5 Keys to SNF Success

A Massachusetts-based skilled-nursing facility sets a high bar for quality, invests in staffing and HIT, and has created operational efficiencies based on the proximity of its facilities.

Research published this month indicates post-acute-care at skilled nursing facilities could be a significant source of wasteful healthcare spending.

The lead author of the peer-reviewed study, Massachusetts Institute of Technology Professor Joseph J. Doyle Jr., says a big next steps is to examine best practices at good SNFs.

By at least three measures, Winchester, MA-based Salter Healthcare is a good SNF organization:

• High Medicare Ratings: All three Salter Healthcare SNFs (Aberjona, Winchester Rehabilitation and Nursing Center and Woburn Rehabilitation and Nursing Center Are the other two) have 5-Star Medicare ratings on Nursing Home Compare.
• Sustainable Finances: "We are able to have a margin that allows us to invest in IT, to invest in training, and to invest in rehabilitating the facilities, rather than just trying to hang on for another year," says co-owner Richard Salter.
• Low Staff Turnover: In a sector with high rates of nursing turnover, Salter says his organization is noteworthy for staff retention. "We keep people for five to 10 years. They get the proper training; they have the proper skill sets; and they are working with other employees who also have proper training and skills."

Salter identifies five essential elements to his organization's success:

1. Invest in Staffing

Salter says his organization invests significant time and money in clinical-care staff, and quality is engrained in the organization's culture.

"When every other SNF looks at our cost of nursing, they say, "'You are spending too much money. How can you be in the 99^th percentile in spending per patient on all of your clinical costs?'"

But if those costs were to be reduced, "you are not going to have high-quality care, and you are not going to have your contracts, and you are not going to be as good."

2. Value Human Resources

Morale is key to retention , says Salter.

"It's not just about how many staff you have, although that is important. It's about how long they have been there, how good they are, and how they show up for work in the morning."

"On the high-tech, high-touch spectrum, the people in healthcare are high-touch people. They want to feel good about the care they are giving their patients; they want to feel proud of their professionalism and their licensing because they chose this career and they chose this path; and they want to work with people who feel the same way."

Mediocrity is not tolerated. "The biggest mistake we make in management is when don't terminate someone who is doing a mediocre job.

"The employees are good," says Salter, "and they want other good employees working next to them."

3. Stay Small

The Salter Healthcare strategy is based on what it is not doing, he explains. "We are not doubling in size. We are not thinking about where we can buy more facilities and ramp up to become bigger."

The organization operates three facilities in the same geographic market, making it "efficient at filling the backroom stuff."

"Our goal is low cost and high quality. That is what everybody says, but it is easy to say and hard to do. The way we stay low-cost is to not over grow, and to not redirect resources to the next new project. We do what we do well, and we just keep doing it."

4. Manage Your Payer Mix

To continue to serve all comers—including frail geriatric patients—without going bust financially, Salter Healthcare benefits from a diverse payer mix.

"Sometimes, they are tough cases and there is great insurance. Sometimes, there is full Medicare reimbursement. Sometimes, you have a Medicaid patient, and you don't get paid much at all," Salter says.

"You have to have the proper mix of Medicare patients, private-insurance patients, and Medicare and Medicaid dual-eligible patients, so you have collectively enough revenue to cover the high expenses of the good care."

5. Invest in Technology

Over the past five years, Salter Healthcare has invested heavily in IT capabilities. "At our three facilities, we spend about a million dollars a year on IT—on software, and hardware, and people in that department. It's a huge number for an operation our size," Salter says.

"All the filing cabinets are gone. The nursing aides are working in kiosks documenting their bathing and weighing—it's like a giant McDonald's keyboard station with icons and pictures, so they don't have to be programmers. The nurses have access to the patient database."

Its investment in IT has boosted Salter Healthcare's care-coordination capabilities with hospitals and physicians, he says.

"We can interact with the hospital systems; and the doctors, when they come into our facilities, they can pop information into our system and the hospital system simultaneously."

The organization is "trying to make sure there is continuity between us and the hospitals, and, eventually, to home care. That's what we have to do to stay in this game."