Upfront Healthcare Magazine Issue 6

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Quarterly for LTC Professionals


The numbers are up again. But how should we speak to prospects in a postCOVID-19 universe?

PATIENTS’ NEEDS ARE CHANGING. Can your building keep up?

FACT OR FICTION? The REAL discharge stats

CAN A HELMET OFFER HOPE? The FDA-approved mental health treatment that’s uniquely suited to seniors.

Upfront Healthcare

October 2021


Some people care too much. I think it is called love. -Winnie the Pooh

Sometimes we need someone to simply be there….not to fix anything or do anything in particular, but to just let us feel we are supported and cared about… -Eeyore This past year has seemingly gone on forever. And yet it has been over in a blink of an eye. For many, we are not sure if we are any better off than where we started, with new assessments and conditions and mandates. However, healthcare goes on. Through all that this year has provided, we all need to remember why we got into our profession to begin with. It was either a family member who was already in healthcare, or someone we looked up to when we were young, or maybe even the ideology of what a TV show displayed. It has always been about caring for someone. It has always been, somehow, a labor of love. It has always been about someone else. And isn’t that what our lives should be all about? Service to others. How many of the military


or emergency task forces have done things for people they have never even seen? And yet we are able to gaze into the eyes of many of those who we care for. The most impressive people I know are those that serve with selfless devotion. Those who spend countless hours working longer than their shift, to do whatever is necessary to ensure the comfort of someone else. Does it sound like a fairy tale job? Those who are not associated with healthcare may never understand.

CREATIVE Rebecca Lieberman Joy Hoberman

But for us who have lived a life full of that service, we really don’t know any other way. There will be many technological innovations along the way. There will be new procedures and medications or nutraceuticals or artificially grown tissues or automation. History has shown and proven that technology has compressed time and new innovations have been made available in what seems like seconds compared to years ago.

ADVERTISING Britt Goldberger

But the most powerful achievement in this world of ours is the enduring heart of any and all people of healthcare. Technology can produce anything and everything — however, the human heart and spirit, teamed with the love for another, will never be surpassed.

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October 2021

Thank you for all that you do, and thank God for giving us the ability to do it. God bless you all and once again…

Thank You. Joe Kubulak V.P. of Operations and Business Development, SpecialtyRx



06 10 16 22 29 35 38

Industry Currents Travel nurses, getting mathy with healthcare and more tidbits.

The Only Constant is Change The Evolution of LongTerm Care Design.

After The Storm The healthcare world has changed.

Digital Marketing for Long-Term Care What you need to know.

Compassionate, But Tired Are our nurses and caregivers suffering from Compassion Fatigue?

Smarter Better Faster Discharge: The myths, the facts, the stats.

Why Doesn’t Granddad Smile Anymore? The mental wellness of seniors is being neglected.

America's Leading LTC Pharmacy SpecialtyRx is your long term pharmacy partner.

Servicing: New York • Connecticut • New Jersey Ohio • Florida • Delaware • Pennsylvania • Kentucky

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Find out more about our long-term partnerships

1-866-773-2479 srxltc.com

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October 2021

industrycurrents COVID-19

Not Just a Supplement As debate over vaccination and vaccine mandates continues, research finds that a popular vitamin may help to reduce severe outcomes for patients with COVID-19. Researchers are exploring if 25-hydroxyvitamin D supplements, or just vitamin D for the rest of us, can prevent drawn-out suffering and death from the virus. A study published in the Journal of Clinical Endocrinology & Metabolism finds that vitamin D levels were lower in patients who had to be hospitalized after contracting COVID-19 when compared with those who presented a more typical recovery. These new findings add to the already mounting pile of evidence noting the relationship between COVID-19 and vitamin D. Another study published in PLoS One several months back finds that patients with sufficient Vitamin D levels have a lower risk of death when compared with patients who have insufficient levels of the vitamin. "This study provides direct evidence that vitamin D sufficiency can reduce the complications including the cytokine storm and ultimately death from COVID-19," said senior author Michael F. Holick, MD, Ph.D., of Boston University School of Medicine. But wait, there’s more: data published as far back as September 2020 showed that individuals with sufficient Vitamin D levels had a 50% reduced risk of contracting COVID-19. And a small, randomized clinical study published in The Journal of Steroid Biochemistry and Molecular Biology in

October 2020 discovered that vitamin D played a role in reducing ICU admissions among hospitalized COVID-19 patients from 50% to 2%. Despite this positive research discovery, experts caution that there’s much we don’t know. Vitamin D has been linked to a variety of conditions, including cancer, but supplements have not necessarily proven useful to preventing negative outcomes. Other trials have found limited or no positive effects, so Vitamin D is certainly no reason to stop talking vaccine mandates. Although this latest research adds to a plethora of data on the potential role of vitamin D in COVID-19, many questions and caveats remain,” says E. Michael Lewiecki, MD, of the University of New Mexico School of Medicine. "There is biological plausibility for benefit of vitamin D, since it is known to regulate innate and adaptive immunity in ways that might reduce the viral load in patients exposed to SARS-CoV-2 and mitigate the severity and consequences of cytokine storm." However, Dr. Lewiecki cautions, an association reported in a study doesn’t necessarily indicate causality. It’s possible that sufficient vitamin D levels are simply an indicator of a healthier person who has a lower risk of developing complications. Nevertheless, experts do recommend vitamin D supplementation for elderly people residing at nursing facilities. The BMJ Nutrition, Prevention & Health Journal discovered that many in this vulnerable population are lacking in vitamin D, despite clinical recommendations. And because the elderly are especially susceptible to COVID-19, facility administrators should take steps to ensure that efforts are increased to ensure that residents receive the nutritional supplements they need. Vitamin D is readily accessible and has few adverse effects, so why not add it to your residents’ diets? And if you needed another reason to ensure your residents head outside and soak up some sunshine, there it is.


industrycurrents MONEY

SNF Nurses’ Salaries Rising, Reports HCS As if the nursing shortage wasn’t bad enough in 2019, the ongoing COVID-19 pandemic has created an unprecedented (haven’t we heard enough of that word?) labor crisis that’s still looming large come 2022. The Hospital & Healthcare Compensation Service’s 44th Annual Report presents new data obtained from 1,613 nursing homes and about 150,000 employees. The report finds that salaries for DONs have crept up by 3.09%, and hourly pay for CNAs is up by 7.13%. Salaries for medication technicians have jumped 6.75%. In 2021, the average salary for a Director of Nursing is around $105,000, and around $80,000 for an assistant DON. Nursing home administrators’ salaries have also seen a 2.29% increase, to an average that hits around the $120,000 mark. Close to half of the survey’s respondents said they expanded their budget for raises based on merit, and around 80% made salary adjustments for “key employees.” Across the nation, across every position, salaries have risen. And they’re not going down anytime soon. Employees are expecting what’s termed as “higher crisis pay,” but even as COVID-19 hysteria subsides and facilities have learned to better control the virus, that higher crisis pay is staying right where it is. These high salaries — and the knowledge that the numbers are staying where they are — has made nursing facilities double down on finding just the right person for the job. Providers are seriously investing in their workforces: to secure employees with appealing

resumes, providers are offering record salaries and sign-on bonuses. Even entry-level workers are now being paid more than the commonly recommended $15 minimum wage. More and more facilities are also offering free CNA training. That CNA or nurse can get paid a lot more than whatever their starting salary was, even if they haven’t advanced significantly in their career. And providers who won’t or can’t pay the steepening prices are in a tight spot. The market is now candidate-driven. Recruitment agencies recommend that facilities move quickly when making hiring decisions, because a potential candidate will be snapped up by another facility if you’re slow to decide (or holding onto purse strings).

