On the mend

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On the mend
On the mend

The acuity shift from inpatient care all the way through to seniors housing is demanding that assisted living — and even independent living, to a certain extent — provide an increasingly clinical service menu for residents, and rehabilitation is a major part of that trend.

As post-surgical, cardio and stroke patients are moved from inpatient services to skilled nursing facilities, seniors housing is receiving a higher number of frail, vulnerable and cognitively challenged residents who need a greater degree of clinical care. With that shift comes a need for senior living communities to provide more robust rehabilitation therapy services, specialists say.

“This has become a focus in all the states where we do business,” said Paul Riccio, vice president of finance for Vertis Therapy. “If you look at almost every senior living facility built within the last five to seven years, almost every one built a therapy area. Before that, most didn't have it. They may have smaller rooms for therapy programs, but no true gym space.”

The acuity shift across the elder-care continuum has caused tangible changes in the physical plant of newer facilities, Riccio observed. For instance, he said, SNFs' focus has gone from providing all the care to residents to preparing them for the next stage — either home healthcare or assisted living.

“What that has done to senior living is move it from wellness and add-on care to essential aging in place,” he said. “It is part of the acuity shift that is changing the face of the senior living market.”

Leigh Ann Frick, chief clinical officer for HealthPRO Heritage, said the acuity shift has been “dramatic” over the past 10 years.

“Assisted living communities of today are essentially the skilled nursing facilities of yesterday,” she said. “Likewise, independent living communities have become more like assisted living. Additionally, senior living operators are facing more competition and challenges because there has been a rise in the number of new communities — some of which feature more amenities.”

From that standpoint, it is advantageous for savvy assisted living operators to leverage their rehab services in innovative, forward-thinking ways, Frick said.

“For example, a strong therapy program can be considered a marketing advantage, because rehab services essentially attract new residents and ultimately enhance census,” she said. “In fact, therapy services — inclusive of sophisticated wellness programs and clinical niche programs — can serve to differentiate one senior living community from its peers.”

Additionally, customized, high-quality therapy services are important because they address the complex needs of a higher-acuity patient population, Frick said, citing dementia programming as a perfect example.

“Ultimately, a strong therapy program will preserve residents' function and quality of living, mitigate risk of re-hospitalization and ultimately to extend time in residence,” she said.

Ramping up rehab

To be sure, there hasn't been much direct rehab inclusion in any aspect of senior living, agreed Chris Krause, director of rehab for It's Never 2 Late.

“If there was, it's was typically provided as a ‘home health benefit,'” he said. “But that has evolved over the years in a number of ways. While assisted and independent living have emphasized general wellness programs, I've also seen continuing care retirement communities pull their SNF rehab teams into the wellness equation while also offering rehab on an outpatient basis. The most significant growth is in memory care, which makes sense, as that population typically presents in a way that is consistent with a SNF setting.”

When it comes to rehab, senior living communities should offer the complete array of services, including occupational, physical, speech and cognitive therapies for residents, rehab specialists say. Although therapy services tend to be less intensive in assisted living than in skilled nursing, Tamara Althoff, clinical speech-language pathology specialist for Centrex Rehab, said they should offer therapies to address balance, ambulation, falls prevention, activities of daily living, communication, cognition and swallowing.

In particular, cognitive therapy has become entrenched in seniors housing, said Pam Brooks, occupational therapist for Centrex.

“However, over the next few years the evolution of the ‘whole-team approach,' including nursing, family, chaplain and therapy recreation, will become apparent in all home environments,” she said.

Customize to need

As an OT, Brooks is familiar with the intricacies of dealing with geriatric residents and said that relationships are an essential component of therapy.

“All caregivers should understand a client's cognitive level to be able to successfully interact, provide appropriate activities and decrease the propensity for negative behaviors,” she said. “In turn, this provides caregivers and clients with a sense of meaning, purpose and satisfaction. Clients can then remain actively involved in daily activities, which will improve their quality of life.”

Althoff added that rehab staff who work in senior living communities must get to know their residents well.

“Knowing a resident's history, dislikes, likes and past occupation will allow you to provide meaningful activities that are geared toward the things they enjoy doing,” she said. “Staff should also ask residents about what stimulates them and what activities they prefer, which supports a person-centered approach.”

In Riccio's view, occupational therapy is a valuable rehab service for senior living — an essential part of the three-legged stool that includes PT and speech-language.

“A dynamic OT program teaches more function than any other therapy,” he said. “It is more directly tied to the home environment and activities of daily living.”

Beyond the basics

As rehab continues to shift into senior living, providers also need to consider forming partnerships to offer other service options to be competitive, said Peter T. Klug, director of category management for clinical and rehabilitation at Direct Supply. Although most senior living won't qualify directly, facilities should be aware of the post-acute bundles the Centers for Medicare & Medicaid Services is making mandatory.

“All providers should be prepared to offer hip and knee replacement rehabilitation that was included in the Comprehensive Care for Joint Replacement bundle,” Klug said. “As part of these bundles, hospitals are looking to discharge their patients to partners that provide the highest functional outcomes at the lowest cost possible for that individual patient. The latest mandatory bundle that CMS announced is cardiac care and includes hip and knee fractures as well. I expect that pneumonia and septicemia will be on the list for the future, as well as chronic obstructive pulmonary disease.”

By offering programs targeted at higher-acuity patients with the equipment therapists and nurses need, as well as the systems and processes to deal with increasingly complex patients that require skilled nursing care, senior living providers are positioning themselves as solid rehab options, Klug said.

Medically complex rehab programs are highly relevant for many assisted living residents now, Riccio said. Cardio therapies address several comorbidities and can prevent rehospitalization, he said, whereas a dynamic falls and balance program also serves to keep residents living safely at home.

New frontier

Building strategic partnerships with SNFs, home health organizations and acute care providers is a critical part of what Frick called “a new frontier” for senior living operators.

“As healthcare reform continues to shape our industry's future, senior living operators who align themselves with accountable care organizations and health systems participating in bundled payment initiatives will be expected to demonstrate measurable, positive outcomes,” she said. “Rehab services play a key role in tracking, managing and optimizing such key metrics as functional outcomes, length of stay, rehospitalization rates and cost of episodic care.”

Technology plays a key role in rehab outcomes reporting, and therapy companies such as HealthPRO Heritage are using sophisticated platforms, Frick said.

“This use of technology is a good example of how senior living operators rely on therapy providers for up-to-date resources and expertise to help them meet the challenges and expectations of this rapidly evolving industry,” she said.

Though seniors housing facilities and SNFs may appear to be competing for the same residents and rehab clients, Riccio said the two entities actually should see each other as partners in post-acute care.

“The senior living and SNF providers are actually in the same boat to achieve the same outcome for the lowest cost possible,” he said. “The providers who work together can team up to market on a unified front to ACOs will see higher results across the board. They should see it as an opportunity across the continuum to help both organizations long term.”

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