LeadingAge Magazine · November-December 2016 • Volume 06 • Number 06

Strategizing Change

November 18, 2016 | by Gene Mitchell

Aging-services providers must always adapt to changing environments and the needs of new generations of consumers. Here is how some are rethinking their organizations while preserving mission.

Adaptation and willingness to rethink old models have always been hallmarks of the aging-services field. A look at the origins of LeadingAge members, some of whom began their existence well over a century ago as “widows’ homes” or orphanages or retirement homes for veterans, illustrates the many paths providers have taken to reach today’s service models.

But today’s service models aren’t the end of history either, and continual change will characterize the future as much as it has the past. Today, we are witnessing many mergers, affiliations and acquisitions as organizations seek the benefits of greater size for long-term financial stability and to better work in a world of integrated health management. Other providers are turning to partnerships to reach new populations of seniors. Many others are changing their service mixes and expanding into home and community-based services. And providers are recognizing that thriving in the future requires not only new initiatives but knowing when to stop certain services.

In this article we’ll look at 4 providers who are rethinking their structures and service mixes, making hard decisions to adapt to future realities. One single-site provider is upgrading its service offerings and campus; another group of providers has created a partnership to allow access to integrated health care systems; and two more have learned that moving forward also means knowing what to stop.

Adopting New Models of Care

For a single-site community in a competitive environment, there is little alternative to changing with an eye toward future needs and service. For JGS Lifecare, Longmeadow, MA, the celebration of the organization’s 100th anniversary was a natural reason to re-evaluate its position.

“JGS Lifecare was founded as the Daughters of Zion Home for the Aged in 1912,” says Martin Baicker, president and CEO. “It started as a 12-bed home in Springfield, MA. As it grew, it moved to other locations in Springfield and in the 1970s moved here to Longmeadow. In the 1990s we opened a 78-unit assisted living building, and also in the 90s, a home health care and hospice agency.”

In 1984, JGS Lifecare also built HUD 202 affordable housing on its 23-acre campus and expanded it in 1992 and again in 2003. The organization is not a life plan community, but offers the full continuum of care.

The 2012 strategic planning process resulted in Project Transformation, designed to “enhance, build and expand our services and facilities to improve health outcomes, and enhance resident dignity, independence and quality of life.”

JGS is embracing the Green House® model in a big way. The centerpiece of its transformation is a new 2-story, 24,000-square-foot building, the Sosin Center for Rehabilitation, to hold 2 Green Houses. It is scheduled to open this month. The Sosin Center, unlike most Green Houses that are designed for long-term skilled care, will be devoted to short-term rehabilitation.

The new center will bring JGS Lifecare’s rehab clients, until now served throughout the organization’s nursing home, the Leavitt Family Jewish Home, into the new Sosin Center. This will also clear the way for the conversion of two units in the Leavitt Home to a Green House model for long-term residents.

A new “connector” building has been built between the Sosin Center and the nursing home, and it includes a café and common space open to the outside community.

Ruth’s House, an assisted living residence, was substantially renovated last year, including major changes to the Garden Level, its memory care unit. Next year, JGS’ adult day program will also be shifted to a larger location in a different building on the campus.

“We’ve always talked about striving to be a center of excellence,” says Susan Halpern, vice president of philanthropy. “I think the centennial celebration gave us an opportunity to pause and look back at our many accomplishments but take a strong look at what the future. We saw a need to serve elders in a different way. Once we learned more about the Green House model and culture change, it all seemed very obvious that this is the way it should be. But if you took a serious look at how we operated it was a traditional model.”

As it does for many providers, increased rehabilitation services help JGS’ bottom line and support its mission for the long term.

Baicker says the JGS board “was ready for change. We knew we did a lot of great things already, but there was a strong sense we needed to do some things better.”

He also offers high praise for the help and advice offered by other not-for-profit providers.

“There are people who helped us along the way, even people who might be our competitors, who were very gracious and allowed us to visit,” says Baicker. JGS board members and staff visited Mary’s Meadow at Providence Place [part of the Sisters of Providence Care Centers], the Chelsea Jewish Foundation near Boston, The New Jewish Home in New York City, and Jewish Senior Services in Connecticut. Baicker says, “As these colleagues helped us, we intend to ‘pay it forward’ by helping others who want to learn from our experiences.”

Partnership Enables Community-Based Services to Thrive

While strategic rethinking involves internal changes to an organization, it also can mean creating partnerships to serve new populations or adapt to changing reimbursement environments.

In Grand Rapids, MI, a group of not-for-profits created TANDEM365 a couple of years ago to create an integrated care model to manage medical, behavioral and social health for seniors. Serving mostly Medicare Advantage clients in 2 counties, the organization helps deliver care and services that are not typically reimbursed.