Quick Tips: How to Find Nurses in a Nursing Shortage Ask your staff: Your employees are likely familiar with qualified candidates at other facilities. Asking staff members for their recommendations will also show you trust them, which will help improve camaraderie — and, of course, find new talent. Bring your culture to social media: When competition is fierce, candidates are looking at the job environment to help them make a decision. Build an organic social media presence (and post new openings) to showcase your facility’s vibrant environment for residents and staff alike. Revamp your training: When it comes to employees that necessitate on-the-job training, like CNAs, turnover rate is often high. Set aside time to study your training protocols and turn your training sessions from chaotic and complicated into short, digestible chunks that make learning simpler. And, as always do everything you can to create a welcoming environment.

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October 2021

industrycurrents NURSING

How does your rehab facility support behavioral health post-discharge? Telehealth companies like MediTelecare are providing post-discharge clients efficient & effective behavioral health solutions Your discharge process is ironclad: you’ve assessed the resident’s health, collaborated with their family and healthcare team, and recommended options for continuing care (from medications to brochures to fridge magnets). After all, effective discharge is the critical link between treatment received, and post-discharge care provided in the community. It’s a win-win: when discharged properly, your clients receive the support they need to maintain their health and flourish at home, and your facility prevents hospital readmission. But do your residents’ behavioral wellness benefit from the same continuity of care as their physical health? 20% of people over age 55 have a mental health condition, and the likelihood of readmission for a person with a behavioral health comorbidity is double those without mental health problems. But the behavioral health component of post-discharge care is typically overlooked. The issue at hand? With multiple residents to discharge at any given time, discharge planners are often strapped for time — and can’t devote their energy to securing accessible behavioral health solutions in a timely manner. Even if they do manage to find a behavioral health specialist, the mental health professional shortage means their client will usually get added to a waiting list that spans several months or even a year, leaving critical gaps in their care. And older individuals who can’t easily access transportation will have a harder time “going into

town” for an appointment. But telehealth companies like MediTelecare are fixing that. By helping patients access behavioral health services over the screen, behavioral telehealth companies ensure that your facility can close gaps in post-discharge patient care. Behavioral telehealth services are often highly available and accessible: post-discharge clients can often receive care within a week of discharge. And clients can access care from the safety of their own homes.

If discharge planners are considering a telehealth solution for clients’ post-discharge behavioral health, proper education is important. Since many older individuals are not likely to manage internet-based programs on their own, patient training is key to ensuring that behavioral telehealth is a boon, not a burden. Everyone on their care team should be aware of the potential for technological difficulties, and ensure that the client is attending sessions properly.

A comprehensive telehealth care model that includes therapy, medication management, and accurate documentation for family can all help clients better manage their symptoms — and find that flourishing life that we all want them to have.



How Has Social Distancing Affected Our Seniors? Feel like you’ve been dealing with lots of social isolation cases lately? Well, you’re not alone. Pun intended. In fact, while loneliness was a growing affliction even before the pandemic, the 2020-2021 lockdowns were the final straw for many. We’re born to be social. Even introverts need friends and some sort of communal framework. And while our social needs don’t diminish as we age, sadly, there’s been a pandemic of loneliness among the elderly long before COVID hit. Isolation isn’t isolated — it’s an underlying condition that brings along a slew of ailments, leading to side effects like depression, cognitive decline, and heart disease. As people age, research shows that few are immune to the ravages of loneliness. And that’s without a global pandemic being thrown into the mix. In a study conducted for the Society of Behavioral Medicine, authors Louise C. Hawkley and John T. Cacioppo from the Center for Cognitive and Social Neuroscience at the University of Chicago point out that some 80% of those under the age of 18 and 40% of senior citizens (65 years and above) complain of loneliness affecting their lives in some way.

The Role of Nursing Homes, LTC Facilities,and Rehab Centers Nurses are often closer to patients than other medical personnel, and their presence can have an outsized effect on patients' experiences. To that end, nurses must be made aware of all the factors within their environments that can influence their patients. And it’s not just the medical staff: the rest

of the nursing faculty also have a major role to play in keeping people engaged. The experiences of the elderly and other patients in skilled nursing facilities reflect what takes place during caregiving, and in return, echo the performance of onsite workers as well as the caregiving process. It can be a hassle, but a systematic survey program should be used to log and track patients’ experiences, helping to give management a look into their progressive success. Based on their research and the data they collect, nursing homes, rehab centers, and LTC facilities can help to reduce the tendency towards isolation by keeping people engaged and meaningfully occupied.

Harnessing Technology Consider smartphones and tablets with video chat features to allow people to interact with others outside their physical space. Many of these apps are designed to be intuitive and do not require any significant technological skill, although you may want to consider educating older people, who are usually less familiar with new technologies. Try voice-activated virtual assistants like Google Home, Siri, and Amazon's Alexa. With their straightforward interfaces, they’re accessible to individuals with vision impairments as well as those who have trouble mastering smartphones or tablets. The dangers of loneliness and isolation for the elderly population should not be taken lightly. But by addressing any issues in the early stages, and taking helpful measures, facility management can work toward developing adequate support systems for seniors and others facing a similar plight.

Upfront Healthcare

October 2021

The Only Constant is Change Design

Byline: John W. Baumgarten Architect, RA, AIA, NCARB, LEED AP

The Evolution of Long-Term Care Design


Common Healthcare Abbreviations LTC Long-Term Care HRF Health-Related Facility Model LTHHC Long-Term Home Health Care ADHC Adult Day Health Care ALP Assisted Living Program CCRC Continuing Care Retirement Communities MLTC Managed Long-Term Care ACS Adult Care Setting

By design, longterm care facilities are changing. In previous decades, LTC residents were younger and more ambulatory; now, they’re getting older. And that everchanging variable is seriously impacting the design needs of your facility. THE EVOLUTION As a senior care architect with over 30 years in the field, I have experienced the evolution of longterm care (LTC) centers from the drawing board. And here’s what it looks like: a wave of changes that

started with the elimination of the old health-related facility model (HRF), which was followed by the development of home-based and community-based alternatives such as long-term home health care (LTHHC) and adult day health care (ADHC). These changes — and a number of other factors, such as improved longevity — started to negatively impact the census of the average LTC center and changed the character of the average LTC resident. They are older, sicker, and less ambulatory than in previous decades. As many LTC centers moved to fill empty beds and deal with a heavier case mix, they did so with a different mindset; residents and families were customers who had a choice as to where they could receive LTC. Although the principles of the Eden Alternative were already well known, this new “customer dynamic” seemed to really launch a wave of LTC culture

change with a focus on residentcentered care.

THE ELEMENTS OF CHANGE As our LTC design work was being focused on implementing the “neighborhood/household concept” the term “rightsizing” began to appear in the LTC lexicon. The first wave of rightsizing resulted in the phased closing of numerous LTC centers and hospitals across New York State. The second wave sought to incentivize LTC centers to surrender LTC beds in return for alternative services such as ventilator beds, ADHC slots, or assisted living program beds (ALP). Almost in parallel, a broader view was taking hold: “age in place”. In other regions of the country, continuing care retirement communities (CCRC) had been in place for some time. Here in New

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October 2021

York, the move towards placing ALP beds within or abutting an LTC center was a move towards a continuum of care. It is important not to forget that, at several points along this timeline of change, state & local governments were faced with unprecedented fiscal challenges which negatively impacted LTC reimbursement rates. LTC centers had to do more to compete — but with less funds.

