:45):
Thanks for having me again.

Abby Burns (01:47):
Monica, listeners might recognize your name, your voice. You are the head of Advisory Board's workforce and post-acute research. Jennifer, welcome to Radio Advisory for the first time.

Jennifer Skaggs (01:58):
Thank you so much for having me.

Abby Burns (02:00):
And Jennifer, I am really glad that you were able to join us, because you bring a long career of on-the-ground experience working all across the post-acute sector. Can you introduce yourself for our listeners?

Jennifer Skaggs (02:14):
Sure, I'm happy to. My name is Jennifer Skaggs. I'm a licensed nursing home administrator. I have worked in the post-acute care space for more than 30 years. I've been responsible for nursing homes, assisted livings, home health agencies, hospice agencies. I've been a part of CCRCs or continuing care retirement communities, and I've also worked for hospital systems as well as large nursing home chains, also mom-and-pop facilities and agencies as well.

Abby Burns (02:44):
Maybe it would have been faster, Jennifer, if I had asked you where you haven't worked in the post-acute sector.

Jennifer Skaggs (02:52):
My current role is as a manager for Optum's clinical team, as a post-acute care subject matter expert. I'm working with a large hospital system in New England.

Abby Burns (03:03):
Awesome. I have to say, I spend a lot of time talking with health system leaders, but my conversations with post-acute leaders have been much fewer and farther between. So can you sort of bring me up to speed on what's happening in the post-acute landscape? What is the current state of play?

Jennifer Skaggs (03:21):
As far as the post-acute care landscape, it has really changed a lot in the past five years post-COVID. We are now struggling with staffing and the ever-increasing and more stringent regulatory piece of it as well. Basically, since COVID, a good portion of the workforce in healthcare in general walked away, but especially in the post-acute space.

(03:43):
So PACs are basically struggling to survive as they face more potential regulations, including some staffing requirements that are on the horizon, and they have even less staff than they had before COVID. So this, along with an aging population, means an increase in the need for post-acute care as those staffing numbers continue to dwindle. So couple that with insufficient funding and significant increase in costs, it really is the perfect storm.

Abby Burns (04:12):
That's a pretty tough picture you've just painted. And a lot of times, people talk about healthcare as an ecosystem. Right? When one part of an ecosystem falters, it has ripple effects. Monica, what are the most important ripple effects from the landscape Jennifer just painted? And really, I'm thinking, why should leaders outside of the post-acute sector be hearing warning bells?

Monica Westhead (04:39):
I have heard more interest from health system executives about post-acute care in the last year than I had in the previous 10 years or so of doing research in this space. And the primary reason for that is that as post-acute facilities and specifically skilled nursing facilities, because that is where the majority of, or at least the plurality of patients that go to post-acute care from the hospital go, as those facilities have closed, as they have seen staffing shortages, you're ending up in a position where hospitals are unable to discharge patients.

Abby Burns (05:14):
Yes.

Monica Westhead (05:14):
So if you're a hospital and you can't get people out of your beds, that means you can't get people into your beds. And for hospitals, that is a throughput problem. It is a reputation problem, and it's also a margin problem for them as well. And so, it is really tightening a situation that was already feeling pretty tight for hospitals.

Abby Burns (05:32):
This came up when we were talking with Isis a few weeks ago about hospital length of stay and how can we reduce hospital length of stay, and one of the biggest barriers she pointed to in her research was the lack of post-acute capacity. Jennifer, you also mentioned the aging patient population. We know that's a population that is also getting more medically complex.

(05:50):
So I imagine that this problem is not, by itself, going to get any easier. Very practical question for the two of you. If hospitals need more access to post-acute capacity, and post-acute facilities are sort of struggling en masse, should hospitals and health systems just build or buy their own skilled nursing facilities, for example?

Monica Westhead (06:13):
I get this question a lot, and my answer is almost always no. It is really challenging to run a post-acute facility well. That's one reason. And Jennifer, I know you know this way, way better than I do.

Abby Burns (06:24):
Better than most.

