ChalkTalkJim: Breaking Down the Game - A Guide to the Future of Healthcare

Long-Term Care, A Struggling Industry Aiming to Dignify the Elderly

February 08, 2023 James Jordan Season 1 Episode 1
ChalkTalkJim: Breaking Down the Game - A Guide to the Future of Healthcare
Long-Term Care, A Struggling Industry Aiming to Dignify the Elderly
Show Notes Transcript Chapter Markers

The long-term care sector is an essential part of the health industry but has struggled for a while.

In this episode, Samantha Rapuk, Executive Director of Lutheran SeniorLife, talks about long-term care, breaking down the different care-continuum services, and the hardships she’s witnessed within non-profit institutions in the space. She reinforces the importance of caring for the sick, the elderly, and their families and speaks about how at Lutheran SeniorLife, every single worker keeps their residents at the center of what they do.

Tune in to learn more about the importance of funding long-term care and its impact!

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[00:00:01] Jim Jordan
Welcome to the Chalk Talk Jim Podcast, where we explore insights into healthcare that help uncover new opportunities for growth and success. I'm your host, Jim Jordan.

[00:00:19] Jim Jordan
Today's guest is Samantha Rapuk. Welcome, Samantha, and why don't you tell us a little bit more about yourself?

[00:00:24] Samantha Rapuk
I have lived in the Pittsburgh area my entire life. I grew up here and I went to Indiana University of Pennsylvania for a degree in Spanish, ended up working in a personal care home as the business office manager after I graduated. It's just, the goal was that that was just going to be a stepping stone in a period of time before I went back to get my master's and probably something related to Spanish, but I ended up falling in love with the industry and long-term care. Got my master's degree in healthcare administration and management with a certification in gerontology from the University of Pittsburgh, and I graduated from there 2013. So I have been a licensed nursing home administrator since 2017, but I have been in long-term care since 2010.

[00:01:12] Jim Jordan
So everyone who's running a long-term care facility needs to have a license?

[00:01:16] Samantha Rapuk
For skilled nursing it's a Nursing Home Administrator's license, for personal care and assisted living, it is a certification, and for independent living, there is no ... requirement.

[00:01:29] Jim Jordan
Tell me a little about where your organization fits in the continuum of healthcare. The concept of long-term care is actually much broader and more complex than what many call a nursing home, right?

[00:01:40] Samantha Rapuk
Sure, so I run a continuum-of-care retirement community, which means we have every level of care on our campus, and our residents that live here can move through the campus as needed for whatever level of care that they need. My company is a nonprofit. We have many different services throughout the company as a whole, but on my campus, I have independent living, I have personal care, I have assisted living, and I have skilled nursing and rehab. In the breakdown of that, we have three separate buildings on our campus. The, one is an independent living facility for more, I don't want to say higher income, but more higher income individuals, it's a higher-end product. Then we have a 30-bed memory care, Alzheimer's dementia facility. That's our assisted living building. It's small building, but again, it's geared towards a higher-end product for those individuals who can afford a little bit more after retirement. And then in the main building, we have our skilled nursing rehab, long-term care, which is all, falls under the skilled nursing umbrella. Then we just remodeled our fourth floor to add additional personal care beds, and that's a middle-income product, that's for those individuals that don't have $500,000 in savings, but they have their Social Security, they have their pensions, and they have a little bit of a cushion so that they can afford the personal care level of care. And then on our fifth floor, we just remodeled and added 27 middle-income apartments for individuals who really can't afford the buy-in of the independent livings ... There isn't a huge, a lump sum of it, put down initially, the rent average is about $2000 between all the apartments that, it starts at $1650 all the way up to $2750 a month, and that includes two meals a day, housekeeping, maintenance, all of that. So to those individuals who maybe wouldn't have the opportunity elsewhere, have a place to come and live once their current living situation or their home becomes unmanageable for them. In addition to all of that, my company also has a hospice, home health, run a PACE-type program called Living for the Elderly, which is essentially skilled nursing care for people still living in their homes. Then there's adult day at one of our centers. There's Meals on Wheels that they do, just really the whole continuum. If an older adult needs that type of service, we pretty much provide it.
[00:04:04] Jim Jordan
So could we walk sort of horizontally through? I think of my grandmother, my aunt, they had a big old home where they raised all the kids in and decided it was too much and they were still pretty healthy, they could still drive around and they moved in, this is Massachusetts, they moved into what they called assisted living. Is that what you call that dependent living in your definition?