THE RULE: STAY FLEXIBLE We are now in the era of Medicare redesign. LTC has been moved towards an HMO model. Emphasis is being placed on the delivery of health care at the community level. LTHHC and ADHC are no longer financially sustainable for most LTC providers. However, the advent of managed long-term care (MLTC) seems to be driving a new wave of social and medical model day care centers and community centers with an “adult care setting” (ACS).

SHORT-TERM REHAB: GO MODERN Rehab will continue to be the primary driving economic force in LTC centers. Today’s short-term residents are technologically savvy, more independent and are used to a certain level of amenities. To meet their expectations, we are configuring rehab units with internet access and a variety of both active and passive amenity spaces ranging from quiet libraries to multi-media entertainment areas.

The aesthetic most favored by short stay residents approaches that of a high-end hotel. We are designing the rehabilitation areas themselves to resemble hi-tech health clubs with sleek lines and a sense of movement. Beneath all the aesthetic layers lies a cutting-edge array of rehabilitative services; with a major area of focus being activities of daily living. Today our typical OT/PT suite includes an ADL kitchen, toilet, laundry area and a mock bedroom configured together to resemble a single apartment. Some clients have gone even further and asked us to incorporate therapy pools for aquatic therapy.

Interestingly enough, the recent evolution of subsidized assisted living into a more medical, age-in-place model has resulted in ALPs which resemble the old HRFs. We truly have come full circle. So, that’s where we have been. Where are we going? As an LTC architect, I can only go where you, my clients, take me. However, I have learned some valuable lessons over the last 30 years. The most important of these is to design flexibly, so that today’s spaces can be adapted to tomorrow’s uses.


As an interested observer, I have spoken to many LTC colleagues about what the near-term future may hold. Several recurring themes came out of these discussions.

The nature of dementia is a varying degree of disorientation. In an “old school” institutional environment, disorientation breeds fear and agitation.

Comfort First

Statistics show that more and more people are suffering from dementia and onset symptoms are occurring at a younger age.


Our job as senior care architects is to translate the special needs of dementia residents into a built environment that is supportive and comforting. Harsh contrasts in light levels and finish colors can increase disorientation and agitation. Therefore, we customarily specify indirect light fixtures which produce diffused illumination and create less glare. When designing finish palates, we stay away from intense geometrical patterns and use soft contrasts between field and accent colors. We also utilize color as a “wayfinding cue” to help confused residents better navigate through their environment. This is usually done in conjunction with three-dimensional

symbolism to reinforce the message. For example, the doors of a dining room would be painted a unique color. A shallow canopy and signage with restaurant symbolism are placed above and near the dining room door to help residents “make the connection”. The tendencies for dementia residents to wander, and “rummage” (and to lose track of time) also dictates physical changes to a typical nursing unit. It is usually relatively easy to create a “rummage room” and/or a quiet room for “sun-downing” residents. Creating a wandering track is usually somewhat more difficult depending on the floor plan.

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October 2021

ANSWERING THE OBESITY EPIDEMIC As a society, we’ve been overweight for some time. The link between obesity and diabetes, heart disease, and renal disease is well-documented. Some LTC centers have already implemented bariatric programs and on-site dialysis in response to this trend. DIALYSIS UNITS Considerations: Keeping it pure A given LTC center’s ability to implement on-site dialysis is driven by two factors; the health departments’ need methodology and the availability of space (at least 3,500 square feet) to configure a treatment suite. Essentially, you are building an on-site Article 28 Diagnostic and Treatment Center with all the clinical bells and whistles. The most important ingredient in dialysis treatment is pure water. Treated water, in combination with acetate (acid) and bicarbonate, form the dialysate solution delivered to each dialysis machine. In smaller operations, treatment can occur locally at each station through the use of a portable reverse osmosis (RO) machine. This approach results in the labor-intensive hand mixing of acetate and bicarbonate at each treatment station and dictates a significant amount of storage space for these liquids. The cleaner approach is to treat water centrally and pump the water and acetate (from a separate central tank) directly to each dialysis machine. There, only bicarbonate

must be added. This approach allows for better quality control and is much less laborintensive. Most facilities utilize disposable dialyzers to avoid the need to clean and reprocess the units on site. This saves time and space and also reduces potential liability. The preparation of special dialysate solutions for specific patients is most often outsourced for the same reason. Virtually the entire dialysis suite must be fed by emergency power, so a facility’s existing emergency generator and distribution system must be evaluated to see if there is sufficient capacity. Additionally, treatment areas require a higher number of fresh air changes than staff, office, or service spaces, dictating that a dedicated HVAC unit be installed for the dialysis unit. In the last two years, the New York State Health Department has approved the Home Dialysis model in nursing facilities where residents are dialyzed in 4 chair suites called “Dens”. Home Dialysis units require much less infrastructure to put in place and as a result, they cost less to build and come online faster.


“barn-type” doors to improve toilet access and ease of use.

BARIATRIC UNITS Considerations: Finding the space In considering whether to create a discrete bariatric unit, a key decision for any facility is whether to place a weight limit on the bariatric residents they will care for. However, there is a basic, “minimum” amount of renovation required to establish a bariatric unit, regardless of a resident’s weight. Bariatric residents require wider wheelchairs (usually 54” wide) and wider beds (48” or 54”). Therefore, the most basic alteration that needs to be made is to widen doorways in all areas accessible to bariatric residents. The retrofit approach most often taken is to install a pair of doors with one leaf at 44” wide and the other 18” wide. This configuration avoids the use of a single, unwieldy door while still creating a wide overall opening usable by bariatric residents. Another “basic” bariatric alteration is a tub room retrofit. Pier tubs are not practical for bariatric residents and most shower stalls are not large enough for their use. It is usually necessary to replace an existing shower/tub configuration with two oversized shower stalls. In older facilities, bariatric room toilets usually require fairly significant alterations (enlargement), especially if their “footprint” does not allow wheelchair access and a proper 5-foot turning radius. Wall hung toilets should be replaced with floor mounted units which can carry more weight and swinging toilets doors should be replaced with sliding

If possible, bariatric rooms should be private rooms. In older facilities, this is the only option, since only one oversized bed and oversized wheelchair will “fit” in the average room while still allowing a reasonable amount of maneuvering space. Where conditions permit, it may be possible to create some “oversized” rooms for the bariatric residents which in-turn may allow some existing 2-bedded rooms to be converted into “privates” for other bariatric residents. These new oversized rooms could be fitted-out with specialized equipment such as overhead lifts to allow staff to better assist the bariatric residents.

FINAL WORDS These are some of the continuing trends your colleagues see holding true for the foreseeable future. No matter what the future of LTC brings, there are

some universal design themes that I feel are timeless; we shall always seek to design to promote resident independence and choice, to ensure resident privacy and dignity, to eliminate institutional barriers, and to create a homelike environment. �

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October 2021

AFTER THE STORM The healthcare world has changed. How are we keeping up in a world that’s po st-COVID-19?