Monica Westhead (06:24):
So you'd probably provide some additional context there. But if you don't know how to do it, if you're used to running a hospital, the types and levels of regulation that are in the post-acute setting are very, very difficult to get your hands around. The other challenge I would say is, patients leaving the hospital, especially Medicare patients, have their choice of where they go to receive post-acute care. And just because you build it, does not mean they will come.

(06:50):
So typically, if you do end up building your own post-acute facility, you're going to end up getting the patients that are extremely hard to place in other settings in the community, which is not only more difficult but also more financially taxing to care for as well. Jennifer, I know you've done this, so I want to hear from you.

Jennifer Skaggs (07:09):
I think it would be a very difficult time to consider purchasing or even building a post-acute care facility for hospital systems. So I think it's probably better to consider how you can better work with them, whether it be through your post-acute care network or maybe even pursuing other types of partnerships such as bed leasing.

Monica Westhead (07:29):
I think it's really interesting that you asked that too, Abby, because I think it highlights some of the misconceptions that certain stakeholders in the industry have about post-acute care, that it is similar to delivering care in other settings, that, essentially, either it is residential care and that's all it is, or it is like a hospital with fewer staff, and it is in no way those things.

(07:53):
I think also there is a lack of understanding about the breadth that is under the umbrella of post-acute care. So we've been primarily talking about skilled nursing facilities, because that's kind of the big one, but home health, inpatient rehab, long-term acute care hospitals, there is so much that fits under that post-discharge umbrella that it's difficult to boil it down to such a simple question of, "Should I build this? Should I buy it?"

Abby Burns (08:22):
Right. Exactly. When you say, "Maybe I'll build post-acute," what I'm hearing is that actually doesn't mean much of anything, because the scope of that is so wide. So it sounds like one of our goals in this conversation today should be to shed some light on the post-acute sector so that other stakeholders, especially hospitals, I would imagine, can start to gain a bit of insight into how to work with PAC partners more effectively. Is that a fair goal?

Monica Westhead (08:48):
Yes. And I also think that post-acute organizations have sometimes been looked down on by other parts of the healthcare industry, that they don't provide the same level of complex care. They serve a really, really important role in the healthcare delivery industry, and I think being respectful of what they do, the unique strengths that they bring will go a long way in helping understand why they make the decisions that they do. I would also want to just raise here that the reimbursement environment for post-acute facilities is very different than it is for hospitals.

Abby Burns (09:28):
Monica, you're getting into almost some of the myths that we might want to bust about post-acute care, or corrections we might want to make in the narrative around it. So I want to just be super explicit here, and I will group myself in with a cohort of people who would benefit from someone essentially sitting me down and saying, "Abby, here's what you need to understand about post-acute." What are the most important things that I need to grasp to really have an understanding of this sector?

Monica Westhead (09:54):
I think the first thing that I would want to raise is the reimbursement environment. Skilled nursing facilities, in particular, are largely on a fee-for-service environment still. They are paid per diem. So that means that they are paid for the individual days that someone is in their facility.

(10:14):
That can also mean, since they're not paid for things like medications, that sometimes they're not willing to take patients, because the amount that they would get paid to take care of them is less than the amount it costs to take care of that patient if they're on, for example, an expensive medication. So their reimbursement environment, which has been made more complicated by an increase in Medicare Advantage and an increase in Medicaid, is one of the things that I think puts them at odds with hospitals.

Abby Burns (10:46):
Jennifer, what would you add?

Jennifer Skaggs (10:48):
I can't agree more. The line between profit and loss in a nursing home environment is razor-thin, and it's imperative that nursing home operators are very careful as far as what types of patients they're able to take. Another misconception is that nursing homes can be difficult to work with because they don't accept all of the potential referrals that they receive.

(11:16):
And a lot of people don't realize that nursing homes cannot accept potential residents that could be a safety risk to themselves or others, and they also have to ensure that they can meet the needs of each resident that they do accept. So some of these complex residents that we're talking about can pose a great challenge for those facilities and could actually be potential liability for them as well.