TANDEM365 was created by, and is jointly owned by, Clark Retirement Community, Holland Home, Life EMS Ambulance, Porter Hills and Sunset Retirement Communities & Services.

According to Teresa Toland, CEO of TANDEM365, the seeds of the organization were planted 5 years ago when Mercy Health, a hospital system, wanted to streamline and standardize the way it worked with the area’s aging-services providers, as a way to help reduce hospitalizations and readmissions. The 4 aging-services providers began meeting to discuss discharge procedures, ways to eliminate poor transitions and information sharing, and to discuss case management possibilities to better serve seniors.

The group went on to apply for a CMS Innovations Grant, a process with side benefits.

“We spent 40 hours putting this transitions of care plan together, and that helped solidify our relationship further,” says Toland. “We were airing dirty laundry and talking about our successes. We had a one-for-all, all-for-one mentality. We did not get the grant, but continued to meet. We met weekly, hammering through some pain points for all of us.”

A series of monthly readmissions meetings with Mercy Health also helped the group work out a way to serve clients and identify problems to be solved.

“We came together to talk about a mission gap for elders in the community,” says Larry Yachcik, president and CEO of Porter Hills and board chair of TANDEM365. “All of us have certified home care divisions and [offer] skilled care. But we saw a revolving door of frustration and despair that chronically ill elders face. A lot of those conditions are manageable, if we could provide support services in the homes outside of the other things we all know about.”

Further meetings with more stakeholders (and another Innovations Grant application) led the group to expand its vision beyond transitions.

“Even if you could fix transitions of care back and forth,” says Toland, “we would still have people who would fall into gaps in a very fragmented health care environment without services or direction.”

The hallmark of the program is developing a personal relationship with each participant. After a referral is received, each client is assigned a nurse and a social worker who evaluate the participant’s medical and social needs and develop personal goals and a life plan.

“It’s a connected world where our individuals are assigned to specific team members so the interventions and care we deliver is well-communicated and there’s a rapid response plan for these individuals specific to them,” Toland says.

TANDEM365 has interdisciplinary team meetings every weekday, reviewing every client’s case. Thursday meetings include the medical director to review specific participants with medical needs. Team members interact with clients’ primary care physicians, personally meeting with doctors so all are on the same page.

“Most of the time the first things we work on are not the [medical] things. We know many other things in their lives are probably contributing to the outcomes of their physical well-being,” says Toland.

The need to deal with transportation—always a major factor in community-based services—led to one of TANDEM365’s most interesting features. Life EMS Ambulance joined the partnership. Integrated care paramedics employed by Life EMS can visit clients in their homes, especially after hours. Life EMS has smaller “responder” vans that can make routine visits as well as emergency calls.

Toland asks, “What if they need an intervention such as an IV, or a breathing treatment or medication that can be administered in the home to prevent an ER visit or hospitalization?” Life EMS triages after-hours calls; its paramedics can handle some interventions in the home, eliminating the need to transport to the ER in some cases. In emergency situations, participants have pendants with automatic dialers; calls go directly to the Life EMS communications center. Life EMS dispatch can place the RN on a call as well as the medial director so there is an exchange of information where all parties together make a treatment decision.

Today, TANDEM365 serves about 440 seniors in two Michigan counties (Kent and Ottawa), with plans to expand into Allegan County. Its clients, with few exceptions, are Medicare Advantage enrollees insured by Priority Health, an insurer. Priority’s desire to reduce costs for its most expensive clients led it to work with TANDEM365.

Two of the partners—Porter Hills and Holland Home—run PACE programs and, Yachcik says, that experience gave them a background in managing coordinated care: “Our experience in PACE gave us a framework in coordination of care. The difference with PACE is that you must be eligible for skilled care to participate but in TANDEM you don’t need to.”

Creation of TANDEM365 meant risking a new approach for its founders.

“We went individually to all our boards and talked about an approach where there is no reimbursement apart from insurers,” says Yachcik. “The biggest thing was for us to realize we were implementing something that didn’t exist elsewhere. The existing models will follow people 30, 60 or 90 days and they’re left on their own. It was an institutional change of mindset. It’s the beginning of how to care for people in the future.”

Future goals for the organization include adding other payers to ensure long-term sustainability, focusing on population health management to serve dual eligibles and finding ways to better support veterans.

Knowing What to Start and What to Stop

The Evangelical Lutheran Good Samaritan Society, based in Sioux Falls, SD, provides the full continuum of senior services in more than 250 sites across the U.S. The organization, which gets most of its revenue from federal and state funding for skilled nursing services, has many communities in rural areas with declining populations and workforces.

Historically, according to Tom Syverson, executive vice president and chief operating officer, the organization has followed disciplined, conservative spending policies and has focused on expense management rather than revenue growth. Faced with many aging properties with significant capital needs, it has had to confront difficult choices between maintaining the status quo—which is not sustainable—and directing capital to new opportunities.