Date: August 25, 2021. Place: The gorgeous rooftop party space at Brooklyn Center, a skilled nursing facility in the heart of downtown NYC.

B y l i n e: R e b e c c a L i e b e r m a n


Three nonagenarians — Thelma Hahn, age 76, Kenny Feigel, 81, and Lev Morozov, age 72 — are celebrating their birthdays. And it’s a party: great food, balloons, streamers, and music fill the space, as the many residents/party goers enjoy the summer heat and a breathtaking view of the Manhattan skyline.

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October 2021

To any layperson who’s heard about “COVID-19” and “nursing homes” in the news over the past year-and-ahalf, the scene seems straight out of a fairytale.

collectively, we’re a lot better equipped now than we were then,” says Elie Schiff, administrator of Brooklyn Center for Rehabilitation and Nursing.

But it’s real: Elderly people living in SNFs and rehabilitation centers have survived — and better yet, they’re thriving. COVID-19 has had devastating effects on our nation’s most vulnerable. But in the aftermath, SNFs and rehab centers are reporting flourishing residents, low infection rates owed in large part to effective regulations, and a hopeful turn for the better.

Elie believes that the best way to tackle fears is to invite prospects to tour facilities and ensure that hospital liaisons can accurately depict the preventative measures that are in place. Constant testing and retesting, vaccination guidelines, and other regulatory policies can be annoying for visitors, but at the same time, the endless infection prevention is deeply reassuring.

But with this optimistic new chapter comes a challenge: adapting to a post-COVID world and presenting to wary prospective residents and their families. It’s a hurdle administrators and marketers are facing throughout the US and beyond: How can we show the public that LTC facilities, SNFs, and rehab centers are, in fact, the safest place for a vulnerable person to be?

GROWING PAINS “People sending their loved ones to rehabs are always anxious, but we’re here to allay their fears:

Some prospective residents or their families believe that home care is safer than long-term care facilities. But the numbers don’t support that. “When COVID-19 hit, many families felt that their elderly parents were safer at home,” says Sara Raichik, a marketing consultant for LTC facilities. “Families need to be told that this is not the case. Many of the facilities I work with offer hospital-like settings that are far more advanced than a home care setup can typically be.” Additionally, she opines, families need to be shown the psychological

impact of home care, which tends to be far more isolating than an SNF with seniors often looking to socialize with each other. “The world has this view that a longterm care facility equals COVID equals death,” says Elie. “And it’s true: COVID hit the most vulnerable population, but we’ve fought back. We catch infections quickly and immediately control the situation before it spreads. I do feel that these days, a nursing facility is one of the safest places for anyone to live or work in. Those growing pains have made us stronger.”

Nursing Home Resident Deaths (COVID- 19 deaths per 100 residents) 0.3


0.10 0.1




In the last month (four weeks ending 8/22/2021) in the United States, on average, there were 1.10 COVID-19 deaths per 100 nursing home residents. Aarp public policy institute




Elie also believes that inviting prospects to tour the facility and observe the vibrant life is another key conversion technique. Of course, he’s at an advantage: Brooklyn Center recently moved to a gorgeous new facility that’s built from the ground up and optimized for infection control with a ventilation system that continuously filters the air.

Communication with family has always been fundamental, but the pandemic has highlighted it - the importance of it and the potential mishaps caused by its absence. “Keeping people constantly updated prevents their concerns from getting out of hand,” says Elie. “Automated calls informing families about visitation is one simple way to help them feel informed and connected.” Once their imaginations begin to run wild, misinformation abounds. “They wonder if their loved ones are in their rooms all day, when the resident is actually on the rooftop spending time with friends.”

Not all facilities can showcase their ventilation systems or modern decor, but there’s more to a facility than its furnishings. “A peek into the rehab room will show visitors that life is here,” says Elie. “A gym full of one hundred people, all working hard, thriving, will quickly replace an image of gloom with one of vitality.” And while a top-notch rehab program is at the top of the list for most prospective residents, a recreational program that acknowledges the psychosocial component of healing is a close second. The atmosphere is another huge draw. Flourishing resident life with safety-conscious activities that encourage socializing help families picture their own loved one enjoying themselves and living life to its fullest. Of course, even minor redecorating can have a substantial effect on the mood of a facility: a fresh coat of paint, new lighting in a dim area, or updated chairs in shared spaces can upgrade your image and bring renewed excitement to your facility.

The Brooklyn Center recreational team tries to keep doors open to visitors whenever they can. Sometimes, visiting is just not possible, but they’ll keep family connected via Facetime or Skype. “You’d think that when a facility is closed to visitors due to state restrictions, it’s easier to run,” says Elie. “Actually, when family members are not in the building and don’t have eyes on their loved ones, they’re anxiously calling to inquire about their loved ones. These days, people feel so much more appreciative of their loved ones.”

WORKING WITH RESTRICTIONS The new regulations are keeping our residents safe — but are they acknowledging the intertwined nature of social wellness and

physical health?

“They wonder if their loved ones are in their rooms all day, when the resident is actually on the rooftop spending time with friends.”

“We have to maintain every regulation, no exceptions, but we also can’t give into the fear,” says Elie. While a resident may appear perfectly safe sequestered in their room all day, recent studies reveal the catastrophic effects of social isolation on one’s emotional wellbeing, something Elie and his team take very seriously. Brooklyn Center encourages visitors whenever possible, and maintains the atmosphere with music — “Music is free. Music isn’t regulated,” — activities, and social gatherings that involve family members. “The feeling is palpable: we’ve conquered COVID-19 and we’re all still here. It’s really celebratory for everyone, staff, residents, and families.” Still, Elie admits that it’s not exactly what it used to be. Testing? Yes, it’s a drag. Masking regulations? It’s difficult to nag visitors about these important policies. But when everyone is on board, he advises us to take heart: socially distanced events can be fun, vibrant, and “just like the old days.” No, not those old days.

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October 2021

CARING FOR THE CAREGIVERS What about staffing? Across every industry, employers are having a hard time finding and hanging onto employees. But nowhere is this more challenging than in the healthcare industry. Elie speaks with certainty: “Keeping staff happy is your best marketing strategy.” He emphasizes that he doesn’t believe that there are any real tricks. “Bonuses don’t work, not in the long-term. The only thing that works is real, honest-to-goodness empathy: going over to each staff member and acknowledging that they have the hardest job in the world.” Even simple initiatives like Employee of the Month can boost morale, especially if leadership takes it — and their employees — seriously.

“Bonuses don’t work. The only thing that works is real, honest-togoodness empathy”

ANTI-VAX? DON’T PLAY THE SHAME GAME Healthcare workers have entered an industry that has always been difficult, often for altruistic motives. But recent vaccine mandates have given them pause, and many have

considered refusing the vaccine and quitting the field altogether. Elie reiterates that empathy and respect will get us a lot further than any other tactic. “Having real conversations with scared or uncertain employees is always the way to go.” And most agree: in a recent roundtable, NJ-based SNF owners observed that an honest, one-on-one discussion with a trusted doctor was most likely to convince reluctant workers to get vaccinated. One group initially offered $50 payments to employees for each shot they receive. But when they had a medical professional on their team call each employee individually, they got a far better response.

