Candid Care: Addressing Clinical Loss Trends

Candid Care Ep 12: Addressing Clinical Loss Trends

Welcome to Candid Care, brought to you by M3. I’m Sarah Kekula, M3’s Director Of Senior Living And Social Services practice, along with Talia Fletcher, Risk Manager at M3. Each episode of Candid Care promises to challenge your current thinking about the long-term care industry and introduce concepts to improve your organization and advance the field from executive risks to key strategies. We’ll approach each topic from multiple angles and invite leaders with unique perspectives to join in the conversation.

Please be advised this podcast and the recommendations throughout are not intended as legal advice and should not be used as or relied upon as legal advice. This podcast is for general informational purposes only.

00:47 Sara Kekula

Well, Lauren, thank you for being here today. It’s great to see you. We’re excited to hear a little bit more from you today about you know clinical risk trends, what you’re seeing from your lens and kind of sharing with you what both Talia and I are seeing.

So I think maybe a good place to start here is with some data. Talia, I know that the CDC just released an updated profile of assisted living facility. So maybe let’s start there. Some of the changing demographics, what we’re seeing and then we could maybe jump into skilled nursing. What do you think?

01:25 Talia Pletcher

Yeah, that sounds great.

Certainly. Of course, we know that skilled nursing usually takes the spotlight when it comes to trends and clinical outcomes, litigation, whatever is going on in that world when it comes to see your living. But assisted living are definitely increasing in their service availability. What they’re able to provide to residents, also residents and assisted living, have historically moved in there so they can age in place, according to the CDC’s most recent profile of assisted livings, over half of assisted living residents are 85 years old or older. And then 62% of those residents do  require three or more activities of daily living or assistance with through more activities of daily living and then 55% of those residents had a diagnosis of up to three or more chronic conditions.

So clearly we’re seeing people age in place, they’re having, you know, more chronic health concerns. They’re needing more assistance from care staff. People want to stay in their homes. Right? So we have to bring services to them. But I think what we want to discuss today is, you know what can we do to help providers be as prepared to take care of these residents.

02:29 Sara Kekula

So with the acuity changing and assisted living, Lauren, I know you have specific data about skilled nursing and some of the you know, maybe recently what we’ve been seeing specifically here in Wisconsin, So what are some of the trends that you think maybe we should start with from a data perspective? And then we can jump into maybe some risk strategies like Talia talked about.

02:51 Lauren Davis

Yeah, I mean it is, it is getting to be the Wild West out there in assisted livings with the amount of patient acuity and complex clinical needs that they’re seeing in that setting.

Which is only showing that skilled nursing facilities are getting also more complex and having more clinical acuity. Having that clinical acuity means they need better training for nurses and we need to have good policies, procedures in place to help avoid those citations.

So just some of some data I have for the skilled nursing facilities. So starting in this first half of the year for 2024, there have been 70 citations specifically to wounds, wounds alone in the nursing home, which is just such a high number. There’s been 36 in the Milwaukee region. So over half of that is solely in our Milwaukee region where the populations of our nursing homes.

The average citations are 5.6, and really there hasn’t been much of a change in that from an average citation perspective from 2020 to 2024, it seems to be pretty consistent. But the severity of that up to 25% of those citations handed out are harm tags. So G level or higher, which just shows that there’s so much more clinical acuity in that setting where we just need to have really good processes, oversight and monitoring.

I think, you know, wounds, wounds is just a high category specific for my consulting and what we’re seeing in organization. Lots of citations surrounding wound care or accident incident management, such as falls.

04:22 Sara Kekula

Yeah. And it’s, I mean, it’s an important topic because we can attest to the insurance carriers. You know CNA as an example, does an aging services report on a regular basis. And I mean if I could look back in time, if I have that report in front of us, it would tell you year over year severity events top cause of loss it’s wounds.

And so I think it’s important topic to continue to talk about for providers and specifically you know what things are changing, what it’s changing in our environment with staffing, what’s working, what isn’t, so that we can kind of maybe reimagine our risk management strategies.

Given what you’ve said just now and knowing that you do a ton of work, you know in this regard with your respective clients, what are some key risk strategies or risk mitigation strategies that providers should consider implementing to mitigate, you know, kind of the risk of a wound?