[00:04:22] Samantha Rapuk
So it depends on what services they were receiving. Here independent living is truly independent. They don't have services in their apartments unless they have homecare coming in. As an added benefit of being in a 55-plus retirement community, they are offered meals and they are offered housekeeping, and there's obviously the maintenance that goes into living in an apartment.

[00:04:45] Jim Jordan
... At that ..., the life, that's exactly where they were. They still had the ability to cook. My aunt drove so they would still go places. They would still go to the beach in the summer for a month and come back. And then as they got into their nineties and they had various health issues, they moved into a main facility where people would check on them every day and help them with various meds and things. So what would that be called? In you're...

[00:05:06] Samantha Rapuk
Right, yeah, that would either be personal care or assisted living, depending on where you end up. In Pennsylvania, it's a weird breakdown for those two, but they do essentially offer very similar services. Personal care, it's 24-hour care. There's always somebody there in the facility or the home distributing their meds, feeding them three meals a day, all services are provided. Most of those residents are still pretty ambulatory. They, depending on what type of facility it is, so like I said, our 30-bed Alzheimer's dementia facility does have residents who need to be in a secured unit. So that's the added benefit of that, it's a secure unit. But here the doctor comes in to see them in personal care, assisted living. We have specialists that come in like podiatry, dental, audiology, optometry, all of that is included in that facility so they're not having to go out and obtain their services out elsewhere.

[00:05:58] Jim Jordan
And so are you responsible for controlling and scheduling those events for them so they don't have to worry about coordination either?

[00:06:04] Samantha Rapuk
Staff will schedule all of that and coordinate all of that.

[00:06:06] Jim Jordan
As the executive director, you've got three or four different business models going in?

[00:06:10] Samantha Rapuk
Yes, so skilled nursing, and there's a lot of different names for it that people refer to it as. Some people say I want to a rehab facility, well that rehab facility was a skilled nursing facility. My mom's in a nursing home, that's a skilled nursing facility. It all falls under that umbrella. It is licensed by Department of Health, which means that we can build for our services as a healthcare provider. We have residents that are on medical assistance, we have residents, and the number gets less and less each year, that pay privately. The bulk of our residents are medical assistance. Then we have rehab where they come in and they are what's considered under a skilled stay, which is insurance paying for them, their Medicare, their Medicare Advantage plan, maybe a commercial insurance for those under 65, but they come in for a brief period of time, it's a short-term residence. They're here from anywhere from 7 to generally 21 days, not too much outside of that, but there's always outliers. Goal is for them to go home and they're just here to get better and live independently again.

[00:07:11] Jim Jordan
The permanent residents, do you get a monthly fee from the government, or is it on the conditions they have?

[00:07:18] Samantha Rapuk
So when a resident is on medical assistance, we have a daily rate that is determined by our case mix index, which is how we report the conditions of our residents as a whole, and then we get a number based on that and then they base our daily rate off of that.
Right now we get about $230 a day for a medical assistance resident and they're about 75% of our resident population. That is going up. Pennsylvania is implementing a 17-and-a-half percent increase in the medical assistance rate, effective for beginning of the year, January 2023. It's the first time in about eight or nine years that we've seen an increase in that rate. Still not enough, but it's, we're very happy to get it and we're looking forward to that increase, it's long overdue that they have a patient pay portion that they're responsible for. It's usually their Social Security or their pensions, less lawful deductions like insurance and maintenance deduction versus spousal deductions or caveats for those, there's, the private pay portion that they're responsible for, and the medical system pays us the difference.

[00:08:24] Jim Jordan
So it's medical assistance and Medicaid program, or Medicare program?

[00:08:27] Samantha Rapuk

[00:08:28] Jim Jordan
Okay, so that's coming from the state itself.
[00:08:30] Samantha Rapuk
Comes from the state itself, right.

[00:08:32] Jim Jordan
And it'll be states variable, from that perspective because every state sort of has their own arrangement with the federal government on how they work with Medicaid?

[00:08:40] Samantha Rapuk
Correct, yes, so our rate in Pennsylvania is different than the rate in Ohio is different than how they calculate the rates in West Virginia and everywhere around us.

[00:08:48] Jim Jordan
Now, is there a group of your patients that have long-term care insurance?