THE NEW DIGITAL FRONTIER Beyond the inner workings of our facilities, the pandemic has also

fundamentally changed a mainstay of the LTC world: the way we market. “The world has gone digital,” asserts Ricky Blau, chief account executive at GCNY Marketing, an NYC-based marketing agency that specializes in healthcare and LTC companies. “People are clicking from hospital beds.” While most industries have slowly embraced the internet for sales, healthcare has been notoriously slow adapting to web-first marketing. In the past, rehabs relied almost entirely on hospital liaisons to meet with patients and give family members in-person tours. But there’s been a huge shift, says Ricky, one that she believes is a positive one. “The pandemic has forced even older, less-tech-savvy individuals to use Zoom and other video software to connect from afar. And at this point, potential residents are a lot more comfortable


with it. With a video call or Whatsapp conversation, people are ready to trust — and commit.” And that’s a good thing, because many hospitals are not allowing liaisons into residents’ rooms. While skilled nursing facilities have increased visitation, hospitals are still reticent to fully open up again. The internet is helping people transition from hospital to rehab or SNF — faster and more productively than ever before. Ricky also says she’s seeing more ad clicks than ever: “Now’s the time to invest in digital marketing strategies like paid social (think Facebook or Instagram ads) and PPC.” Whereas in the past, a Google ad might receive limited interest, the numbers are now better than ever. More importantly: those clicks are converting into new residents.

MOVING FORWARD Like Elie, Ricky is optimistic. “Things are picking up again, the numbers are turning around, and collectively, administrators have learned a lot from this crisis.” And considering the year we’ve put behind us, a cheerful forecast is not a bad thing. �

Digital marketing is finally working for healthcare. “People are clicking from hospital beds.”

Make your website smarter with these strategies for LTC facilities and rehabs in 2021 There’s a new world out there, and it’s digital. Embrace the latest healthcare marketing trends to meet prospects where they are.


Conversational Marketing. Chatbots and live chat are both powerful tools to add to your website. While most facilities

can’t maintain a live representative with 24/7 availability, chatbots have become increasingly sophisticated. We recommend Drift or Intercom!

2. Video.

Since visiting a facility is impossible for many, bring the experience to them. Many facilities have outdated video tours, and now is the best time to invest in your website and create new, enticing videography. Consider interviewing the people in key positions, like your Director of Nursing, physical therapists, specialists, and your recreational director — it will help bridge the gap and build a relationship.

Upfront Healthcare

October 2021


Digital Marketing for LongTerm Care: What you need to know

B y l i n e: R e b e c c a L i e b e r m a n

Upfront Healthcare

October 2021

Lauren Leone Senior Vice President at Cardinal

Cardinal’s Lauren Leone simplifies the nuts and bolts of foundational digital marketing — and advises healthcare facilities on what to focus on (and what to ignore).


Pay-per-click, SEO, digital marketing: if you’ve spent some portion of your life in the internet age, you’ve heard those terms. But what about white hat? Black hat? Crawling? Breadcrumbs? Is blogging still a thing? It’s 2021 — isn’t growing your social media following important? (Spoiler: yes to the former, no to the latter.)

RL: As a marketing agency with plenty of experience in the healthcare industry, where do you see the most ROI right now for your clients’ marketing dollars? LL: Clients often come to us and ask us what they need to be doing. They already have a website, built in, say, 2015, and they’re not quite sure what to do with it. They built it to work for them and convert clients while they sleep, but it’s not happening the way they intended it to. Having a website is no longer a forward-thinking strategy; it’s an essential. And in an increasingly competitive digital landscape, having a search-optimized website is an essential, too. When we create a marketing plan, we always start with SEO, (search engine optimization). We’ll audit the website and discuss how the website can rank as high as possible on Google. How? In a nutshell, through adding valuable keywords and content that people are actively searching for on Google, and ensuring that the backend of your website is built in a way that communicates well with the search engines.


So the most important thing to invest in first is always SEO - it is the long-term play. Only once that’s under control — and of course, it can always get better and better — do we recommend diversifying your strategy and focusing on things like paid search. SEO is the low-hanging fruit; a solid website with great SEO is the foundation of their digital marketing strategy because nearly everything that happens on the internet will lead back to their website.

Having a website is no longer a forward-thinking strategy; it’s an essential

RL: Can you break down the practical application of SEO?

program, that may inspire you to write a post about the most important elements of a solid memory care program. Any time you have an opportunity to educate, that’s a blog post, ready to be written. Your website should also have pages about every aspect of your nursing home. Have a page for your renal dialysis program, have a page for your recreational program. By giving each topic a page, you’re helping people who are searching for specific information find it — on your website. And whatever it is that you boast of your differentiator, make sure you highlight that.

RL: Sounds like content creation is something that anyone familiar with the industry can do. LL: Yes. Blogging and content writing is something that you don’t need necessarily highly specialized skills for; knowing your audience and understanding what keywords they’re searching for is more valuable. However, if you don’t have anyone to assign this to in your facility, I do recommend hiring a marketing agency to take care of it, because it’s important for the health of your website. The more relevant content you can put out, the better!

LL: Sure. There are 3 pieces of the SEO equation. You can do some of them yourself, but some are specialized, and for those, I’d recommend a marketing agency that specializes in SEO.

RL: What about the other 2 pieces of the SEO equation?

Number one: Content. I’m sure you’ve heard the phrase “content is king.” In the SEO context, that means that having quality content — a description of your services, relevant resources, and a comprehensive blog — is the best way to introduce new eyeballs to your site.

Your website must be coded in a certain way that allows Google to understand the content.

So what’s quality content? Well, that depends on your audience. For healthcare, I find the easiest route to finding new content is simply paying closer attention to your intake calls. If a prospect asks you to explain the difference between an SNF and a rehab center, that’s something that people might be searching Google for. If they want to hear more about your memory care

LL: The second aspect is Technical SEO. Here’s where it gets more complicated.

Our SEO specialists have a deep understanding of website code and how a search engine crawls and understands websites. It would be a shame to be putting out all that quality content in a way that isn’t compatible with Google, right? So you need to make sure that the technical components are meeting best practices. A simple technical audit from a prospective marketing agency can give you more insight into

Upfront Healthcare

October 2021

how your website is performing — and what can be improved. And the third important consideration is your Website Authority. Essentially, the more authoritative your website is, the higher it will rank, as the crawler recognizes that it will likely be valuable to people. So how do you get a website to look authoritative to Google? One major driver: backlinks. A backlink is when another website links to your website. For example, one of our clients is a senior living facility that has a considerable base of church members. So they collaborated on projects with their local churches. The church wrote up about the collaboration on their website, linking back to the facility’s website. The more relevant links you can get like that, the better. I recommend that you look into relevant industry publications, community organizations and businesses, and bloggers that have something (good!) to say about you. One more thing: there are seedy marketing agencies out there that engage in “blackhat” activities like getting backlinks from irrelevant or even low-quality websites. (Blackhat is the term for tactics that go against Google’s SEO guidelines). Avoid those; while it may initially boost your rank, eventually, the crawler will catch on, and it can have negative long-term effects on your website. RL: Say a client feels that they have control over their site’s SEO, they’re putting out new content regularly, and they’re ready to expand their marketing strategy. What’s next? LL: It can take some time — months, even a year — for the effects of your optimization efforts to kick in. But once you’ve done everything right, and your website is starting to work for you, it’s time to get as many eyes on it as possible. And we do that by finding

people whom we call “hand-raisers.” These are people who are virtually raising their hand by searching for a facility like ours on Google, and all we have to do is present ourselves to them. Searches for “top-rated skilled nursing facilities” or “LTC facility near me” are full of high intent. All we need to do is capture the existing demand for our services. How do we do that? Paid search, also known as PPC (pay-per-click) or Google Adwords (when focusing on Google). Your search engine presents a handful of paid ads on the top space of any result, and we want to bid against our competitors for that top space. If the searcher clicks on your ad, you’ll likely pay $8 to $12, but of course, a new resident will bring in significantly more, so it’s a smart investment. When you’re setting up a paid search campaign, you’re entering keywords that your audience is most likely searching for. But competing facilities are bidding for those high-value keywords as well.

