As Covenant Care shakes its leadership team up and down, its new CEO, Nathan Ure, is focused on the clinical acumen of the skilled nurse operator.
Drawing inspiration from what is being done both in the state of California and what is being called for by the Centers for Medicare & Medicaid Services, Ure believes qualified nurse operators like Covenant Care should adopt purchasing programs based on value and “seeking quality”.
Such decisions also led to a noticeable increase in the census, he said.
“They said yes to a lot more patients than [the clinical team] wasn’t used to it. So the nurses say, ‘I’ve got support, I’ve got somebody supporting me,’ and so our count has gone up dramatically – about 60-70% qualified mix in the last three months,” Ure told Skilled Nursing News at the 2022 NIC Fall Conference in Washington, D.C.
It’s part of the larger idea of taking a much more proactive approach to patient care or, in Ure’s words, being firefighters instead of firefighters.
Ure joined the Covenant Care team in June after spending nearly eight years in leadership positions at Sun Mar Healthcare. Ure is joined by a new leadership team, including Bryce Porter as Chief Strategy Officer and Tammy Pirhekayati as Clinical Director.
Aliso Viejo, California Covenant Care operates 29 skilled nursing facilities in California and Nevada.
If nursing homes can accommodate more acuity residents and meet the quality metrics set by the federal government to receive these incentives, then “nobody can touch us.”
“With such a cost-effective solution for lower DRGs, there are lower DRGs that hospitals don’t need to deal with — you can. But you have to pay us for it,” he told SNN.
The interview has been edited for length and clarity.
Tell me a bit about your vision for the future of Covenant. What are your short and medium term goals?
CMS put out a letter a few weeks ago…it outlined the intent and essential nature that any program should be quality driven, and that’s what’s happening in California as well.
So even though CMS has made purchases based on value and a lot of these different things, the letter, I think, reinforces the urgency to create new programs. There were several Covid rewards that were really large sums of money, and we took advantage of them.
Covenant Care wasn’t built around chasing quality metrics and chasing those things, so we’re very clinically driven by data. We are also looking at clinical projects that have an umbrella effect. So you’re handling something with skin, you’re going to be dealing with nutrition, and several other aspects of that process.
We had this awesome moment last week where the clinical team really got together for the first time in their new iteration and the lights came on and they really understood how data drives each regional nurse visit. Data gives meaning to meetings. If you do that, if you execute that plan that our clinical team has, and proven works, the quality will be there and we will be rewarded. So that’s the direction they didn’t really have in mind.
Is there anything else that excites you?
There is also confidence in the clinical teams with this support. They said yes to many more patients than before. So the nurses say, “I’ve got support, I’ve got somebody supporting me,” and so our count has increased dramatically – about 60-70% skill mix over the last three month.
It’s this idea of fire marshals versus firefighters. Firefighters go to where conditions exist that have created a fire. The fire marshals will make sure everything is in place so that you don’t have a fire.
We have also changed the way we recruit. So it looked like there was a bucket with a hole in the bottom that water was poured into to try to get ahead of staff shortages. We did some things to normalize salaries, to create a better sense of belonging. We’re only as good as our worst station on the worst shift, and so we’re really diving into where we have those holes and where the leadership is that backs that up.
Aside from CNAs, are there any other positions that you see as difficult to recruit, and even on the retention side, what is Covenant trying to do there?
We need to better celebrate our housekeepers. LVN [licensed vocational nurses] are like gold. Many LVNs have been sucked into Covid testing or other emerging care areas at our expense.
The thing that breaks my heart is that I feel like the DONs during Covid have gotten to a point where then with the prolonged shortage of nurses they’ve been pushing carts for a long time and being responsible for all their responsibilities that someone just said, ‘Why have we given DONs a reason to believe that it’s still okay to be a DON?’ Is there still a meaningful future of work for DONs and so we’ve really looked at that and we’re trying to adjust those issues and make sure they’re not exhausted.
On the regulatory side, how has Covenant kept up with all the changing regulations and been proactive with those regulatory challenges like you are on the clinical side?
It’s kind of mind blowing because I could never have foreseen a time when they would have suspended polls and people would no longer have the practice. Whenever there is something compliance that comes out, our team operationalizes it so quickly… We also just do mock investigations… We use the same tools as an investigator to try to ask the same questions as the investigators so as to discover and play together in this era that we are opening anew.
Where do you see the future of behavioral health for both Covenant and the industry in general, and how important does it play in nursing homes?
It just requires more training for your teams and it also requires everyone just to say to themselves to ignore, you are going to have a lot of mental health problems and you cannot treat people… These are the people of our community. So part of that is just acceptance another part is training.
There must be more sophisticated training for our people. And then you just have to be careful, a lot of safety and sanity. I foresee it’s going to have to be more sophisticated in how we look at the GDR [gradual dose reduction].
I’m also rethinking what smoking breaks look like because nicotine is honestly one of the best possible antipsychotics and we were trying to evolve into the non-smoker. There are also a lot of non-pharmacological approaches, we have done a lot of aromatherapy in our establishments. So I think it’s up to each institution to figure out what works for them to deliver those things and really reinforce and reward those programs.
Aside from staffing, what do you think is the biggest challenge facing vendors coming into the peak?
We must carve out a place for ourselves and defend ourselves well in the spectrum of care. The acuity that was forced upon us, I don’t think has always been embraced, and we need to look at higher acuity and look at the value proposition as an extension of hospitals.
People need to invest in operational partners who really know what they’re doing and you can’t cut corners on the clinical team and that game plan. So it’s time to really double the clinical programs.
What is an industry trend or innovation that excites you?
I think it’s buying based on value, rewards for clinical results, and reward for higher acuity. It’s so exciting for me. It means everything people have to look for quality, and you have to prove it. I think the government has done enough identification of these quality metrics and based on the MDS, I think you can know the quality of people is and it is definitely worth playing.
If we really lean where we need to, no one can touch us. With such a cost-effective solution for simple lower DRGs, there are lower DRGs that hospitals don’t need to deal with – you can. But you have to pay us for it.