Tech Shows the Way to Performance Improvement

This article, written by Patrick Connole, was published in the March 2019 issue of Provider magazine.

Technology for long term and post-acute care (LT/PAC) providers is in many ways all about how best to procure new software or hardware options to improve caregiving. The foundational goal is to make the operation of a facility more efficient and more beneficial for residents and their families, staff, and the bottom line.

At a time when venture capital and other funding is flooding into the health care sector to seed possible breakthrough start-ups for nearly every product and service category, providers entrusted with caring for the nation’s elders and people with disabilities demand straightforward answers when it comes to their decisions on which new advances to deploy in their communities.

What providers say they want to know is how will these new ways of processing data, populating electronic health records (EHRs), moving to mobile devices for clinical charting and other nurse functions, monitoring for falls, or EHR connecting devices actually improve care and operations, and importantly in this era of tight to nonexistent margins, show a return on investment.

Criteria to Consider
John Baker, chief technology officer for Marquis Cos., tells Provider there are some basic hurdles each new technology being pitched has to clear, such can it be integrated into the company’s existing systems?

“We are going through this now with our new time and attendance payroll software, and how it will work with our charting systems and paycheck vendor. So, integrations are key,” he says.

There is also the need for providers to keep pace with what staff are most comfortable with, for instance, like having more work responsibilities tied to iPhones or other mobile devices. Baker says it is amazing how quickly an iPhone-capable workforce can be trained on the same type of devices they use in their personal lives but for work-related purposes.

Another priority for Marquis and its Consonus Healthcare unit (pharmacy, rehabilitation, and data analytics) is to have technology that offers ways to communicate performance data for meaningful conversations with hospital systems and physician groups.

“This is the new Holy Grail for marketing your facility as a preferred provider partner and to take advantage of referral opportunities in coordinated and value-based care reimbursement models,” Baker says.

“It used to be you showed up with donuts to have a meeting with the discharge planner in the old days. Now you show up with numbers showing your fantastic outcomes and how the changes for readmissions are low,” he says. Coordinated care demands data and technology are needed to crunch the numbers and produce actionable reports, he says.

Where Is Technology Headed?
What Baker describes as the priorities for Marquis are just one example of what is happening in the technology realm as it relates to LT/PAC. To further examine what all of this means to skilled nursing and assisted living, Provider talked to leading thinkers in the technology and health care space, as well as to owners/operators and vendors tasked with acquiring and implementing new products and services and gauging their performance.

Lynne Katzmann, founder and chief executive officer (CEO) of Juniper Communities, based in Bloomfield, N.J., says when starting a discussion on technology in the LT/PAC setting, or in health care overall, it is important to realize this country is behind the curve in many ways. While she says technology in all of its forms holds many possibilities for providers, regulators are not keeping up.

She cites a recent examination in The Wall Street Journal on the advances in robots in Japan and how the machines help offset labor costs. This type of advance is not yet possible in most parts of this country because of requirements that have not kept pace with the times, Katzmann says.

“Technology offers us opportunities, but we have to make sure that regulations start moving more quickly to keep up, and that is always hard. Down the road, technology will have even more of a tremendous impact,” she says.

Technology a Necessity
The idea that much more is coming from technology is a theme that Bharat Rao, PhD, also addresses. A principal for KPMG’s Advisory Services practice with 25 years of experience using data analytics for clinical, financial, regulatory, and operational improvement for health care and life sciences organizations, he not only sees more technology as a certainty, but a necessity for every stakeholder along the care continuum.

Rao says that the country needs a health care system driven by technology, whereby decision making is based on using the “cloud”—shareable information and data stored on physical or virtual servers and accessible by computer—and on machine learning/artificial intelligence (AI). Computer science academics define machine learning as the scientific study of algorithms and statistical models that computer systems use to perform specific tasks without the need for explicit instructions, relying on models and inference instead. This process is considered a subset of AI.

“We use these things [machine learning] now to tell us which movie to see, which product to buy on Amazon, but we don’t use it to make life and death decisions for our loved ones,” he says. “That has got to change. It is the only way to fix the cost curve and improve quality.”

Machine learning/AI in the health care sense is mainly about manipulating data to arrive at treatment decisions. Rao notes that a 2017 study in the Journal of Health Economics found that 25 percent to 40 percent of health care costs are waste, thus making it vital to cut down on unnecessary or wrong procedures.

To help remedy the problem, machine learning can crunch huge amounts of data and in turn give clinicians the ability to use this information to refine their treatments and procedures based on what has worked on other patients with similar characteristics. The “learning” from these data can then be put in the cloud for sharing across the health care system.