RL: So how do facilities find the right keywords? LL: I believe that you can succeed by sticking to simple. Take the same keywords that you’re working on in your SEO efforts. If you’re not willing to just outspend the competition every time, take keywords that are harder to rank for. “Best LTC facility near me” — everyone is bidding for that. But if you hone in on a differentiator you know your audience cares about, like “LTC facilities memory care near me,” you’ll have more success. Be sparing about overly broad terms (“Best LTC”) or very keywords where intent is likely lower (“LTC vs home care” — that’s likely someone researching, not yet ready to find a facility). It’s always good to test, but I recommend going where the intent is highest first — and then work your way toward trickier keywords. The best advice is to think like a consumer! Think like the adult children who are searching and reaching


out. Again, look back at those intake interviews. You can start asking every potential client, “How did you find us? Do you remember what you searched for on Google?” and then write that down.

RL: What’s something readers can do today, right now, to improve their digital marketing game? LL: Here’s something you can absolutely do for free: Ensuring your facility is listed on Google My Business. Don’t just claim your map pin; take the time to use every field available to you and share as much as you can about your business. And that’s important, because when people search the zip code or “best LTC Atlanta,” Google My Business will return map results before it spits out anything else. Boost your star ratings by encouraging happy families to leave reviews. Because the first thing people glance at is the stars. Implement an active program with family liaisons to reach out to families: “Your mom has been here for a while, how’s it going? Can you leave a review on Google? It would really help us.” Families who’ve had happy experiences are less likely to leave reviews on their own, but once asked, they’re happy to put in a few good words! A small incentive can help as well.

RL: When most people think about marketing, they usually think about something highly visual and enticing. Is it difficult to convince them to invest in something invisible and not too exciting?

When prioritizing conversions, we go where the intent is high. That’s true — it’s easy to get distracted by the latest shiny thing. We have had clients that invested a lot of their marketing budget in organic social media, and I understand the urge to see something real.

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October 2021

But here’s the thing: social media is not the place to make conversions. It’s where people come to chill and see photos of their friends and their friends’ dogs. The intent is not there.

RL: You mention that it’s important to team up with a good marketing agency. In your opinion, what makes a marketing agency good? Do you have any advice for facilities who are on the hunt?

When prioritizing conversions, we go where the intent is high. And that’s Google Adwords. When an adult child searches “LTC facility 5 star rating near me,” their intent to transition their mom to long-term care is high.

LL: I would say this: If you’re price shopping, know that the lowest price may not bring the highest value. Don’t always just sort low-to-high.

That’s not to say that there’s anything wrong with organic social media. It can be a wonderful way to build your community of residents, staff members, and leadership, and once the more foundational elements of your digital marketing are in place, we recommend building that community. But it’s a retention strategy, not an acquisition strategy. To think that you’ll get residents as a direct result of your social media page and following is incorrect.

And another thing: if they’re controlling or lack transparency, that’s a red flag. Make sure that you own your Google My Business page, not them. No one but your company should have ownership over your online real estate. Look for an agency that feels like a trusted advisor. Someone who wants to help you understand, offers an audit, and presents comprehensive strategy that you understand in plain English. They should feel like an an extension of your marketing team rather than a tactical partner. Lauren Leone is senior vice president of client services at Cardinal, a Google-recognized digital marketing agency that boasts partnerships with some of the most recognizable healthcare, legal, and corporate brands in the country. Find them at www.cardinaldigitalmarketing.com.


Social media is a retention strategy, not an acquisition strategy.


Compassionate, But Tired


Are our nurses and caregivers suffering from Compassion Fatigue? And how can we help them through it?

B y l i n e: R e b e c c a L i e b e r m a n

October 2021

Sheila pulls up to work at 6:30 AM. Over a year has passed since the pandemic shook the LTC world, and she gets her requisite swab on the way in. Once in the long-term care unit, her work begins: med pass, hospital transfers, symptomatic residents, doctor reports, chart writing. Between administering nitroglycerin to a resident with chest pain and schmoozing with another about her grandkids (“Oh wow, a tooth already? Yes, very advanced”), she’s soothing anxious families over the phone, since the facility is closed to visitors today. Two patients are returning from a long COVID-19-related hospital visit, and Sheila pastes a smile on her face to greet them, but inside, she’s vaguely irritated that they’re interrupting her 12 PM med pass. It’s not that Sheila doesn’t care for her patients. It’s that she doesn’t have a moment to breathe, let alone feel anything.

The Numbers

Upfront Healthcare

According to the American Nursing Foundation, the pandemic has exacerbated the difficulties nurses have been having for years.

50% 35% 20% feel exhausted,

feel an inability to relax,

are depressed.

But the most striking part of the study? Less than a quarter have been seeking out professional mental health support since COVID-19 hit, many saying there has simply been no time.


Sheila concurs. “I’ve been working 14-hour shifts,” she says, “day in, day out. Lunch gets eaten while filling out charts. It’s always been that way, but now, there’s sometimes more panic than stress. I try not to sit down for too long, because if I do, I know I’ll start thinking, How am I going to do this? Because while COVID is going on, there are also medications to give out, and patients going into septic shock, and the flu, and regular, everyday emergencies.” “I want to become the person I was when I just started out. But I don’t know what will help me be that person again.” Like so many nurses, Sheila used to love her job. And she wants to become that compassionate, idealistic person again. “I don’t know where that person went.” Of course, it isn’t just nurses’ job satisfaction that is on the line here, affecting nursing turnover and nationwide shortages. When nurses are fatigued, their patients are at risk as well.

While burnout usually begins gradually until it builds into something that’s impossible to ignore, Secondary Traumatic Stress symptoms — fear, trouble sleeping, intrusive imagery of the event, or feeling triggered by people or places that remind you of the event — are rapid in onset. The ProQOL, or Professional Quality of Life, is the most widely-used measure of caregiver satisfaction worldwide. Measured from data of thousands of people, it determines what factors lead to compassion fatigue — and how to swing the pendulum back to what the organization has termed “compassion satisfaction.” “Compassion satisfaction is about the pleasure you derive from being able to do your work,” explains the ProQOL team. “For example, you may feel like it is a pleasure to help others through what you do at work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society through your work with people who need care.”


WHAT IS COMPASSION FATIGUE? Compassion fatigue, a term first coined by registered nurse Carla Joinson, is also called “the cost of caring.” It describes the negative fallout of offering care in a stressful or traumatic environment, leading to a “loss of the ability to nurture.”

These two elements often trigger compassion fatigue: 1. Burnout. This feels and looks like exhaustion, frustration, anger, depression, and hopelessness. 2. Secondary Traumatic Stress. STS is workrelated secondary exposure to extremely stressful events. This can occur when listening to other individuals’ personal traumas, or when witnessing these traumatic events happening while at work.