05:20 Lauren Davis

You know, we were talking about with the IJ’s from 2022 to today. It’s the second highest cited citation is the pressure injury prevention. So I think that’s a great place to start and some of those risk strategies that I feel are so important is ensuring that your facility does a proper facility assessment of all of their processes, policies, procedures specific to wound care.

I think having certain questions you go through and different assessments that you’re going through to ensure that you’re capturing all of those high-risk areas are so important. Having a certified nurse or having someone on staff who is wound-care certified or has additional education specific to wound care is also so important. Making sure that your staff have adequate access to different product and making sure that they’re helping recommend good product for wound healing.

Like I said, the updated policy and procedure is huge and not having updated policies and procedures and not having staff really understanding what they can and cannot do specific to wound care is also one of those big strategies.  

06:30 Sara Kekula

Super helpful and I think, of course I am not in operations but I would imagine, and Talia, you could probably add some colored commentary to this, but you know the challenge that we know continues to, you know, plague providers is staffing and perhaps staff turnover. It may not be everybody’s reality, but to some extent it’s their chronic problem. And so I think knowing that staff turnover is going to be an ongoing, evolving risk just given you know, kind of conditions that we foresee for the future.

Any, like any tips you’ve seen be successful with? How do you combat that knowing that you’re going to have turnover and turnover. How do you continue to educate staff or building those systems recognizing that’s a continued challenge for providers?

07:22 Lauren Davis

So turnover, like you said, is going to be something that’s going to happen no matter what. So how can you standardize process to make them as efficient as possible and as simple as possible.

So one of the things when I go into a building, what we always recommend is making sure you have a wound care formulary. There is wound care dressings that you have in house that those are the dressings that you are going to recommend that help staff stay more consistent as well and have access to.

You know, a lot of times some providers or nurses who might have worked in other settings will say they want to recommend a certain type of dressing, but what they don’t understand is that it might cost the nursing home $200 for that dressing change. So then we have a delay of care or delay in treatment because then it doesn’t get delivered, it doesn’t get applied. And so there’s no big changes for that wound or that quality for that resident.

So making sure that you have standard and consistent processes, whether it be the wound care formulary, maybe standing physician orders from your Medical Director. Every skin tear first you know stage 1 is going to be treated the same way or pressure injuries. Stage 2, we have preventative measures that go on, just as kind of that standing house order.

A  lot easier to train standardization and house orders or house processes than having more free flow of ideas and people able to just make their own judgment calls because like you said, we don’t know always where those nurses are coming from their backgrounds.. And so we need to make sure that it’s compliant and making sure it’s providing good quality care

08:55 Sara Kekula

Compliant and clear. That was my take away. Thank you. Mic drop Talia.

09:08 Talia Pletcher

That’s a good point, especially as we’re, you know, bringing in agency staff or temporary staff to help. You’ve said it so well, it has to be clear and concise, and that’s one thing too, that many stakeholders look at when you’re hiring staff. Even if you’re using temporary staff, how are they trained to take care of the people that you’re surveying and that’s standardizing is huge.

I think another thing too from an operation side of things that I think could be a good strategy for providers is you know, obviously as you’re balancing or as they’re balancing staffing changes and hiring issues that they may run across. It’s looking at continuously reassessing who you’re able to take and how many you’re able to take at one time of a certain what certain diagnosis so wound care is obviously a great example. Maybe you can’t take 5 wounds at one time, right? It’s reassessing that admission process and capping it at certain times based off of where you’re at with staffing to help ensure successful outcomes, so I think that’s another area too.

10:04 Lauren Davis

Oh, 100% and a lot of times we get wounds from the hospital that might have everyday dressing changes. That’s a lot of staff time. Yeah. And sometimes we’re able to convert those dressings to something that’s changed once every three days or five days or seven days, which promotes better healing outcomes, but also saves on that staff time.

So if they’re able to be covered under a skilled need or some other focus or other topic, you know not having daily dressing changes is sometimes some something that will really help be more efficient for staffing.

10:37 Sara Kekula

Good point. Well, let me ask you now, this is top of mind. I know for our team and I think it’s top of mind for a lot of healthcare organizations is technology. You know, what can we look at adopting or implementing that can certainly improve quality outcomes to your point, but also maybe even build inefficiencies.

Curious from your perspective, what are some of those kind of maybe emerging technologies or maybe existing technologies that you’ve seen with that are cool that you would maybe challenge providers to consider diving into further, maybe even implementing.