Abby Burns (11:41):
Yup. I'm so glad that you brought this up, Jennifer, because I do think that a lot of the tension between the acute and post-acute parts of the industry really stems from issues around the process of trying to discharge a patient from a hospital to, for example, a SNF. Can you speak to the regulatory side of that? Because my understanding is, that is a huge piece of the puzzle here.

Jennifer Skaggs (12:03):
A lot of people don't realize that the nursing home industry is one of the most regulated industries in the world, and it certainly is the most regulated in the healthcare sector.

Abby Burns (12:11):
Do you have any examples that might help sort of ground us in that?

Jennifer Skaggs (12:15):
For example, a dialysis patient could potentially be a challenge for a post-acute care entity to accept, especially the transportation piece of that. There are some states that actually reimburse for transportation to dialysis, but there are some states that do not. And so, if they do not, you're typically looking at about a $25,000-per-year, per-resident cost, and PAC facilities cannot afford that.

Abby Burns (12:40):
Yeah, back to your point of their margins are razor-thin.

Jennifer Skaggs (12:44):
Yes. Exactly. And then on top of that, if you take a patient and you can actually provide the transportation, something that always made me nervous as a PAC operator was if I had a Tuesday, Thursday, Saturday chair. If that transportation falls through, even if it's arranged, it still falls back on the facility. They are responsible for ensuring the resident is transported to dialysis. So I have had to personally take dialysis patients myself in our facility van on a Saturday morning, because the transportation that was already scheduled fell through. So that's a personal liability that the facility has to consider.

Monica Westhead (13:22):
I think it's worth noting that post-acute facilities and SNFs don't have the same infrastructure that a hospital does. So they may not offer on-site dialysis. They might not have the ability to handle ventilated patients. They may not have an on-site pharmacy. So all of these things that are standard in a hospital just might not be there in a SNF.

Abby Burns (13:43):
Another regulatory consideration I'm wondering about is actually around staffing requirements. A couple of weeks ago on Radio Advisory, we were talking with our colleagues Ali Knight, Anne Schmidt, and Sherilynn Quist, and we were talking about staffing minimums, for example. How does that play in the post-acute space?

Jennifer Skaggs (14:00):
Staffing minimums are very important and dramatically impact your capacity to be able to take new patients. There is a federal minimum already established across the country, but some states also have minimum requirements as well, and we actually are looking at a proposed rule that will increase the staffing quite dramatically in the space.

(14:23):
And unfortunately, we have facilities that are already struggling to meet the minimum that already exists. And so, with this additional staffing requirement that could come to fruition, it's a very concerning time. Facilities are doing everything that they can to recruit and retain staff as it is, but there simply isn't enough staff to go around.

Abby Burns (14:46):
It's really helpful to sort of understand these various regulatory and other pressures that post-acute facilities are balancing, because it really speaks to just how much is going on beneath the surface of decisions, for example, to accept a patient or not. And for me, I think it really underscores how important it is for acute and post-acute care facilities to communicate really clearly and to ideally develop those close, collaborative relationships. So that's where I want to take our conversation next. Where would you start us off? What is the status quo of that collaboration today?

Monica Westhead (15:21):
What's interesting is I started doing research on post-acute care in 2013. And if I think about where we were in 2013, it was very much about, how do hospitals build preferred provider networks for post-acute facilities? How do they identify the highest-quality providers in their market? There was a lot of progress made. And I think unfortunately, while COVID did result in some additional collaboration in the moment, it also kind of threw some of those longer-standing priorities out the window, because everybody was just focused on emergencies all the time.

(16:04):
If I look at where we are now, and Jennifer, I'm curious if you're seeing this too, it feels like everyone is kind of back where they were, realizing, "Actually, we really need to develop partnerships." And some of them are starting from scratch. Some of them are picking up where they were. But in many cases, partnership between acute and post-acute providers had taken a step back due to the pandemic and were kind of just returning to that need because of the acute care capacity constraints that we're seeing.

Jennifer Skaggs (16:36):
I think that hospitals are reapproaching the networks that they had established prior to COVID, and they're realizing that the post-acute care entities that they worked with before are not necessarily the same.

