March 22, 2021, Maggie Flynn, Skilled Nursing News - In the investment and finance side of skilled nursing, “regional” is commonly cited as a strength for an operator; the idea is that a strong presence in a concentrated geography allows for better relationships with hospitals and referral partners, physicians, and the community generally. But thinking regionally goes beyond the financial well-being of a facility, and even larger chains have been able to use the concept to their operating advantage.
Dr. Sunil Pandya, the new chief medical director of Atlanta-based SavaSeniorCare Administrative and Consulting LLC, is taking a regional approach to its clinical programming, as the provider works to position itself for success in an operating landscape permanently altered by the effects of a global pandemic.
That means talking in-depth with leaders at Sava’s facilities about their clinical needs and listening closely to what they need — all with the goal of improving quality of care on a range of initiatives, from the Quality Assurance Performance Improvement (QAPI) program to bringing strong infection control principles “from the bookshelf to the bedside.”
Sava has outsourced to the CMO role to Geriatric Administrative Provider Services (GAPS), a Dallas-based physician-led organization that provides medical directorships to SNFs; Pandya serves as GAPS’s national medical director of telehealth.
Skilled Nursing News spoke on March 22 with Pandya and Annaliese Impink, executive vice president of compliance, ethics, and customer experience at Sava, about how the company is planning for the new future of SNF operations — and what’s it’s doing now to get ready.
Can you go into what is entailed in the chief medical director role at Sava? What are some of your immediate priorities for the clinical programs?
Pandya: I actually appreciate you asking us what the title means, because many larger groups have what’s called a chief medical officer, and I’m not an officer of the company. The role is really a medical director; I’m a servant leader to both the currently existing medical directors both in the facility and regionally, and [in] more of a collegial situation where I’m a resource for them for a variety of things — everything from bedside clinical to quality to any sort of administrative functions that they provide as medical directors.
What we’re trying to do is provide some consistency and quality to the side of the stool of health care. I look at health care as a three-legged stool; I don’t think you can stand with two [legs]. In the skilled nursing world, nursing is obviously huge. They’re the caretakers at the bedside. The administrative — you can’t be without them. [There are] so many regulations, so many quality measures, so many things that they do. And then the third that is recognized by Sava is that you need the medical side.
That is part of what I wish to humbly present to them: the medical, nursing, and administrative all working together in a consistent and quality manner.
You asked about the short-term priorities. Right now, all of us are still feeling the effects of COVID. We know there’s a light at the end of this tunnel, and I would be remiss if I didn’t say the number-one short-term priority of the whole company and myself is COVID. The idea of vaccination, the idea of the post-COVID syndromes and sequelae, that is definitely our primary focus.
But as far as what I’m doing day-to-day, starting with this role, is that I’m starting to listen to the facilities. I’ve been talking with two and three facilities in person at the facility level and even regionally. We’re prioritizing the western North Carolina first, and then what we lovingly term the Lone Star area of Texas, so around Dallas.
Then we have national tools, different ideas in our toolbelt if you will, and we listen to the facility: What are the intrinsic needs of the facility? Do they want to create something more with telehealth? Do they need more QAPI standards? Do they need some medical optimization? Is it about COVID rounds? Is there a dearth of medical specialty in the facility?
There’s a variety of different things. So my priorities become the priorities of the facility after I do my initial interview.
So after those interviews are done, what comes next?
Pandya: Then starts the ramping up process. Sava has outsourced their medical directorships, for lack of a better term, to GAPS Health, and I’m a proud member of GAPS — not only serving the role as chief medical director for these few pilot places where we’re starting, but also for Sava in general. The concept, starting in North Carolina and then getting over to Lone Star, is: “Let’s go ahead and find out what the needs are and start implementing.”
To give you a quick example: Marketing is an issue, where one of our facilities did a yeoman’s job during the middle of the COVID pandemic to become a COVID-receiving facility and now they’re looked upon only as a COVID-receiving facility. So they told me, “Dr. Sunil, is there any way that you could help us with some of the marketing to the hospitals, for them to know that we’re a three- to four-star facility for any patient as we’re now coming out of the pandemic? Because we’d like to see our census at a certain quality so we could help more people in the community.”
Certainly that became a strategic objective of mine after I heard that. You start making the calls out to the hospitals, and you start looking at who you know. It’s a very small family network in the skilled nursing and hospitalist world.
What are some of the common factors you’re seeing facilities raise clinically? You’ve mentioned the post-COVID syndromes, so how are you thinking about adjusting and responding those at the facility level?
Pandya: Definitely when we talk about the clinical conditions, the aftermath of COVID, we actually think that they’re getting more complex. You have a lot of COVID sequelae that you have to deal with; you have a lot of pandemic sequelae. The difference being the COVID-related ones are actual physiological things. We’re seeing COVID dementia from not-good flow to the brain, related to some of the clotting that we’re noticing. We’re noticing clotting issues all over the body that can cause deep-vein thrombosis, can cause pulmonary embolisms, can cause something called microscopic ischemic colitis, which is bleeding in the intestinal tract.