11:14 Lauren Davis

Yeah, I think the photography of wound care is a big topic of discussion. I’m a strong believer that having better assessment techniques and better imaging picture can tell 1000 words. And so it’s important that we have consistency of measurements. If I measure a wound. And Sarah, you measure a wound, we might have different measurements based off the angle of the patient. We shouldn’t. But the likelihood that we will is pretty strong.

So the picture itself is able to measure.

There’s a company called ECare. And it’s an insight app that you can download to an iPhone and then be able to upload those images into your EHR, that is something that has come across my purview that I feel is something that really is kind of above what we’ve seen in the past. I think pictures started out in one way and I think it’s evolved and it’s improving the ability of nursing staff to have more reliable, consistent documentation.

12:14 Sara Kekula

What about wound coach I know a little bit about that, but talk to us. You mentioned that before we started the episode. Talk to us about wound Coach and the value that you see in that piece too and how it could maybe bring some education to other staff in the community outside, maybe the wound nurse or RNs too.

12:30 Lauren Davis

Yeah. So this this wound Coach application was created by the Nancy Morgan Wound Care program. And it is again another platform online where non licensed caregivers can get continuing education through maybe their wound Care essentials program, but also provides different certifications. And so in non licensed settings such as assisted living, this is a great opportunity for caregivers who are seeing that higher acuity, more complex wound care, skin need. This is really a good platform that I would highly recommend looking at as an opportunity to increase that education.

13:08 Sara Kekula

Yeah, it’s almost like, I mean it’s education, but it’s also it’s like the awareness, which is valuable.

Whether it you know that platform or something else that’s out there, but it is, I mean I think it would be helpful as we continue to see, you know again a higher acuity and AL as an example and maybe you know an increase in acuity in numbers in, in skilled space.

13:28 Talia Pletcher

I think one question we get often with using the technology is, I mean there’s a little hesitancy because you know people are concerned about, oh, I’m taking the photos or I have them in my record. And historically, I think photos were always a no, no, in long term care, especially in the skilled nursing side, but you know to your point it can be a very useful tool.

But one thing that we always advise on is if an organization is going to adopt a technology that is there to help with prevention, monitoring, whatever it may be. The organization does have to use that data that they’re given and use it appropriately to help with their outcomes. Would you agree with that? What is? What are your thoughts around that piece of it?

14:03 Lauren Davis

Oh, 100%. You have to adapt the technology and then you have to measure the outcomes of success. So making sure that whatever program you’re implementing in your organization is having positive patient outcomes and you’re able to really identify the pros of using that technology.

The goal is really to eliminate staff time doing maybe some manual work having that technology present and so being able to measure that and show effectiveness, maybe better survey outcomes, whatever that measurement of successes to your organization, I think it’s just important to know the data.

14:40 Sara Kekula

Yeah, that’s a good point and I mean, again, like I I’ve already mentioned, pressure injuries are a top cause of loss, you know, for from a severity perspective for insurance companies. So Talia and myself, certainly the vested interest in helping our clients build out systems or improve them.

But maybe as we look to close the conversation, if I were to ask you two things you want listeners to walk away with, what would you what would you say?

15:10 Lauren Davis

Yeah, I think you first have to understand where your risks are. So your facility assessment is going to be huge, knowing where your areas of opportunity are. And then from there doing something with that data, implementing some sort of strategy, whether that be technology, whether that be facility education staff, education, standardization.

And then having don’t close that loop and circle back and say did what we implement make a difference? Did it improve patient outcomes? Did it improve the satisfaction? So it’s that full circle of that process.

15:47 Talia Pletcher

It’s quality improvement, it’s risk management. We all have that plan. Do study, act process like yeah, that is exactly what it is. Yeah.

12:56 Lauren Davis

And we can use it for anything. Yeah, not just wound care, but any process in the facility that they’re struggling with. Plan, do, study, act. And then just start over.

16:03 Sara Kekula, Talia Pletcher, Lauren Davis

Yep. So appreciate those insights, Lauren, you just reaffirm that it’s a dynamic business that we work in. It’s not static. We always need to be looking at our circle. So grateful for your time today. Thank you so much. And we look forward to the next conversation.

Thank you for listening to Candid Care brought to you by M3. Connect with us at m3ins.com for access to more resources, more insight and to join the conversation.