Abby Burns (16:49):
Yes.

Jennifer Skaggs (16:49):
COVID has changed the landscape without question. So I think it's important for hospitals now to get out and visit the post-acute care entities that they can potentially partner with. There have been facilities that have closed across the country. There have been facilities that have been bought and sold. So the landscape has changed. So we have to re-evaluate the landscape, and even facilities that still exist. Just because they offered something pre-COVID, doesn't mean that they can still offer that same service post-COVID.

Monica Westhead (17:20):
It's worth noting, we can help with that. So we have a tool on the Advisory Board website. It's called the Post-Acute Pathways Explorer, and it uses claims data to show you patient movement patterns, from acute to post-acute care as well as between post-acute facilities or entities. So you can see. If you're a hospital leader, you can log in and see, "Where are my patients going when I discharge them? Are they overwhelmingly going to a post-acute facility that maybe I didn't realize was one our primary partners?" There's also outcomes data in that tool so that you can identify partners that could be a better partner with you based on their readmission rates or their mortality rates, or even for specific diagnoses.

Abby Burns (18:03):
Is that sort of analysis, Jennifer, something that's happening regularly already among hospitals, health systems?

Jennifer Skaggs (18:11):
Yes, it is. Hospitals are starting to look at the data to see what is available out there, what services are being provided, where their patients are going, and really trying to look and see if their patients are going to the right setting, because in order to ensure a successful transition, you have to ensure that they're going to the right setting.

(18:32):
I think initially, post-COVID, it was just a matter of finding a bed. Well, we have to look beyond just a bed at this point. We have to make sure it's the right bed, that patients are getting the right care in the right facility, and that ensures a successful transition, and that they don't return back to the hospital as well.

Abby Burns (18:51):
Yup.

Monica Westhead (18:53):
And Jennifer, I think that's a great point, because I think especially during and following COVID, I heard a lot of home-first methodology, that we're going to send patients home. We're going to use home health as much as we can. Home health is an incredibly valuable tool. However, it is not the most appropriate setting for every patient. And so, health systems that might think, "Home health is going to solve my discharge problems," will be disappointed, because that can't be the entirety of your post-discharge strategy.

Abby Burns (20:25):
So in the spirit of understanding what effective partnerships look like, I feel like mostly so far, we've been speaking to hospital and health system leaders. They're obviously not the only actors here. So when it comes to strengthening partnerships, what should post-acute facilities do?

Monica Westhead (20:39):
I think one of the things that's most important for post-acute facilities to focus on is to know their own data. They need to know how they're performing, where their opportunities are, what patient populations or demographics they are particularly well-equipped to care for in order to be able to approach hospitals and health systems with that information. Hospitals and health systems, as we mentioned, may not fully understand the post-acute industry, because they're not in it. That's where post-acute facilities can make their case in terms of, "Why you should partner with me, why my outcomes are better for a specific population."

Jennifer Skaggs (21:20):
I think during COVID, most post-acute care facilities circled the wagons and went into survival mode. And so, now, it's time to open the curtains and welcome others in and dust off the notebooks, if you will, and have a good understanding of their data, and talk about it and share it. As you said, with hospital systems, help them to understand what you have to offer.

Abby Burns (21:46):
Yup. Yup. Yeah. What I've been hearing a little bit, Monica and Jennifer, in what you've been saying is there's almost been a shift in the power dynamic where hospitals recognize that they, in fact, need post-acute care. And so, our goal here is, "Okay. If we know that we need post-acute care, how can we actually go about partnering with them?" So that is maybe a good transition point to turn the microscope on hospitals. What steps should hospitals take to partner more effectively with post-acute?

Jennifer Skaggs (22:12):
I think it's important for hospitals to get out into the community and visit the PAC entities that they could potentially partner with, to meet with them, to actually see what they have to offer hands-on in the building, to also partner with them in looking at barriers that they can address together, seeing who can handle those special circumstances, those clinically complex patients, bariatric patients, substance use disorder. There are all kinds of different challenges as far as post-acute care placement, and lots of facilities have different things to offer. So it's just understanding what each entity can offer and working with them.