ProQOL recommends practical strategies to cope with difficult work and maintain resilience, including getting enough food and sleep, varying work, exercising regularly, learning from mistakes, meditating, and supporting other colleagues. The ProQOL team also discusses the role empathy plays in compassion satisfaction and compassion fatigue.

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October 2021

“The most resilient workers are those that know how to turn their feelings to work mode when they go on duty, but off-work mode when they go off duty. This is not denial; it is a coping strategy,” they explain. To improve at switching between work and off-work modes, ProQOL advises: 1. Make this a conscious process. 2. Use images that make you feel safe and protected (work-mode) or connected and cared for (non-work mode) to help you switch. 3. Develop rituals that help you switch as you start and stop work. 4. Breathe slowly and deeply to calm yourself when starting a tough job.

HERO, OR HURTING? But ultimately, it is up to leadership, not individual nurses, to create marked and lasting change for the nursing industry’s collective mental health. “At the beginning of the pandemic, there were a lot of hospitals and facilities and communities that created campaigns about nurses being heroes,” says Sheila.

Compassion fatigue, noun. The cost of caring. It describes the negative fallout of offering care in a stressful or traumatic environment, leading to a loss of the ability to nurture.

“And it did feel good for the work we were doing to finally be acknowledged. But now, I don’t need to be called a hero. I wish that was enough.” It’s not pencils emblazoned with hospital or facility logos in goodie bags that are keeping nurses in the healthcare field, Sheila stresses. It’s something to lighten the load, whatever that is. “I wish I had time to listen to Angie in Room 238 when she wants to talk to me about her grandkids. Because that’s what makes Angie feel better. That’s what makes me see her humanity, makes me feel compassion, makes me remember why I got into this. Unfortunately, I usually don’t have the time to listen to Angie. I’m charting and giving out meds and talking to doctors.” But Sheila, like many smart, compassionate nurses who are excellent at their jobs and want to stay in this field, knows that there are no easy solutions. “I know that there’s a nursing shortage. This is just how I feel.”

LEADERSHIP THAT LEADS “There are some hospitals and some chief nursing officers that are listening to their employees. They have


a wonderful open-door policy. A staff nurse may feel that hey, I feel comfortable enough going to my chief nursing officer to say, “This is what’s going on, on the floor.” “I think actively listening — and the keyword is ‘active’ — to what the nurses are saying that they need, and then working to get that and keeping them informed; ‘we hear you, and this is what we’re doing,’” shared Dr. Ernest Grant, PhD, President of the American Nurses Association, in a candid conversation with Kadesha Smith on Modern Healthcare’s podcast, Next Up. While Dr. Grant was addressing the hospital scene, many facilities will do well applying his advice as well. It bears examining whether your staff nurse feels comfortable confiding in the Director of Nursing and honestly describing what’s happening in the facility’s day-to-day. An open-door policy and a judgment-free environment go a long way in making a caregiver feel safe, secure, and energized. “I think also getting the chief financial officer to understand that a nurse, is not a nurse, is not a nurse,” Dr. Grant continues. “Sometimes when I’ve spoken with chief nursing officers — when they’ve made the pitch to the CFO and those who control the budget, we need more nurses — they don’t quite understand what it is that a nurse does. And so, I think bringing that chief financial officer along with them when they’re going on those trips to visit the various floors and see how things are going — I think it would be a great eye-opening experience for that individual.” Shadow a nurse for a couple of hours, says Dr. Grant — “if you can, without getting in their way” — just to get that day-in-the-life insight of what the strains really are. You can access the Professional Quality of Life Scale, or ProQOL, to measure compassion satisfaction and compassion fatigue at proqol.org.

LEAD WITH LOVE. The current healthcare climate is chaotic, and solving the nursing shortage is above mostly everyone’s pay grade. But there are some practical, real-life things that nursing and facility leadership can do to support nurses and lighten their load. Help them take care of themselves. Grab lunch for the too-busy-to-breathe caregivers, whether it’s the DON or a CNA. That extra bit of compassion — not to mention an energy boost from much-needed calories — will go a long way. Listen, and act if you can. Hear out employee concerns seriously. Even if it’s impossible to find a solution for their problem, create an environment where employees feel comfortable airing their frustrations. Communicate and share information. Employees who feel like they’re part of the team are more likely to stay on board, even in a tough environment. Tell them what’s going on early, before they hear it from someone else — and keep their trust. Recognize accomplishments and acknowledge errors. Frequently offer your genuine appreciation. On the flip side, if there’s an elephant in the room, don’t skirt it; this only makes your team members feel uncomfortable. Communicate clearly and respectfully!

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Smarter Better Faster Discharge: The myths, the facts, the stats. The research-proven facts about high-quality, low-rehospitalization discharges (and 5 ways your facility can improve patient outcomes) Thelma Jacobsson, Hahn Collins

B y l i n e: S t e p h a n i e E l l i s o n

Upfront Healthcare

October 2021

More at-home support = more health.

The Stat:

The solution:

A study published in the Journal of the American Geriatrics Society indicates that patients who are discharged from nursing homes and receive home healthcare are less likely to be readmitted to hospital or long-term care, and also have lower mortality rates1;. home health aides and nurses can help train clients and their families to take medications and prevent dangerous falls2.

Only team up with the best. Ensure that your facility is connected with competent local home health care agencies. Higher quality home health care and support means lower readmission rates for your facility!

Stars are just vanity metrics.

The Stat: You may just want to improve your nursing home ratings to attract more residents, but Medicare data suggests that more stars = more days spent at home3 . Residents at SNFs with 2-5 stars had far better spent more time at home than 1-star SNFs.

The solution: Boost your staff to boost your stars. Great staff-toresident ratios are a surefire way to improve star ratings. “Staffing is the number one challenge in nursing homes across the country,” says Karolee Alexander, director of clinical and reimbursement consulting for Pathway Health, a Minnesota-based long-term care consulting firm. “Keeping the good staff that you have is very important because there may not be other staff out there readily available to recruit.”

Therapy should be easy.

The Stat: A study held in SNFs in Ohio, Michigan, and Ontario, Canada, found that more intense rehab programs led to shorter discharge times for stroke patients, especially those with poor or uncertain prognosis4 .

The solution: Evaluate your current rehab programs to see how it could be made more challenging — and rewarding! — for residents. And focus on the morale of your PTs, too: Their high spirits and enthusiasm for their work will spill over, boosting energy & ambition, and speeding up overall facility discharge.


Mood affects movement.

The Stat:

The solution:

Certain factors are significantly associated with home discharge after stroke, most importantly, the resident’s mental health: absence of depression consistently leads to more, and better, discharges5.

Acknowledging your patients’ emotional struggles — and looking out for it. “It may feel natural to just attribute residents’ low mood to their basket of woes,” says Heather Finegold, LTC consultant, “but treating it efficiently and effectively with proper medication and therapy, when applicable, means acknowledging their holistic experience — and it will get them home faster.”

Keep family close by.

The Stat: In their desire to connect with their loved ones, family members can sometimes be, well, hard to deal with. But those nudgers have a positive impact on residents’ outcomes: A study published in the Journal of American Geriatrics Society found that social engagement vastly improves mortality rates, and visitors reduce rates of

The solution: The solution: Especially in a post-COVID-19 world, with its rigid regulations, that extra effort to involve family is so important: “Staying in touch with family members and helping them stay connected directly impacts residents’ happiness,” says Elie Schiff, administrator of Brooklyn Center Rehabilitation and Nursing. Take a look at your discharge process: does it include family members as much as it could? Educational resources are available for physical therapy as well as other specializations. Investing in staff members who train residents’ caregivers may seem like an extra expense, but those low rehospitalization rates? Priceless.