Very important for our nursing home, bed-bound patients is [that] it affects their skin. So the skin is not as resilient as it was previously, because you don’t have good blood flow. Then on top of that, you have pandemic-related issues. What do I mean by that? Isolation, loneliness, depression. Some of us on this call have felt it a little bit. Well, certainly our elderly population, the most vulnerable, have felt it even more. They’re being turned, they’re being cared for, but [they were] someone who was used to walking around; now the skin is in a higher-risk state.
[There’s] just much to do to help with the assistance of this transition, when you’re coming out of the pandemic. In our lifetime, none of us have done this, so this is not something that we know about. We’re just trying to react as best as possible, and proactively think about the things that are coming in the aftermath. We’re still in it, but we’re thinking about when we get out.
Impink: I think the other thing just to add to that is weight loss. That’s another area that we’ve seen as a result of COVID, because people aren’t up and around, and they’re not going to communal dining, so they don’t want to eat, and sometimes they lose their sense of taste and their sense of smell, and that impacts their ability to eat. That’s another area that we really focus on.
What are some of the priorities for Sava in terms of QAPI, and what are some of the areas of focus for more development?
Pandya: No. 1 is skin, skin, skin, skin, skin. We’ve had this situation before COVID, and now it’s made worse because of COVID, and Impink just mentioned about weight loss; well, some of nutrition even affects skin. So that’s a super important quality improvement that we’re focusing on. We’re also looking at nursing documentation, and we have a big project centered on rehospitalizations.
What does that project include?
Impink: Certainly a root cause analysis for why that’s occurring, and we have a lot of different focuses on that, because there are a lot of things that go into rehospitalizations. It’s physician education; it’s nurse education; it’s patient education. It’s enhancing and improving skill sets for our nurses, clinical judgment, communication with physicians. There’s a whole bunch of factors that contribute, and one of the reasons that we as a company engaged Dr. Sunil and GAPS was to help us really do that root-cause analysis and focus on developing an action plan based on what the data and the information tells us.
So [rehospitalizations] and skin are probably the priority projects for us now in QAPI, and nursing documentation is also a project. But we need to impact skin and rehospitalizations, and then we’ll probably move to medication management.
In terms of continued COVID-19 challenges, can you go into the vaccination efforts — what is Sava seeing in terms of uptake among staff and residents? What has been your experience on that side of getting out of the pandemic?
Pandya: I believe it’s gone really well. I’ve been part of the effort from the beginning, the first national COVID call we did internally and then all the various different modalities we’ve tried. It’s been a very sustained effort, and we know we need to continue it. There’s no one in our call saying this is even half-done. We have office hours — even at 4 a.m., to provide office hours for the night shift on the other coast. We have Sava senior executives, one of which is myself on these calls just listening, waiting for questions.
We’ve done a panel of our regional experts and our other medical experts called myth-busting, if you will, and really we were on the science. Now we’re kind of at the level of data, right? We’ve [gone] from science and explaining the vaccine and this is what it is, and a million people taking it, to now tens and tens and tens of millions of vaccines being delivered — and now we have data to share with people.
I think a lot of people have science responses, and then there’s another group of people that have data responses, and they’re still very much logical people. There are some that are science-versus-data, and some that need the data before they can make a decision.
What we’re seeing is not so much “vaccine no” as much as we’re seeing “vaccine hesitancy,” where they’re waiting for this data to decrease their resistance. So with Sava, they want to use the chief medical director role as being a source of truth and a source of calm and a source of not going to into the world of Facebook and Instagram knowledge and running amuck with it — but really staying focused on the science and the data.
As we move forward, we’re moving toward the potential of mandating vaccination, but we’re rapidly getting our numbers up as far as close to herd immunity. I will share with you that our patients are upwards of 70%, and in North Carolina, where I’m starting, there wasn’t a facility that I’ve spoken to that was less than 85% in the first seven or eight that I’ve done. We’re pretty excited about that, and we’re seeing that number wanting to go up as patients are asking for more clinics, and certainly with [a one-shot vaccine], that’s going to help.
As far as the staff, we’re above 50% and I think that’s huge. When you get above 50%, you start getting “herd mentality,” I call it, where people start listening to each other and listening to their staff.
They don’t have to listen to administrative people like myself or scientific [arguments]; they can just listen to each other and say, “You know, this wasn’t so bad.” We’re still going to be sustained — we’re considering strongly a mandate. We’re looking at that. But if we can get to two-thirds plus 90% of patients, we’re getting very close to herd immunity, and then the question becomes moot, and we’re hoping that’s going to be the course for us here over the summer.
Are you thinking about vaccinations for new patients and new admissions at all, and do you have any plans for that issue?
Impink: We do have a plan, probably beginning April 1. We’ve partnered through our COVID vaccine clinics with CVS Health, because they were one of the two major players.