[00:08:53] Samantha Rapuk
Very few residents have long-term care insurance. More in our assisted living and personal care, those residents will rely on their long-term care insurance, maybe 5% of our residents have it, but the bulk of our residents, personal care, and assisted living as low as independent living, it's all private paid.

[00:09:08] Jim Jordan
It's a good segway into discussing what are the challenges that are facing your organization. So I imagine in all your different business units that you describe, the 75% of your people are in these skilled nursing facilities and they're the ones that have the broadest variance of care needed. So how do you keep them in statistical process control, for lack of a better word? Because I could imagine one fall, one major adverse event can ruin your profit for the month.

[00:09:36] Samantha Rapuk
Yeah, there are a lot of variables that we're looking at. That's the business, that's what we do every day. We have a wound nurse that goes around and checks the wounds. We have our therapists that evaluate the residents to ... if they need therapy, they're getting therapy.

[00:09:50] Jim Jordan
So I imagine that the things you worry about are the same type of things that the government and the insurance companies want to measure, is that true?

[00:09:59] Samantha Rapuk
And all of it plays into the areas that we have to report to. So this next index for medical assistance, for Medicaid, that determines our Medicaid rate for those residents, but then we also have skilled residents that we have to track and monitor, and there's metrics for each insurance company that we have to try to stay within. Highmark is different than UPMC is different than United, and then Medicare has its own metrics five-star quality, a measure score that we're always working towards. In fact, our files, they track our infections, our, in wounds, or pressure injuries. How ... labs, the hospital, how long after they discharge that they go off to the hospital? We're always trying to provide the best care that we can. We're always trying to avoid hospital visits and falls and wounds and all of that, but one thing can have a major impact on us and how we're perceived.

[00:10:49] Jim Jordan
Just in dichotomy, isn't it? So on one aspect, process excellence has to be in your brain 1,000,000,000% of the time and at the same time it's a business of people, it's a business of compassion and caring and holding a hand every now and then. How do you keep that straight in your head? How do you make sure your culture keeps that straight in its head? Because I know you and I have talked privately about the wonderful things you guys did during COVID, and when we talked about that, you mentioned that culture is very much part of process excellence. I love that concept. Can you expand upon that?

[00:11:20] Samantha Rapuk
It's what keeps the job interesting. I work for a nonprofit which, there are for-profit and nonprofit facilities, and how they run is different between them, and I worked for both. I will say that working for a nonprofit that isn't focused on the bottom line all the time, we have leeway to really take the individuals into account. We're not taking care of a UPMC resident. We're taking care of Mr. Smith in room 287.

[00:11:51] Jim Jordan
You had mentioned that often regulations have gray areas that need to be sorted out at the provider level. Can you expand upon that a little bit?
[00:11:58] Samantha Rapuk
There are so many gray areas. The regulations, especially in skilled nursing, we're one of the most heavily regulated industries in the nation. So we're always looking at it. Is that a violation of a regulation? If it's not, is it a gray area? How do we interpret this? How do we ensure that, you mentioned COVID, what can we do to make sure these residents are seeing their families? How do we get people in the building safely so that all the other residents aren't at risk for infection, but also meeting those social needs for those residents and making sure that they're cared for, because they are people, this is their home. That's the biggest thing that we instill in our staff and our residents. Don't be afraid to ask for anything, this is your home, we want to make sure that you're being cared for and that you feel comfortable here and you feel that your needs are being met. But at the same time, we have to make sure that they're falling inside those regulations. So there's a lot of discussions that happen with our team on, okay, how do we make this work, how do we do this so that everybody is happy. And I'm always trying to get to the yes. I'm always trying to get to, okay, how do we make it happen? We can't do it this way, but could we do it this way? Could be, look at it from this angle and I would say my team as a whole has really embraced that ideology and that resident-centered focus on the care that we're providing, the services we're providing, and it shows in the interactions that our staff have with our residents and how the families feel about resident care. I'm the executive director, over 250 residents, and I know the bulk of them and of their families, and so I take all of that very personally.

[00:13:33] Jim Jordan
Contract employees have been both a blessing and a challenge for institutions such as yours. Can you share how many employees you have and what your mix of agency employees is?

[00:13:42] Samantha Rapuk
So we have about 100 of our own employees, and that's between all departments, that's housekeeping, dietary activities, maintenance, nursing, all of it, and then all the management that has to be embraced to keep the building running. So, and then we have at any given time, 20 or 30 agency staff as well. And as much as we can, we treat them as our staff because we want the people in our building caring for our residents the same, regardless of who's employing them.