Abby Burns (22:54):
Yup. Jennifer, I'm wondering if you have any examples you can share from your experience what an effective partnership between a post-acute and an acute facility has looked like.

Jennifer Skaggs (23:05):
Sure. In the past, we actually recognized across our network that there was a higher percentage than both the state and the national benchmark as far as UTIs.

Abby Burns (23:15):
Oh, wow.

Jennifer Skaggs (23:16):
And so, we worked together on an education plan for the network, educating providers, educating staff within facilities in the PAC, and then also educating patients as well, and we actually saw the needle move. When you focus on something and you work hard on something, you actually see the needle move. And so, it was great to see that happen.

(23:37):
And I saw it quite a bit during COVID as well. There were so many things going on during COVID, and everyone was struggling to keep up with supplies, so constantly communicating with each other and sharing supplies. I think everyone, at some point, had to borrow from someone else, and they were happy to oblige in return. And I think that relationships is really the most important thing, having those relationships with each other. We can work together to ensure that patients get the care that they need.

Abby Burns (24:11):
Monica, anything you'd add?

Monica Westhead (24:13):
I think one thing, Jennifer, that you said that really stuck out to me was the idea of partnership and relationship and being willing to share. I think one thing that sometimes hospitals don't realize about post-acute facilities is they don't necessarily have educators, for example. And so, we have seen examples of where hospitals have sent an educator to the skilled nursing facility to provide education around a new technique they were working on or how to care for patients with a particular type of wound VAC, for example.

Abby Burns (24:47):
This would be a clinical educator.

Monica Westhead (24:49):
This would be a clinical, like a nurse educator, typically. We've also seen examples of hospitals offering joint training sessions for their own nurses as well as nurses from the community. That not only provides the education that those nurses might not be able to get otherwise, but it also facilitates the building of a relationship.

(25:09):
And Jennifer, as you were talking about just setting foot in facility, a lot of the people who work in acute care have not necessarily ever been inside a SNF, unless they were there to take care of their own loved one or visit a loved one. And so, they don't really know what happens in those buildings, and it's kind of a scary black box. Any opportunity that you have to build those relationships and really humanize the people that work there, the people that receive care there, the residents in those facilities, makes a big difference in facilitating a more collegial relationship between the different parts of the continuum.

Abby Burns (25:48):
And ultimately, a more effective partnership. Monica, Jennifer, we've covered a lot. What is one lesson or action that you want our listeners to walk away with?

Jennifer Skaggs (26:01):
I would just emphasize, again, the importance of relationships. Handling difficult transitions to the post-acute space, that is so much easier to deal with when you have an established relationship with someone. You can work together to resolve whatever problem may arise. Sometimes it can be challenging when it is a challenging patient, and they have a challenging family on top of that. All of those things can be worked through, and you can build trust in each other and work through any problem that arises.

Monica Westhead (26:34):
I agree, Jennifer. I think it is always a question of relationships. And because of the differing incentive structures and regulations, it can often result in a lot of tension, and hospitals and post-acute organizations can sometimes find themselves at odds or thinking negatively about the motivations of the other. And I think the more we can break that down and the more that we can foster that collaborative environment, the better it's going to be for both of those types of providers as well as for the patients and the communities that we serve.

Abby Burns (27:11):
Well, Monica, Jennifer, thank you for coming on Radio Advisory.

Monica Westhead (27:16):
Thank you for having us.

Jennifer Skaggs (27:18):
Thank you.

Abby Burns (27:18):
The post-acute care landscape is challenging. An effective partnership between hospitals and post-acute facilities is only going to be more important as our population ages and becomes more clinically complex. The good news is, we're here to support you. If you want to learn more about effective post-acute partnership, we have a rich library of resources at Advisory Board.

(27:45):
If you're at the stage where you're ready to do and you want some help, we can get you in touch with Jennifer and her team. We'll put links to help you do both in the show notes, because remember, as always, we're here to help.

(28:11):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Abby Burns, as well as Rae Woods, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson, with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.