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Care boundaries blur as providers morph to match payment types

Nursing home avoidance continues for both investors and care recipients. You might have read about investors cutting back on nursing home investment within ‘healthcare’ REITs.  CMS and Medicare are reimbursing less for ever-shorter nursing home stays, ending their multi-year ‘billion dollar pie eating’ wave of investment.  Note that the biggest chains of skilled nursing facilities (SNFs) like Signature Health Care (which has a web URL signaling LTC -- LongTerm Care) Revolution) – what might that revolution be?  Consider the consumer’s first encounter with the industries for health care, long-term care (LTC), skilled nursing facility (SNF), nursing home, or post-acute facility. This terminology morass mirrors the reimbursement patterns of government agencies, which, in turn, drive investment language, behavior and labeling.

Assisted living increasingly provides health-related services.  With assisted living, a frailer resident, one of the 750,000 in their mid-80’s who didn’t want to move in, is likely pressured by family to move, selling a home to help pay the upwards of $60K annual cost.  As many as half of the residents have at least two chronic conditions, one of which is dementia, needing assistance in 3 activities of daily living, and as many as half with some level of dementia. Although there is no (visibly marketed) skilled nursing/aka ‘healthcare’ in assisted living, all variants of consultation, doctors’ and home health visits, therapies, and nurse administrator oversight. And thus assisted living communities are largely private pay – compared online with the cost of remaining at home. Note the apples-to-apples cost comparison items for full-time activities staff, exercise and wellness programs, and 24-hour emergency alert system.  

Home care agencies see greater frailty and oversight complexity. Walk into any assisted living community, especially memory care where the residents need more help -- and you will see staff care augmented with private duty companion care aides. You might see home health nurses and hospice workers, depending on the state of resident health. Likewise, in a home setting and depending on an individual’s health status, you might see each of those categories of care provided – and as in assisted living, each with their own billing, payment, and/or eligible reimbursement practice. And all of that is outside of any incidents of ambulance trips to the E/R, hospitalizations, and rapid discharges to ‘post-acute’ facilities.

What’s missing from this picture – the individual’s profile and care evolution.  As this place-to-place migration wears on, each of the providers gets to wonder -- who is Mrs. Smith and what is her care history – as well as how will we be paid?  Where is the standard view of this individual and her profile and does it fit with her insurance coverage?  If there was a place to find this information other than carrying an EMR CD, next-in-line providers could speed up intake, and improve cross-environment care coordination.  Most of all, Mrs. Smith would have a better chance of surviving the next transition, enabling her to return to where she is most comfortable.