[00:14:08] Jim Jordan
Was recently talking to a nonprofit hospital in Idaho, and they were talking about the challenges of the agencies, the contractors, and maintaining your culture. So I think you speak about that quite well. Why do you need the agencies? Is it because you can't find the assistance you need or is it you have peaks and valleys in needing more or less during certain seasons and it's a temporary workforce?

[00:14:33] Samantha Rapuk
In theory, it's a temporary workforce, but for most facilities, it is a long-term workforce because we rely on them. I have agency staff that have been in my building for over five years. They continue to want to come back, they know our residents, they might as well be our staff. Staffing agencies have never been regulated, not really. There's starting to be a focus on those, at least in Pennsylvania, at the state level of, what are these agencies doing? How are they charging? What services are they providing? What kind of staff are they providing? We're all competing for the same staff, essentially, is what it comes down to. So any agency can open up and they're going to post for the same jobs that we're posting for, but it doesn't cost the agency anything to have those staff because that, they bill back to the facilities. So an agency can tell an aide that would go into a facility. If the facility were higher, then the facility would pay $15 an hour. Agency hires them, hey, we'll pay you $30 an hour. And then they bill a facility $40 an hour, however, their overhead, where's that aid going to go? They're going to go under, make $30 an hour, pretty much the exact same here, right? And there are drawbacks to being in agency. Some staff don't want to be in agency because you never know where you're going to be or, and there's no guarantees. But for a lot of people, what it comes down to is that bottom line and the agencies are able to pay more because they just charge it back to the facilities. In essence, we're just all competing for the same workforce.

[00:15:53] Jim Jordan
And if you magically started paying everyone $30, you would still have shortages where this would continue to happen. In your opinion, they would just charge $60?

[00:16:03] Samantha Rapuk
Sure! Yeah, exactly, and that's what happens. We increase our rates, they increase their rates and it just keeps going like that because again, there's no liability on there, they just charge it back to the facility. The facility is, their hands are tied because we have to meet the needs of our residents and we can't meet the needs of our residents without staff. We have minimum staffing requirements which are staff above that because it's still not enough, but we have to be able to provide care to residents. We have probably 80% of those residents are long term, we're, we can't just say, sorry, you've got to leave. We have to take care of them, so we need the staff to do that, so that cycle just continues.

[00:16:37] Jim Jordan
So if you had an unlimited budget, what personnel or technology would you buy?

[00:16:42] Samantha Rapuk
Ooh, that is a good question, right? I'd have an unlimited budget?

[00:16:45] Jim Jordan
Would there be a process technology or a magical artificial intelligence that could tell you if people were behaving slightly different, something that could give you an early warning?
[00:16:56] Samantha Rapuk
Yeah, so there are technologies out there. There's a ring you can get that tracks your heart rate and it tracks things kind of going on in your body. We could have something like that for our residents so that we could be ahead any changes in conditions that are coming, that would be wonderful. Something that would prevent falls and not be considered a restraint. We have 50 residents in my skilled nursing with dementia or Alzheimer's, and those residents don't know that they shouldn't be standing up and taking themselves to the bathroom because they forget that they're supposed to call a bell and ask for help. There is technology right now. There are, kind of, like airbags for the hips doing trials on at the moment. I think those would be wonderful. Something to push, not fall, protect the residents that do fall a lot because we don't want to tell them, no, you can't walk around because we want to keep our residents mobile and active for as long as they can be, but a lot of the times it's just not safe. So anything like that would be wonderful.

[00:17:52] Jim Jordan
So switching topics back to your career, can you share with our audience a time when you had to adapt or shift your strategy quickly and how you did that?

