How I-SNPs are enhancing nursing home care and economics

0:04
Hi, and welcome to today's webcast, How Isnips are Enhancing Nursing Home Care and Economics.

0:10
I'm Mcknight's Editorial Director, Jim Brooklyn, and we have a great session for you today.

0:16
As skilled nursing facilities look for new ways to improve outcomes while strengthening financial performance, institutional special needs plans are gaining attention as a potential path forward.

0:28
Today, we're going to have Advisory Board and Optum take part in a data-driven discussion on how Isnips are reshaping care delivery within nursing homes.

0:39
Among other things, they'll share results of a nationwide survey of 500 long term sniff resident caregivers, including what families value most when selecting and evaluating facilities.

0:52
Now, there's a whole lot more besides that about Isnips and their value, so I know you're going to enjoy it.

0:58
We'll get to it right away and I'll introduce our speakers in a moment.

1:01
But first we have a few housekeeping matters to take care of.

1:05
Today's slides are not available for download, but they're going to be a ton of great note taking opportunities, so get your keyboards and pens ready.

1:13
If you're having any hearing problems, please check the volume control on your machine.

1:16
Believe it or not, that's the number one cause of these problems, but you also have a troubleshooting button there you can use if you need.

1:24
We're on the other end, and we will have time for AQ and a session near the end of the presentation.

1:29
If you have any questions for our speakers, please feel free to type them out and submit them directly to us.

1:36
We'll see them on our end and we'll get to as many as we can before we run out of time today.

1:41
We'd also like to note that this program is made possible by support from Optum.

1:47
Please visit the fine folks there at optum.com.

1:51
Now, I'd like you to meet our presenters.

1:54
Our speakers today are Sally Kim and Marika Rousa.

1:58
Sally is a Managing Director of research with the Advisory Board.

2:02
The Advisory Board helps healthcare leaders make better decisions through research, strategic guidance and practical tools.

2:10
Backed by 200 experts, more than 40 years of research experience, and a network of more than 4500 members, it delivers actionable insights and proven strategies to improve performance.

2:24
Now, Marika is a market vice president with Optum Health.

2:28
Optum delivers an institutional special needs plan that provides clinical care and specialized benefits tailored to nursing home residents operating in 30 states.

2:40
The organization partners with more than 1900 skilled nursing facilities to help improve resident outcomes and care coordination.

2:49
So Sally, that's saying a lot.

2:51
And I guess I want to start off by saying, is it fair to say there's a lot of opportunity out there with Isnips that many either don't know about or aren't taking full advantage of?

3:03
Yeah, there's definitely more curiosity.

3:05
I'm getting a ton more questions on this hot topic from from sniff operators.

3:12
Well, you know, that sounds like it sets the sets the stage great for today's presentation.

3:17
So if you're ready, why don't you take it away?

3:21
Wonderful.

3:22
Thank you so much, Jim.

3:23
And hi, everyone.

3:24
Thank you for joining us.

3:25
As Jim mentioned, I'm a researcher at Advisory Board, which just means I have the pleasure of sitting with big questions like are Isnips helpful for Snips?

3:36
And today's topic is extremely timely because skilled nursing facilities are operating in a very constrained environment and Isnips have emerged as at least one strategy for responding to these challenges.

3:51
And when implemented well, they offer a different approach to managing cost, quality and care delivery within the nursing home setting.

4:01
Of course, the big caveat being on implemented well.

4:05
I'd like to start any session with our objectives.

4:09
So here are the three for today.

4:10
I don't want to hide the lead.

4:12
1st, we want to make sure everyone leaves here with a clear understanding of how Isnips work and the role they can play in coordinating care for long term nursing home residents.

4:23
I will be honest with you all.

4:24
When we started this research, I thought I knew and then I learned so much throughout this process.

4:31
Second, we'll share findings from a survey of skilled nursing facility resident caregivers.

4:37
Say that 10 times fast.

4:39
So these findings will help us understand what families value most and how these priorities affect the way they experience and evaluate and eventually choose a facility.

4:52
And then third, we'll examine the clinical, the financial and the experiential benefits that Isnips can offer SNPs.

5:01
Our goal is to make this practical for you all.