What we expect to occur beginning in April is that we will order vaccinations — 10 doses or more, it wouldn’t be less than that — from Omnicare, which is a branch of CVS. We then would get vaccinations from CVS to Omnicare; Omnicare would then provide vaccinations on the day of a clinic to us. We would administer the vaccine to our residents and staff: new admissions, newly hired staff, corporate field support staff, and then CVS/Omnicare would do the reporting back to the federal and state agencies about vaccination rates and that kind of stuff.
The plan is to at least, on a monthly basis, have vaccine available to be administered by our centers to our staff and residents, and when we need to keep up with this vaccination rate — which is what we had hoped would happen.
In addition, the CVS retail store will be available for staff and ambulatory residents, and they’ll get vaccinated through a separate hotline for long-term care employees, where they will call and have a separate set of appointments and get vaccinated that way.
So there’s basically two options for us. We are probably focused more on the in-center option. There’s a little more detail to come about that, but that’s generally what the plan is going forward.
It’ll be new employees, new admissions, and current employees that have waited to take the vaccine. We also know the vaccine that we’re going to get through the plan is going to be the Johnson & Johnson versus Pfizer-BioNTech or Moderna. We do think our rates will go up, because people really have been waiting for Johnson & Johnson and just want to do the one shot.
Got it. And going back to the clinical side of Sava’s plans, Sava has talked about focusing on dialysis as a way to focus on patients’ increasing acuity. What are some of the other clinical programs the company is looking at and thinking about as priority areas for clinical programming?
Pandya: It’s something I’m definitely going to be dealing with, have a role in setting the agenda for, and certainly can be a resource to what we call field support. So memory-care units — our loving term for them is life engagement units — there has to be a focus on right-fitting those in certain environments, where there’s a huge need for that. And it’s even greater with some of the dementias that we’re talking about coming out of COVID.
Wound certifications — we want to go through that as a as a clinical practice. There’s some infection control practices, IP [infection preventionist] certifications. Bringing infection control from the bookshelf to the bedside is something that I did when I first started with GAPS — and that’s how I got linked up with Sava, was performing some of those things.
You mentioned dialysis, so dialysis dens — we have them in Maryland abd Georgia, and we are seeing what that looks like as far as a service that we can provide in other locations.
When you talk about bringing infection control from the bookshelf to the bedside — which is a great phrase — what does that look like? What is the process of going from the principle of it to the practice of it, and how would you like to see that implemented?
Pandya: So, you coined a great phrase too – that’s exactly what it is, taking the principle of it, which we all know with our hearts and minds, and putting it to our hands and feet. You’re taking from principle to practice or bookshelf to bedside. So many of us know to wash our hands frequently, so many of us know to keep six feet distance and use hand sanitizer, but this pandemic proves that a lot of us were not doing it.
So the idea of what an infection is, and how much it can staggeringly affect all other aspects of our existence — I think we all got a dose of humble pie. So how does that work as you bring it down? We have something called STATt rounds, which stands for: Surveillance, Tracking, Assessment, Training and then a lower-case t for treatment.
What we were doing was telehealth rounds for COVID, for each of these Sava-sponsored facilities across the country. We did multiple states, and we were classifying those COVID patients, and that was bringing our knowledge base of these specialists, these “COVID-ists” if you want to call them that, down to the bedside. We were literally looking at their feet; we were some of the first people who said: “Wow, that toe looks blue.” And that was the beginning of “COVID toes.” We saw that in Connecticut, and that was so long ago last summer, when I saw my first.
Those are the types of things that we’re able to do to bring it to the bedside, but we’re not stopping there. Now it has to be a relentless pursuit of infection control, right? So we’re thinking about the next pandemic — that will never come because we are going to be ready for it.
Now everyone knows that we have to put the time and energy into it, and I’m pleased and amazed that Sava is doing that before I even mentioned. I think that’s one of the reasons they wanted me in this role, because they saw some of the success stories coming out of that telehealth initiative, which was an infection control initiative.
Impink: The other thing is the certification. We have infection preventionists in all of our buildings, not just because we’re required to but because it’s the right thing. Now we’ve got to make sure they have the tools they need — through a certification process the company’s committed to — to make sure they have everything they need to be successful.
We’re hiring 60 new infection preventionists across the country to supplement or take to the next level the skill set of infection prevention. So there’s a lot of effort on that right now.
When you talk about the role and the tools needed for success, does that include the amount of time spent on the role? There’s been a lot of calls for full-time IPs, and I’m curious if that’s something you’re looking to do?
Impink: Some of our bigger centers, our 200-bed, 150-bed, multi-story centers, we’re bringing on a full-time infection preventionist, because the way that job was designed originally, they were part-time educators and part-time infection preventionists. That works in a small building; that’s a good model. But it doesn’t work in our 300-bed Philadelphia building, or in our 198-bed center in Maryland, where we’re going to bring on full-time IPs, because we need full-time IPs.
We did a center-by-center assessment to determine whether we could do with a 20-hour week, or whether we needed full-time, or whether we needed two IPs.