“I’ve been working on these problems for three decades, and there is nothing more challenging, fascinating, and complex than health care data. It comes in so many forms: lab tests, billing data, notes from doctors, images, genomics, web articles,” Rao says. “We take all of that and figure out what is the right way to treat someone for a condition from many alternatives. That is what machine learning can do, and so that to me is the promise of machine learning.”

Making the Most of Technology
Part and parcel of providers having new technology on hand is to be able to use it properly, especially in the area of electronic health records (EHRs), says Steven Chies, lead consultant, Care Paradigms, and president, North Cities Health Care, based in Minnesota.wall

An expert in the field of health information technology (HIT) and its applications in the LT/PAC setting, Chies says his own personal experience as a provider and the evidence from surveys in the field show a vast majority of those in the sector, especially on the skilled nursing side, believe they are utilizing EHRs. But, they really are not, he says.

“What they have is a financial record that allows them to do billings, and do their general ledger, payroll work. And, you know, they have the ability to do the MDS [Minimum Data Set] data as well, but they are not using the capability of the systems to their fullest extent,” he says.

To combat this underuse, providers need to understand what vendors are selling and how that fits into their needs, and brush up on basic statistics and how to read spreadsheets.

An overriding issue, Chies says, is that providers need to change their workflows. “When you go and adopt the electronic format to do whatever paperwork you are doing, you need to stop doing certain manual things,” he says. “What happens often is [providers] are running dual systems. They are doing paperwork, printing everything out, and not realizing the full [capabilities] of the electronic systems.”

This leads some providers to complain that their software system doesn’t save them any time.

“Well, it doesn’t save any time because they are not reevaluating their workflow process. The way that some people operate their EHRs is they are basically using it as a word processor in some instances rather than a data electronic system,” he says.

To get more bang for their buck, providers need to start thinking about how to effectively use their EHR information to make better decisions going forward. The MDS, Chies says, is a great data set that can be used to do sophisticated analysis of a resident’s condition. The analysis can lead to a better understanding of what it takes to get better outcomes and what it costs to take care of each particular type of resident.

“The challenge is that organizations need data analysis to be able to say, this is the information we have, here are the questions we are trying to answer, and here are the data elements to go through. To do that takes somebody with IT skills and an understanding of what problems a provider is trying to solve on a daily basis,” he says.

One example of an area providers should be getting better at analyzing data on is antibiotics usage, Chies says. To keep up with the demands of the Centers for Medicare & Medicaid Services on this issue, a provider can do detailed analysis of antibiotic usage and figure out which residents are using which drugs, and what circumstances are in play for each resident. “This information allows providers to understand medication management for antibiotics,” he says.

Discovering New Solutions
Taken as a whole, technology offers a plethora of ways for providers to improve their performance, be it via new tools for nurses or marketing outreach software or new lighting, bedding, or monitoring equipment.

First off, leaders in the EHR connectivity sector point to the ways in which their products and services have evolved to allow providers in nursing facilities and assisted living communities to share data on residents with other providers, like labs, primary care physicians, and acute-care hospitals.

Harold Landers, executive vice president at Nurse Rosie Products, says his company knows its turf well, being a 41-year-old company of the nursing vendor space. “Nurse Rosie Products got its start by providing large medical equipment to hospitals, but when our owners saw the need for higher-acuity equipment in nursing homes, we were able to fill that need. In fact, we were the first company to provide electronic blood pressure machines in many long term care facilities, and this had a very positive impact in helping to raise the standard of patient care” he says.

Over the years, as the need for newer clinical tools increased in the medical industry, Nurse Rosie has become a top supplier of this technology across long term care, taking data from the point of care into the EHR through its Rosie-Connect product.

Active mostly in the skilled nursing setting, the company has customers at all levels of the care continuum, Landers says. A significant part of the job Nurse Rosie does as far as bringing new technology to its customers comes from something very traditional, which is to listen to those on the front line, he says.

“We are most proud of the fact that we keep close watch on the constant and evolving demands across the entire sector. Everything we do is geared toward having a positive impact on improving efficiencies, decreasing employee turnover, and improving our customers’ bottom line,” Landers says. “We remain very close to the advances in technology and pay special attention to how we can use technology to help caregivers do their job with greater accuracy and ease as well as to help improve overall patient care.”

Providers Want More
What Nurse Rosie representatives hear a lot from facilities these days is the need to improve their census, their staffing levels, and their overall referrals. “And, the other thing is just to be able to do more by consolidating steps in the work flow process. There are more demands placed upon caregivers every day, so this translates into them having a need to be able to do more with fewer people because of staffing constraints and other challenges they face,” he says.