5:04
So by the end of the session, you should have a better sense of not only what an eyesnip is, but also how the model could potentially affect your residents, your staff, and your organization.

5:19
The agenda for today follows that same theme, so we'll begin by setting the context around the state of skilled nursing facilities today.

5:27
This will be very quick, just one slide since I know it's what you all live and breathe.

5:33
From there, we'll explain what Isnips are and how the model works, as well as market uptake.

5:39
We'll then turn to the caregiver survey findings.

5:42
These results give us a useful window into what families value most.

5:47
And then the second-half of the presentation will focus on the potential benefits for skilled nursing facilities.

5:54
We'll look separately at financial benefits, at clinical benefits and benefits related to the resident and caregiver experience.

6:03
Then we'll close with considerations for building an ISNIP in house versus partnering with an existing program and then leave time at the end for questions.

6:13
Pretty jam packed agenda as you can see.

6:15
So let's go ahead and get started.

6:17
Please feel free to put questions in throughout and we will answer them all at the end.

6:25
Before we go into ISNIPS, it's important to understand the conditions nursing homes are operating within today because it almost begs the question of why are we even talking about ISNIPS?

6:36
So skilled nursing facilities are dealing with three closely connected challenges, financial strain, staffing shortages and rising resident acuity.

6:47
So starting with the financial picture on the left, nearly half of nursing homes, 45% to be exact, are operating at a loss.

6:57
At the same time, 56% report low occupancy as a serious challenge.

7:04
So this combination limits revenue growth and leaves facilities with a very little room to absorb additional costs.

7:12
At the same time, labor and other operating costs are also rising, with reimbursement increases from public payers struggling to keep pace.

7:21
The second big challenge is staffing.

7:25
Nursing homes are at this point competing with hospitals and other employers for LPNS, certified nursing assistants, and other essential staff.

7:34
The employees who remain are frequently caring for more residents with more complicated needs, which contributes to burnout.

7:43
And in response, facilities may rely on agency nurses or other supplemental staff.

7:49
But we all know that those options can increase costs, which brings us back to problem one.

7:55
And some of these facilities are even developing CNA to LPN pipeline programs to grow their own workforce overtime.

8:04
They're getting very innovative and scrappy here.

8:07
The third challenge is the changing complexity of the resident population.

8:11
You might have felt this already, so I'm here to tell you, you're not imagining it.

8:16
Facilities are seeing residents arrive with higher rates of falls, wounds, dementia, psychiatric conditions, and other complex needs.

8:25
Some residents may have limited awareness of their physical limitations or may exhibit behavioral challenges.

8:32
That creates a need for more supervision, more specialized behavioral health support, and more careful care planning.

8:41
It can even affect decisions such as roommate placement.

8:45
The important point is that these pressures do not occur independently.

8:49
Rising acuity makes staffing more difficult.

8:52
Staffing challenges make it harder to maintain quality and consistency.

8:56
Higher labor and care costs then compound the financial pressure.

9:00
So this is the not so rosy environment in which nursing home operators are being asked to improve outcomes, strengthen the resident experience and remain financially sustainable.

9:14
You all know this, You all are doing this.

9:17
So truly hats off to you.

9:22
And with that context in mind, that's why we're talking about Isnips today.

9:27
So let's talk about what an ISNIP actually is.

9:30
An institutional special needs plan is a type of Medicare Advantage coordinated care plan designed for people who require an institutional level of care that includes long term residents of skilled nursing facilities and nursing homes.

9:45
These plans serve Medicare Advantage eligible individuals who live in a participating facility for at least 90 days or who have required or are expected to require long term skilled nursing facility level services with no intention of moving out.

10:02
Like other Medicare Advantage plans, Isnips cover Medicare Part A and Part B services.

10:07
They also typically include Part D prescription drug coverage and supplemental benefits such as vision, dental and hearing coverage.

10:17
What distinguishes an ISNIP, though, is its model of care.

10:21
When a resident enrolls, the plan completes A comprehensive health risk assessment.

10:26
That assessment informs an individualized care plan addressing the resident's medical, functional and psychosocial needs.

10:34
That structure is intended to support more proactive and coordinated care for residents who frequently have multiple chronic conditions.