1. Source: J Am Geriatr Soc. 2020 Jul;68(7):1573-1578. doi: 10.1111/jgs.16457. Epub 2020 Apr 15. 2. Source: J Gen Intern Med. 2021 May;36(5):1189-1196. doi: 10.1007/s11606-020-06332-w. Epub 2020 Nov 2. 3. Health Serv Res. 2021 Feb;56(1):102-111. doi: 10.1111/1475-6773.13543. Epub 2020 Aug 26. 4. Wodchis, W. P., Teare, G. F., Naglie, G., Bronskill, S. E., Gill, S. S., Hillmer, M. P., Anderson, G. M., Rochon, P. A., & Fries, B. E. (2005). Skilled nursing facility rehabilitation and discharge to home after stroke. Archives of physical medicine and rehabilitation, 86(3), 442–448. 5. Everink, I.H.J., van Haastregt, J.C.M., van Hoof, S.J.M. et al. Factors influencing home discharge after inpatient rehabilitation of older patients: a systematic review. BMC Geriatr 16, 5 (2016).

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October 2021

Why Doesn’t Granddad Smile Anymore?


The mental wellness of seniors is being neglected. The risks, the barriers — and a unique new solution.

B y l i n e: Ve r d a B o n d m a n

Upfront Healthcare

October 2021

“He’s a grumpy old man.” “She’s just a cranky old lady.”

THE BARRIERS So what’s standing in the way of our seniors’ health? Some of the most debilitating barriers include: •

“Older adults are part of a generation where feelings were talked about less,” suggests Perry Wise, a nurse who works with aging seniors. “They’re more likely to talk about physical symptoms than emotional ones.”

When it comes to the elderly, there’s an uncomfortable trope out there. As a society, we’ve labeled older adults, normalized their mental health problems, and made it difficult for them to get treatment.

THE RISK FACTORS While people in all stages of life are at risk for mental health problems, some stressors are more common later in life. With the decline in function — both cognitively and physically — and other common symptoms, like frailty and chronic pain, often comes distress, pervasive sadness, and hopelessness. And while elderly people still living at home have their own challenges, many new residents at a long-term care facility experience a loss of independence that can be hard to overcome. Mental health has an impact on physical health and vice versa. For example, older adults with physical health conditions such as heart disease have higher rates of depression than those who are healthy. Additionally, untreated depression in an older person with heart disease can negatively affect its outcome.

Normalization of mental health problems: Frailty, a lack of ability, and reduced control: it seems obvious that it would cause feelings of hopelessness. But major depression should never be accepted at face value — and it can be helped.

The National Institute of Mental Health reports that an estimated 17.3 million adults suffer or have suffered from major depression. Of these, about 65% received medication, therapy, or a combination of treatments. And while older adults aged 60 and older experience the same mental health concerns, with 15% suffering from depression or anxiety, they face some very real hurdles to getting the treatment they need.

Underreported symptoms:

Difficulty accessing proper care: In younger people, a combination of therapy and medication is typically found most effective. But many antianxiety or antidepression treatments interfere with other medications that seniors are taking for serious health issues, and people with Alzheimer’s often can’t participate in traditional talk therapy.

For some, their mood lifts suddenly: “On Sunday they’re depressed, and on Tuesday they’re smiling for no good reason.”


HOPE IN A HELMET But some thoughtful LTC researchers are now looking into alternative treatments that won’t get in the way of medication or cognitive decline. “People often discover Deep TMS therapy when they’re desperate — when traditional medication and talk therapy isn’t working for them,” says Naftali Salomon, clinical director of Neurocare TMS, a mental health company that touts an FDA-approved mental health treatment that’s medication-free. Is it considered “alternative?” Deep TMS therapy, which involves a helmet that pulses gently to stimulate different areas of the brain, may be considered an alternative treatment, but Salomon doesn’t think it should be. It’s covered by Medicare and has been used in healthcare facilities like the


The patient is seated in a comfortable chair.

The dTMS helmet is placed on the head by a trained technician.

Gentle pulses are delivered for 20 minutes.

After the treatment, the patient can return to his day.

Inside the helmet is a magnetic coil that’s designed to stimulate different areas of the brain repeatedly. “It works the same way standard anti-depression medication, like an SSRI, works,” explains Salomon. “The pulses mimic brain activity, and positive hormones like serotonin are activated. Think of it like a train stuck on a track: the stimulation gives it a little push that gets things unstuck.” The treatment takes 6-8 weeks of regular attendance, 20 minutes a session, for results. This regular routine has the added advantage of lending structure to seniors’ day.

DOES NEUROCARE TMS HAVE EXPERIENCE WITH THE ELDERLY? “We’ve treated 85-year olds,” says Salomon. “Seniors have had the same rate of success as younger people.” Salomon attributes the high level of success of dTMS therapy to hopefulness. “As they start feeling better, they become more and more motivated to continue with treatment and increase that foundagain happiness.” For some, feeling better is gradual. For others, their mood lifts suddenly: “On Sunday they’re depressed, and on Tuesday they’re smiling for no good reason.” After the treatment, many patients find that they can successfully stop medicating. Patients who do still need to medicate can often lower their dose — and respond better to the medication, too. Best of all, it’s safe and predictable. The side effects are minor: As the helmet can take some time to get used to, some patients experience a mild headache or scalp discomfort for the first few days. This quickly wears off. Salomon is optimistic about bringing dTMS therapy to nursing environments. All that’s required is a small dedicated room to house the helmet and some comfortable seating. And since mobility is a common issue for seniors, an on-site mental health solution can be eminently practical. Currently, there are helmets approved for depression and OCD. An anxiety helmet is in clinical trials, and helmets that treat smoking addictions and other emotional challenges are on their way. “This solution is perfect for long-term facilities,” says Salomon. “If 15% or more residents in your facility are suffering, know that there’s hope! And it comes in a helmet.”


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October 2021

Create a support group. Residents with early-stage Alzheimer’s are especially likely to experience hopelessness and depression. Sharing their feelings and helping others can help them open up and accept their experience. There’s strength in numbers!

Acknowledge their pain. Uncomfortable caregivers often ignore an older person’s complaints. But they may experience real symptom relief if you hear them out, acknowledge their real feelings, and express hope that they’ll feel happier soon. A simple yet empathetic “That sounds so hard!” is often all that’s needed.

Four practical ways you (or your staff!) can offer more emotional support. Your staff — from recreational directors to CNAs — can help emotionally struggling residents find happiness beyond treatment.

Get to know them. Some older adults with mental health problems feel crippled and unable to reach out to caregivers on their own. Sit down with them and make a list of their favorite activities (or foods, people, or places) — and then work those into the schedule. Learn their routine, and schedule difficult tasks for when they’re at their best.


Help them feel gratitude. Begin a recreational activity by asking each member of the group to say something they’re grateful for. While gratitude can’t cure major depression, it can give people something to focus on, strengthen relationships, and lighten the mood!


Depression, both minor and major, is as prevalent in older people as it is in younger people. While treatment is available and recommended, anyone with goodwill can increase feel-good hormones like serotonin with simple activities, social support, and mindfulness.

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