[00:18:01] Samantha Rapuk
There's been a lot of that over the last several years. Healthcare is always changing. Long-term care was heavy focused during the COVID pandemic beyond, we were, as I'm sure everybody in healthcare was doing, constantly changing with new regulations that were coming out, constantly adjusting our policies, educating our staff, educating the residents, trying to figure out what health alerts were saying to us, and how we were to interpret that. So clinically, we're always adjusting, adapting, changing to the regulations and the needs of our residents in a broader sense. As a campus and as a company as whole, we have conversations frequently with the executive leadership team discussing how do we remain viable when the reimbursement isn't where it needs to be. How Medicaid ... about $230 a day when our cost of care for a residence is a little over $400 a day. How do you remain viable? What services do you offer? One of the big projects we just completed just three weeks ago, the construction project on the fourth and fifth floors, repositioning those floors that were once skilled nursing units, taking those beds offline, and making them independent living and personal care, because that's a private pay model. The staffing requirements are much less and much more manageable products than skilled nursing. So I always say to managers when they say, oh, I just passed by Target, I passed by Sheetz, they have signs out front that say starting at $20 an hour. And that's disheartening for us because there is only so much that we can pay our staff when we can't change our reimbursement, not on a grand scale like Target can. They can increase the price of the products that they're selling. Our reimbursement is set by insurance companies and by medical assistance and by government. We have to, we're constantly trying to adjust and see what else we can offer. Everybody wants to be paid more, we know that. Everybody has families and a life and they need to be able to fund that. If they're not going to get paid what they need to get paid, they need to go find it somewhere else. We're always looking at retaining our current employees because we need them. How do we make a positive work environment? We're now offering free health insurance for full-time employees as a means of gaining the staff that we have and hopefully recruiting others who might not get that benefit if they're working at Target or Sheetz or wherever. We're always adjusting. We're always trying to find ways to keep moving forward. Working for a nonprofit means that we're mission-driven. We're here to take care of the residents. And for a lot of companies that are closing their doors, we just had a 90-bed memory care, personal care facility just close right down the road from us. They had to displace 48 residents that they had, and they're all memory care, which means there aren't a lot of facilities that are going to be able to offer that care to them. There's other personal care hubs in the area closing down. There's another nonprofit closer to where I live, just closed this month, and it's happening everywhere because the funds aren't there to make it reasonable to stay open.

[00:20:57] Jim Jordan
For-profit, you'd go to the independent living and you would get out of this part of the business.

[00:21:01] Samantha Rapuk
And that's what a lot of them are doing. That is what a lot of for-profits and even nonprofits are doing because they have to stay open and stay viable. So we're constantly evaluating, reevaluating where we are in this space. What it comes down to is, if we aren't providing the skilled care, who's going to? Who's going to do that? It's an industry that is struggling right now. I don't know where it's going to leave us when all these facilities are closing down because they just can't afford to stay open. Where do those residents go? Where do the future residents go? Where are the people that can't continue to stay in their houses, what are their options? There are the PACE programs, the life programs that keep them in their homes, but that's not an option for everybody, it's just not, regardless of what the public opinion is of them, they are a necessary part of the healthcare continuum.

[00:21:49] Jim Jordan
I think what's interesting is, we don't solve this in the next 30 years, we probably won't solve it. We're sort of in the middle of the baby boomers and there's probably 30 more years to the rest of them pass through the system, and I guess the pain will cause change eventually. So let me ask the next question two different ways, because there's an aspect of how you keep current on rapid change that's necessary for you, for your business model. And then there's this aspect of how do you keep track of change for you personally as a creative leader. So that's the first one first, how do you keep all this regulation and all this change? Do you have a group of people that are constantly monitoring this value and feeding it back to you?
[00:22:28] Samantha Rapuk
Yes, so you cannot run a facility in a silo. You need a team. So we have several so we have our internal management team that consists of the department heads for all departments. And when change is coming, for me as a leader, it's important that I get input from everyone because I don't know everything. I can't look at something from every side, so I rely on my team to give their input and then we make informed decisions from there. And it's not always a quick process, sometimes it has to be a quick process, but it's not always a quick process. And it's not just the management team, we bring in our floor staff, our aides, people that it's directly affecting. We say, how will this work for you? And then we also have corporate compliance officer who keeps track of all the regulations that come out.

[00:23:12] Jim Jordan
So this isn't a 40-hour week job that you have, right? You're always worried about the residents and what's going on and needing to be involved in all the details. So how do you worry about compliance, worry about all those details and find the time to step back and figure out where the innovation is in the industry? Where do you go for that information?