As a result, the Good Samaritan Society board launched a new 7-year strategic plan with "aspirational targets." The approach aimed to:

  • Reduce dependency on federal funding
  • Diversify service offerings
  • Develop new products and revenue streams
  • Focus on excellence and strengthening current operations
  • Attract a highly engaged workforce

A new focus on performance would evaluate the organization’s work in light of best practices, understanding of market demands and a dashboard of financial indicators. In addition, more attention would be paid to potential partnerships and acquisitions as opposed to building new communities. The organization set its sights on being the #1 or #2 organization in their target markets.

Strategies would need to be developed to adjust to new payment models such as ACOs, bundled payments or other managed care systems. An early step in putting these principles into action was a "facility assessment process" that used a cross-functional team to review and assign recommendations for each location:

  • Sell
  • Close
  • Maintain
  • Rehab
  • Redevelop
  • Hub and cluster

The process yielded useful results but the Good Samaritan Society decided that it didn't offer enough analysis on market needs or help in understanding how to prioritize capital investment. The next step was a "market assessment process" which involved hiring CliftonLarsonAllen to help add market data, information about trends in the senior services field, a better understanding of competitors, and what partnerships or affiliations might be needed.

Hard decisions were a part of the plan. Some communities, located in low-population rural areas and determined to be unsustainable for the long term, would need to be closed, sold or donated. In some of those markets the Good Samaritan Society ended some services (such as skilled nursing) but did not leave completely, for instance focusing on home and community-based services or affordable housing instead. Major infusions of capital were focused on communities with populations of 10,000 or more.

“These were very difficult decisions to make,” says Syverson, referring to markets where the organization chose to exit or alter its services, “but in some cases there aren’t enough people to serve.” He notes that some of the communities in question are in areas categorized as “frontier.”

“Certainly our first desire would be to continue to provide services,” he adds, “but sometimes we have to make the right decisions where there may be more than one provider, and ultimately we had to decide, what’s the right thing for the community? Is it that we exit so the other provider can be stronger? The hope is that with new services we can touch more lives.”

Under the new approach, revenue sources would need rebalancing. Services to be expanded included post-acute rehabilitation, home and community-based services, housing and assisted living. New services to support people "wherever they call home" would be developed, and outcome metrics would be developed to measure success. The greatest growth in persons served would appear in affordable housing, home health, hospice and private duty.

“One of our most recent acquisitions … provides services to family members through a managed Medicaid program,” Syverson says. “Sometimes that means hiring family members to care for loved ones. Financial support comes through us and then to the family member, and it allows us to provide education and training. One additional outcome is that when these family members no longer need to provide for their family member, they are trained people who can serve other people as well.”

In some communities, technology is part of the answer. The Good Samaritan Society’s Living Well@Home, a remote monitoring service, combines many technologies to keep people in their homes.

Ending Unsustainable Services Allows More People to be Served

Westminster-Canterbury on Chesapeake Bay, a single-site life plan community serving over 600 people in Virginia Beach, VA, recently decided on 2 “stops,” according to President and CEO Ben Unkle.

One of them was the decision to sell the Ballantine Home, a century-old assisted living community in Norfolk, VA.

“The cost of not stopping on the Ballantine Home was the realization that every 10 to 15 years, another large capital investment would be needed,” says Unkle. “We knew it would never sustain itself independently. The cost was a drain on the organization, and it would prevent us from evolving in the way we needed to have more impact on more lives.”

The second stop was a service change in independent living. Westminster-Canterbury had been running a private-pay home care service on the campus that lost more than $400,000 each year. One thing contributing to the losses was the practice of giving more than 50 independent living residents free medication administration.

“We’re talking about independent living residents getting free medication administration when that’s a hallmark of the assisted living level of service,” says Unkle. The organization began charging a $10-per-day fee for the service in independent living to discourage unnecessary overuse.

By ending unsupportable services, Westminster-Canterbury was able to redirect resources into an expansion of Medicare certified home health and hospice services that dramatically increased the number of seniors served. Two new entities were launched: Westminster-Canterbury at Home, a home-health and hospice provider that went beyond the walls of the organization, and Senior Options, which offers consultancy and billing services to help other aging-services providers launch and sustain their own home health and hospice services. Senior Options now serves 9 other life plan communities, helping them set up home health services and handling their billing. Combined, over 6,000 extra seniors are now being served.

Unkle says it’s difficult for a mission-driven, not-for-profit organization to end a service, but the word “mission” has to be paramount.

“Even when you’re stopping, it’s to do more of something else or to do something better,” he says. “It’s not a decision for a moment in time, it has to have a longer-term perspective. We’re all tempted to think of these things with a 1-2-3 year horizon. But if we’re going to survive we need to think with a 10-20 year horizon.”

Gene Mitchell is editor of LeadingAge magazine.