Landers says it is important for employees to have the right tools in their hands. “When employees are equipped with the right resources and technology to help them do their job, they are much happier. This, of course helps to address the problem of constant employee turnover,” he says.

How the latest iteration of RosieConnect works is straightforward. First off, the system is more than just a blood pressure cart. It is an “all in one” mobile kiosk and a platform that pulls data from multiple sources, feeding the data into the EHR. He says it offers the solution for making sure the data are documented correctly and timely each and every time. This helps to relieve the caregiver from having to write anything down by hand and thus eliminates many of the potential errors that can be costly on so many levels.

“We understand that employees want a solution that is easy for them to use. With this in mind, we have designed RosieConnect to be as simple as operating a smart phone. All it takes is one touch,” Landers says.

Another major player is Stanley Healthcare. Mike Webster, director of solutions, senior living portfolio, tells Provider his company also has a long history of providing traditional products in the industry. There are, for instance, solutions for emergency call products, wander management products, and fall monitoring and prevention products, among a host of other offerings.

“There is a whole new world of solution sets with all the new technology, features that we call our Smart Senior Living Solutions,” he says. “These include health and wellness monitoring, care coordination, remote patient monitoring, resident and family engagement and socialization, activities of daily living monitoring, etc.”

To think of what Stanley is marketing for seniors housing, Webster says imagine a smart home for seniors, whether in assisted living, independent living, or in the home. The smart home has typical smart home features—such as digital thermostats and smart appliances—covering safety, security, and environment.

“Add to that automated tools and capabilities to help [residents] manage their chronic care conditions, overall health and wellness monitoring, their care coordination, and engagement tools that keep family members and caregivers and everyone engaged with the seniors in that environment,” he says.

To maintain its business strategy and growth goals, Stanley ferments its new technology from many sources, starting in house with its own developers and including attending trade shows and a lot of customer engagement, from talking to executive directors, directors of nursing, and senior corporate executives, to clinical teams at facilities.

Customers Want Safety
One of Stanley’s main focuses is on fall prevention, a top priority in its market, which includes using intelligent sensor monitoring and general health and well being to gauge a resident’s chance of falling. Webster says this can come in many forms, such as if there is a change in a resident’s urination patterns, this could be tied to a urinary tract infection, which can be a risk factor for predicting falls, in addition to health issues.

Webster says another customer concern is decreasing occupancy levels, which has spurred the creation of new socialization tools to reach out to families of residents and prospective customers. “Occupancy rates are around 88 percent throughout the industry, so our customers are constantly looking at ways to improve. We do this by providing tools to the residents, such as engagement platforms, where they can share information with family members and photos of what they do, for example,” he says.

Health data can also be shared with loved ones, allowing family members to get directly involved with fulfilling care plan commitments and promoting the health and safety of residents by keeping track of treatments, rehabilitation schedules, and prescription drug adherence.

Among other new products and services coming online is the six-letter word many people associate with advanced technology: robots. Webster says Stanley has a product being developed by their Futures Breakthrough Innovation team labeled under the Black + Decker brand called Pria, which is coming soon to major retail outlets and E-Commerce channels.

“It is an AI-based robot that has facial recognition tools in it to help it engage with people socially,” he says.

“It has voice capabilities to talk to seniors who are living alone or independently and has a built-in medication dispensing system that notifies the senior when it is time to take their medication.”

Predicting a New Workforce
One of the biggest, if not most difficult challenges facing LT/PAC providers—and an area where robots are not a factor as of yet—is workforce, which can be further narrowed down to how best to recruit and keep staff on board. Providers want to know which new job applicant is best suited for the organization and even best suited for a particular facility, as well as how to gauge which current staffer is a promising long-term prospect and a quality choice for promotion.

To help in this area, a technology-driven company called Arena is gaining traction across the health care sector with its data analysis used to answer these questions about potential and already employed workers.

With clients in the LT/PAC space, Arena has made use of cutting-edge AI methods to not only sift through the resumes and backgrounds of recruits and staff, but also to measure keystrokes on a computer and assess other personal factors as part of its in-depth assessments. This ability to follow how an applicant answers a question through keystrokes, seeing if they needed help with search functions to do, say, basic math or comprehension, is invaluable for feeding data into algorithms that are then used to help providers in the hiring process.

Michael Rosenbaum, founder and CEO of Arena, says his company is simply applying AI to an age-old problem. “How do you make sure you have people who end up in a place that they will thrive and stay? We use AI to predict where someone is likely to achieve that outcome,” he says.