[00:23:30] Samantha Rapuk
So it's all coming from a lot of different sources. You have to stay informed. A lot of things pop up in the news that might not seem like it's related to long-term care, but when I look at it or one of my colleagues looks out, oh, this might affect us, it's, it might be something to do with supply chain ends up affecting us pretty severe when, we have consulting groups and advocacy groups that help the process. There's Leading Aid, which is a nonprofit advocacy group. There's the National, but then there's one for Pennsylvania as well that keeps us informed and has calls. PHDA the equivalent of that for-profit industries, but we're all operating same facility, so we stay up to date with them. But really, more than anything, and anybody in long-term care knows this, long-term care is a small world. So we all keep in touch with people that we work with before we've all developed relationships. I frequently text a friend that was an administrator, was a mentor to me. I reach out and say, hey, how are you doing this in your facility? All of us in the industry rely pretty heavily on each other.

[00:24:29] Jim Jordan
Is there an industry magazine or something that you would recommend to people in this space to follow?

[00:24:34] Samantha Rapuk
So I get McKnight's Medical. It gives all the monthly updates. I read that, that is a huge resource for me and they're online as well, so I get a lot of Google alerts. They put out a lot of really good articles and updates on what's happening in the industry, wonderful resource.

[00:24:50] Jim Jordan
So in this journey, what's the biggest lesson that you've learned thus far?

[00:24:54] Samantha Rapuk
So I thought on that question, and I don't know if there's one thing in particular that stands out because I feel like I'm always learning. I have progressed pretty quickly through my career to get to where I am now, and I know I don't know everything. And so I'm constantly learning, I'm constantly adapting with the sole focus, always being the residents and their care. So I think the biggest things that I've learned is that one, change is inevitable. We don't change, we don't survive. So going into this with that headspace, knowing that just because we used to do something one way doesn't mean that that's going to be the way we go tomorrow. Change has to happen in order to continue growing in this space. The other thing, and I think COVID really highlighted this, it was always there, but COVID really highlighted this, is that the public perception of who we are and what we do is not always accurate. That has given me a lot of perspective of areas outside of healthcare. You see things on the news saying, oh my gosh, I can't believe they would do that. It really has given me the ability to take a step back and think, is that really what happened, or is that how they want us to make it happen? There's been a lot of, a lot in the news about long-term care, about skilled nursing facilities, and about personal care. I don't think people realize what the difference is between all those levels of care to begin with, they all just lump us in together. We're not in it to make a buck because we're not making a buck right now, we're in it because there's people that need our care.
We're here for these residents and for a lot of them, we're the only ones here for them. They need us and we take that personally and we take it very seriously. My biggest takeaway so far is we're not just taking care of our residents, we're taking care of their families. We're taking care of the people that care about them and love them because it's difficult to get older, but it's also difficult to watch your family members and your loved ones get older and having to make those decisions and figure out what you need to do when there isn't a lot of information out there about long-term care that really explains it, really gives people an idea of what they need to do and what kind of funds they need to have. Everybody's always worried about the money and what it truly is to be in a nursing facility or a personal care facility. A lot of people come into this line, so our job is, it's not just taking care of the residents, it's the families, it's the friends, it's everybody. There's nobody in long-term care, especially after this pandemic that isn't here for the residents.

[00:27:24] Jim Jordan
What do you see is the biggest opportunity for growth or threat to healthcare system today?

[00:27:30] Samantha Rapuk
The biggest threat is reimbursement right now. So what we're getting paid by insurance companies and by medical assistance, you would think with the rising costs that we would start to be reimbursed to meet that, and Medicare has said, oh, no, we're going to pay you less this year. We're reducing what we're paying you. Insurance companies are constantly reevaluating ways to pay us less. So Highmark, for example, used to pay us our RUGs, so it would be based on their daily RUG rate.
[00:28:00] Jim Jordan
What does RUG stand for?

[00:28:02] Samantha Rapuk
Resource Utilization Group. It is a score based on the therapy needs, the nursing needs, and, any other care that somebody is coming in on a skilled stay might need, and then there's a daily rate associated with that RUG score. That is an old method of calculating daily rate that most have moved to what's called PD/PM. If they're doing a daily rate, PD/PM stands for patient-driven payment model, and that's the new model that Medicare came out with, and some insurance companies have followed suit. So back to Highmark, we used to get paid based on that RUG score and they recently came in October, that we're getting paid as a bundled payment. So they say you can keep that resident as long as you want, but we're only giving you $3,000 for the entire time that they're there. So manage that care how you want so that it makes sense that you make money. That has been an adjustment and we have some that just have it, they pay on levels, which means they set their rates and they say if they meet these criteria, this, and that's all you get paid. It's just, it's not enough and they won't increase their rate. I was hopeful, probably naively hopeful during COVID that the insurance companies would see that they need us, that they need skilled nursing facilities because their residents were sitting in hospitals, because skilled nursing facilities couldn't take them. They didn't have the staff, they had over outbreaks. Staffing wasn't where it needed to be to take people, a lot of places, and us included, for a period of time, stopped taking any admissions just because we couldn't get our hands around everything that was happening all at once. And when somebody is in the hospital, the insurance companies are paying a significantly higher rate for that bed. And so I was hopeful that they would see that and think maybe we should pay the skilled nursing facilities more so they could give their staff more so that we have a place to discharge our residents too, but instead of being in a hospital for a month because there's no bed available for them, but so far that has not happened. So I would say that that is biggest threat, it's just reimbursement.

