More Skilled Nursing Providers Fill Care Gaps with Palliative, Hospice Services

More than two years after Covid-19 first hit the United States, more nursing home operators are expanding services for residents, in part to address care gaps exposed by the pandemic.

Palliative and hospice care in particular are two service lines operators are targeting.

Murfreesboro, Tenn.-based National Healthcare Corp. (NHC) acquired outstanding stakes in Caris Healthcare for $38.95 million in June 2021. Marquis Health Consulting Services more recently set to expand its chronic illness support model across the organization, which includes palliative and hospice services. Roughly 75% of its mid-Atlantic facilities, about 25 buildings, have rolled out the chronic illness support program.

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Jennifer Hertzog, vice president of marketing and business development for Marquis, considers the program to be a primary focus for the company; the team eventually wants such services to be offered across all of its SNFs.

“We’ve realized for years that there was a void in the care that we were providing,” said Hertzog. “Like many operators, the pandemic drew even more attention to the gap in care opportunities.”

The Brick, New Jersey-based company, which provides administrative and consulting services to 58 facilities across seven states, has built out a specialty care division over the last five to seven years, she said.

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The division, which focuses on chronic disease management, has grown in the last six to nine months; the pandemic prompted Marquis to build on its chronic illness support model across the organization.

While NHC deals primarily in nursing homes, its affiliates also operate 28 hospice agencies. At the time of the transaction, an NHC spokesperson said full ownership in Caris gives NHC further opportunities to expand its overall continuum of care for seniors, and strategically grow in states where NHC and Caris operate, among other markets.

Other providers, such as PruittHealth, have had hospice offerings for a number of decades. Now, the Norcross, Ga.-based company has just gotten into palliative care through nurse practitioners, according to CEO Neil Pruitt; Pruitt treats its hospice line as a completely separate company, he added.

As of August 2022, Pruitt was caring for 12,045 patients in hospice, he said. At the same time, about 70% of Pruitt’s SNF patients are sent home after care.

“Our job is to do everything we can to get you better and to get you home, and make sure you stay home,” said Pruitt. “When that’s not the case, we need specially trained people that are completely separate from our other health care center operations, that can help residents through their last journey.”

Diversification and differentiation

In addition to improving continuity of care and potentially improving length of stay, there is a potential financial reward for adding hospice and palliative care as ancillary services to a SNF business. The anticipated 2021 Medicare margin for hospices was 13%, according to the Medicare Payment Advisory Commission (MedPAC). This is higher than MedPAC’s estimated 2021 SNF Medicare margin of 10%. And given that the average non-Medicare margin for SNFs was -2% in 2019, it’s easy to see why operators are looking for additional revenue.

Legal experts have warned operators that getting into ancillary businesses simply to take advantage of an additional revenue stream is a bad idea, especially with state and federal agencies paying close attention to SNF financial transparency and ownership breakdowns.

Most recently, the HHS Office of the Inspector General added a probe into Medicare payments for “related parties” in order to determine if SNFs are reporting such costs in accordance with federal regulations.

At least five states have passed laws to limit where nursing homes may spend Medicaid revenue, along with requirements to report finances and ownership changes.

Still, if done right and for the right reasons, service lines like palliative and hospice care can help a SNF provider separate itself from other operators, according to Janine Finck-Boyle, vice president of health policy for aging services organization LeadingAge.

Service line diversification helps operators evolve, she added, in terms of contracting and collaboration with third-party businesses in the future.

For most operators just getting into these service lines, partnering with hospice and palliative care providers — or acquiring them — is needed, since many SNF companies don’t have the existing resources to launch these offerings in-house, according to Finck-Boyle.

“Hospices have chaplains and social workers … there are ways that nursing homes could work with them, where it’s not taxing their current staff,” said Finck-Boyle. “It takes a board to think strategically, start thinking out of the box. It will take time for the executive staff to put all that together and make sure that it’s compliant.”

Pruitt doesn’t suggest operators integrate palliative and hospice into SNF operations – these really need to be separate programs with specially trained staff members.

Forging partnerships

Skilled nursing operators that cannot or prefer not to acquire or build in-house hospice and palliative care divisions can still bring the offering to residents by identifying preferred partners.

For Marquis, finding and identifying the right hospice and/or palliative care partners for the chronic illness support model was first priority. Selection and rollout was based on where the company engaged like-minded organizations, according to Hertzog.

In some cases that right partner was a local hospital system, and in other instances it was a standalone hospice and palliative care provider.

“We always look to see if there’s an opportunity to align with our community hospitals – that’s our first priority. If those opportunities don’t present, we move on to community-based providers,” added Hertzog.

Providers with the expertise and resources to support the Marquis clinical team on the floor added value to this kind of care, she said.

In-facility palliative care under the direction of AccentCare, formerly Seasons Hospice & Palliative Care, is a perfect example of the type of partnership Marquis looks for as part of its chronic disease management model.

Westgate Hills Rehabilitation and Healthcare Center in Baltimore, Md. and Orchard Hills Rehabilitation & Healthcare Center, also in Maryland, have AccentCare staff available at facilities to help with palliative care, she said. AccentCare’s billing and revenue remain 100% independent of Marquis.

Bridges Palliative Care and Keystone Care are other partners for facility programs in Pennsylvania.

“You will absolutely see a trend evolve here. This is a larger industry topic … standout operators will step forward to provide a continuity of care that is expected,” Hertzog said.

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