Solving a Difficult Problem
One of Arena’s LT/PAC clients is Sunrise Senior Living. Mike Rodis, Sunrise’s senior vice president of human resources, tells Provider the predictive analysis Arena provides has been “very helpful.”

Sunrise is a major employer in the sector, hiring some 12,000 people a year, with the vast majority of that number, around 11,250 people, being customer-facing staff, from care managers to cooks, to housekeepers. “It is those positions that we use the Arena scores for,” he says.

Rodis says there has always been the challenge to understand why people might depart their jobs, and he thinks there is a delicate balance, especially in the LT/PAC industry, to compete with people for frontline roles who day in and day out care for residents. In other words, Sunrise and all providers need help in assessing who may want to make a career of the profession, versus settling for employees who may be short-timers.

“We compete with other nursing care providers, other health care providers, but we also compete with Target, Wal-Mart, and fast-food businesses,” he says. “This is the type of person we attract in that compensation zone. But it is a very different mentality in caring for seniors versus serving up a hamburger.”

How Sunrise Uses Predictive Data
The Arena assessment system supplements what the provider already does, and is embedded in the recruitment application process. “It is part and parcel [to do the Arena assessment] when you come in and apply for a job at Sunrise with things you normally would do, like filling out an application” online or in person, Rodis says.

The Arena portion takes around 10 to 15 minutes to complete, and applicants are scored based on an Arena-produced algorithm. The scores are generated on how applicants answer questions, but also on the manner in which they answer questions, keystrokes they use, the time it takes, and their ability to comprehend what they are being asked. It ends up being an AI-assisted selection and sorting program for employers to use or not use in making decisions on staff.

Rodis also notes that the algorithm is constantly being updated by Arena because new data from new applicants keeps being inputted into the calculations. “As the data continue to grow we get a better sense of the people who will want to stay in our business and company,” he says.

Returns Are Solid
As a fast-growing provider, Sunrise has plenty of needs in the staffing space. Rodis says that the company is adding around five to eight new buildings a year through acquisition or ground-up development. The challenge in using new technology like Arena is to make sure the price being paid has a good return on investment (ROI).

“Yes, we need ROI, and we were able to do that with our Arena pilots. We started with one market for six months and added two more for six to nine months, and it much more than paid for itself, and we needed to see that,” he says.

With 32,500 total employees, Sunrise has yearly turnover and additional job openings that reach the aforementioned 12,000 jobs filled per year. Since adding Arena, Rodis says the reduction in turnover has been 14 percent on a year-over-year basis, but the number is even more significant when looking at turnover in the first 90 to 180 days of a new hire’s work life, with the 90-day rate reduced by more than 20 percent and cut by 18 percent at the 180-day mark.

Benchmark Sees Value
Another provider, Benchmark Senior Living, uses Arena as well. Tim Reilly, Benchmark vice president of human resources, says his organization has been using the AI-enabled software analysis platform for about a year.

“We found this technology very interesting because we had turnover at Benchmark that was pretty much on par with the industry, but much higher than what we really found acceptable,” he says. “In order to provide excellent care, in order to take great care of residents, it is about keeping quality staff since our work is about relationships and human connection.”

To improve the onboarding processes in place at Benchmark, the organization added Arena to the mix with the focus on retention issues, but not before taking other steps.

“At different points along the line we have redesigned the structure of the regional teams that support our communities with the thought this might have an impact on turnover, and also gave managers more leadership training,” Reilly says. This has helped, as has the increase of employee surveys, which has made Benchmark what he jokingly refers to as “survey crazy.” All these things have helped to incrementally reduce turnover.

“Then we decided to try Arena as an additional solution,” Reilly says. “Basically, the way it works is when someone applies for a position they get a request from Arena to take the assessment, and we let the candidate know this is part of the application process and ask if they would like to take the online assessment.”

Benchmark is using the process for most of its frontline positions, not management level openings. The Arena assessment asks these applicants timed math, reading comprehension, and multiple-choice questions. “The job opening has nothing to do with math for the position, but Arena is looking at behavior during the taking of assessment. They are really watching behind the scenes, not for the right or wrong answer,” Reilly says.

The end result is the scoring report that will tell Benchmark which certain applicants are deemed likely or unlikely to stay in the job they are seeking. “Initially, it looks like we dropped our turnover rate by about 10 percent so far,” he says.

“We encourage people to take the assessment. It is not mandatory that our hiring managers only hire people who take it or those deemed likely to be retained, we need to be more flexible with the current job pool so tight. So, we need as many candidates as we can when making these decisions.”

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