[00:30:03] Jim Jordan
So at some point you have to cap how many people you can take in your skilled facilities given that day rate? Because, you know, for our audience, you had mentioned 75% of your people are under this cap, which means the other 25% of the people, if your $400 a day, I can't remember your exact number, and you're getting $200 something, you have to make that up to break even, that's just the fact. So what's society to do? Have you seen these studies on the implications of this, on the economy, on the working people? I mean, the whole idea of this is that from 20 to 65 years old, people are working and contributing to the economy and they save. And when they get to retirement, they spend their money, which hopefully is a more joyous things than the nursing homes. But when they get to that occasion, if they can't cover themselves and there's no capacity for it, then that means we have to ask their families to do it. And that could mean that families may be out optimizing their income, or particularly in areas that have health equity issues, you have people that are leaving their jobs to take care of grandma or they're working a minimum wage when they could have been making more. Are there any studies that you've seen on this?

[00:31:11] Samantha Rapuk
Most recent study I've seen with just more information on the number of people over 65 and those who are going to need care in the next ten years. There are roughly 25 million people over the age of ... 75, and in the next ten years that number's going to jump to 37 million and the burden is going to be on families to provide that care if we don't have this level of care available to them, and the number of facilities is dwindling, like I said before, so what are people to do? People need to be angrier about this. People need to understand that it might not be affecting you right now, but it comes quick. It, you think mom's going to stay in her house forever and she'll be healthy and she'll live there and be fine, and if something happens, I will take care of her. Or, oh, there's home health to take care of her. Well, the home health is facing the same struggles with staffing that we are. It's not always available like it was maybe five, ten years ago. So write your elected officials, tell them you need to pay facilities more. That anger and the changes that everybody wants to see made shouldn't be directed, and I know I have a very biased opinion on this, but it shouldn't be directed at the nursing facilities and the long-term care facilities. It needs to be directed at the people setting our rates, which are the healthcare companies, it's CMS, it's the Pennsylvania governor and his team that are setting our Medicaid rates, and it's just not adequate to provide the care that everybody wants to be able to provide. I think it was very easy during COVID to blame the facilities. It's very easy for an elected official to say, Oh, that was on them, that's not on us for not providing the supports they needed. It's on the facility because they didn't care about the residents or they didn't they weren't doing what they should have done. So the focus is now, what new regulations do we put in place for these facilities? And one of them is staffing, they're trying to increase our staffing numbers and our advocacy group ... jumped in and said they wanted to set up 4.2 PPD per day, which is 4.2 hours per resident per day of care.
Right now it's at 2.7, so that's a huge job. That's a massive jump on the number of staff needed. They worked with the lawmakers and the people working on those regulations and got it down to 2.83 in the first year and then 3.2 in the following year, because they want to say, oh, you just need to staff better. Well, we would love to. We would love to staff better. We don't have the funds to do that because you're not reimbursing us and you haven't been reimbursing us for far too many years. There's this misconception, 10, 15 years ago, facilities were making a lot of money, they were. They were able to get a higher rate from Medicare for those residents that were skilled because of the drug payment model that was in place, that has changed pretty drastically in the last 10 to 15 years as most people have signed up with Medicare replacement plans. People aren't on straight Medicare. In Western Pennsylvania especially, we have a lot of former union workers who now have a pension plan that selects their insurance for them, and so if they're tied to a Highmark plan or a UPMC plan and they set the rates and it's just a matter of negotiating with them, but no facility is making out on it. And then in addition to that, it's just that, how do I say it,the insurance companies know that we need them and they know that we're going to continue to accept their patients, our residents. So what incentive do they have to increase those rates? Like I said before, I was naively optimistic that the fact that we don't have the beds readily available like we did either three or four years ago might give them the push to reevaluate where we are.
[00:34:56] Jim Jordan
I think part of it too, is that so, I think you know the story I'll just share with you. My grandmother lived with us my entire life and we would move around, I mean, my college schedule, we moved around to take care of her, but she was healthy. We would maybe help feed her or she had bouts of having some immobility that you'd help around, but she always handled the bath, and she was always, her mind was always sharp, right? So for the most part, we could keep her at home until you couldn't. And when I look at my grandmother's generation, when they went in the home, it was usually that they were in pretty bad shape and they didn't last terribly long. And I think today we're living longer with more co-morbidities, we're not having the heart attacks and cancers that kill us. We live longer, we have the diabetes, we've got the COPD, we've got all these other things. I don't have data on that, but do you think that's part of the lack of appreciation for why this needs to be a bigger and a more comprehensive long-term solution?

[00:35:51] Samantha Rapuk
Oh, absolutely, well, coming into our facilities are very sick. There are people that can't go home. There's too much going on. They cannot go home. They're too sick, and the amount of care that they need is so much more. During the pandemic, when everybody started working from home, we did see a big shift there in people going home because they had kids at home to take care of them, which was wonderful. People are now going back to work and people are busy. It's just not always an option to take care of mom in the home. And you talk about your grandma's generation, I would be willing to bet that the bulk of that generation had daughters or daughters-in-law that didn't work. They stayed at home with their kids, they were homemakers, so they didn't have to worry about a work schedule, even if the husband was working, there was always somebody at home. And I think that the fact that there are so many more women working full-time jobs, taking care of kids limits their ability to take on another person that's going to need care or help.

[00:36:51] Jim Jordan
And I think too, the other aspect probably at play here, I know you're part of the big family and for the most part, there's still around. My grandmother grew up with a big family around, but now my cousins are dispersed all over the country. I have four daughters, one's here, three of them live far away, and if 20, 30 years from now, if I'm needing that situation, they would not be able to come down the street and help me out. So I think that's another aspect of our economy is dispersing it.

[00:37:19] Samantha Rapuk
And you do speak to the big family and my mom is one of eight, and when their mother got to the point that they needed someone to spend the nights with her, they would trade off spending nights with her. And then when it got to the point where people needed to be at the house during the day, they were doing that, but it got to trying to schedule everyone, and trying to provide that care to her was just difficult because they all work. It was a lot of stress on them and they were happy to do it, but it got to a point where it was untenable and my grandma now lives here in my personal care facility. And honestly, her life is so much better being here and she's admitted it. She was not going to be moving here. She was not going to move out of her house. It took about a good month and a half before she admitted, I didn't want to be here, but I know that this is where I need to be. It gave my family the ability to enjoy being with her again because they weren't ... And there's so much guilt associated with it, like they're giving up on them. But when really they're giving themselves such a wonderful opportunity to be able to enjoy their loved one again and be a family member and not a caretaker. A very tough industry. I'm that person that wanted to go out and save the world and you grow up and realize you can't do that. But, and I feel my staff feel the same way that we're doing our part. We're taking care of others where there's meaning to what we're doing. And that is a benefit that can't be measured, but that I think makes a huge difference and just how we live our lives, so.

[00:38:45] Jim Jordan
Fantastic, well, thank you very much. I'm so grateful that I have not cried during our interview. Had you at Carnegie Mellon University before, and speaking to our students who are going for master's in healthcare, and I think the majority of them did not appreciate this industry, the business models, the balance of compassion and care with finance and operations, and that complexity, and so thank you for sharing that with our audience. And hopefully some of the people that listen recognize that they have to lobby for this segment to get better funded.

[00:39:15] Samantha Rapuk
Yes, I agree. Thank you.

[00:39:19] Jim Jordan
Thanks for tuning in to the Chalk Talk Jimm podcast. For resources, show notes, and ways to get in touch, visit us at

Automated transcription by Sonix

Who is Samantha's Background
What does your organization do?
What is your business model?
What are the challenges your organization is facing
The impact of contract employees in healthcare
Can you share a time when you had to adapt or shift
What news or information sources do you follow?
What is the biggest lesson you have learned?
What is the biggest opportunity for growth or threat to the healthcare system today?