10:43
They can also have functional limitations or a need for ongoing monitoring.

10:48
Isnips also commonly integrate clinical support directly into the facility, and we'll talk a little bit more about that later as well.

10:56
Nurse practitioners or physician assistants may round regularly collaborate with nursing home staff, manage chronic conditions, and intervene when a resident's condition begins to change.

11:09
That team can also support family members and caregivers as they navigate medical, behavioral health, social, and pharmacy needs.

11:18
There is a related model called an institutional equivalent Special Needs Plan, or IE SNP and IE SNP serve people who meet the clinical criteria for an institutional level of care but do not live in a long term care facility.

11:34
For today's discussion, we're going to focus on Isnips operating directly within institutional settings because we assume that is what's more relevant for this audience, OK, and for market uptake.

11:50
Isnips currently serve a relatively small portion of the nursing home population, but the model has meaningful room to expand.

11:58
Approximately 130,000 people are enrolled in Isnips and about 85% of those enrollees reside in nursing homes, which represents roughly 12% of the total nursing home population.

12:12
But access is broader than that.

12:14
Approximately 34% of nursing home residents live in facilities that participate in or offer an ISNIP.

12:22
And as of 2024, which is as recent as we can get, 177 Isnips were offered by 32 different Medicare Advantage organizations.

12:33
For nursing home operators, there are several ways to participate in the model.

12:37
A facility may partner with a national insurer, they might join a provider sponsored plan, or they might even build an ISNIP in house.

12:47
A small number of national insurers account for much of current special needs plan enrollment.

12:53
United Healthcare has been a dominant participant across multiple States and nursing home facilities, and we'll talk about their slash Optimus Isnip throughout this presentation.

13:04
At the same time, provider sponsored models are also gaining traction.

13:08
Of the 31 organizations who offered an ISNIP even just a few years ago, 23 of them were provider sponsored plans and many of these involve joint ventures between long term care operators and insurers, while others were regional initiatives developed by nursing home companies or health systems.

13:29
So while Isnips are not yet available to all nursing home residents, the market includes several participation models and significant room for further growth.

13:41
OK, let's move on to the survey and let me share some of the methodology first, because if you all are data nerds like I am, then you will want to know this to understand how caregivers experience nursing Home care Advisory Board surveyed 500 caregivers of long term skilled nursing facility residents this year.

14:04
All respondents were primary caregivers responsible for health care decision making for the resident.

14:11
The respondent group included a mix of children, spouses, siblings, and other family members, and demographics were balanced by gender.

14:21
The residents themselves were predominantly between the ages of 65 and 84, and they were geographically dispersed across all 50 states, with higher representation from Florida, Texas, California, and New York.

14:34
As you can imagine, we ask these caregivers about care quality, about communication, quality of life, and insurance benefits.

14:45
Then lastly, we close the survey by asking them what mattered to you when you were selecting a nursing home for your loved one.

14:53
So the next several slides we'll walk through what we heard by section.

15:03
OK, so the first theme from the survey is that caregivers place a very high value on reliable, respectful care from people they trust.

15:13
Now that might sound like a no brainer, but let me go into the specifics.

15:18
Across the full responding group, 91% agreed that care was provided consistently by familiar caregivers.

15:26
The same percentage agreed that staff treated their resident with respect and dignity.

15:31
91% is a very high percentage.

15:35
So pat yourselves on the back.

15:37
Great job.

15:38
Those were the two highest measures on this chart and they speak to something fundamental.

15:43
Families are not only evaluating whether a task was completed right.

15:47
They are paying attention to who is providing the care, whether the resident recognizes that person, and whether the interaction preserves the residents dignity.

15:56
It's what we would all want for our loved ones as well.

15:59
Confidence and competence also matter.

16:02
90% of caregivers agreed that staff were well trained and competent, and 89% said they had confidence in the nursing staff.

16:12
The weakest area, although still rated positively by most respondents, was care during evenings and weekends.

16:19
86% agreed that evening and weekend care was as good as weekday care.

16:24
This goes back to that staffing challenge that we were talking about.

16:28
The comparison for the United Healthcare slash Optum ISNIFF was also notable.

16:34
95% agreed that staff were well trained and competent compared with 88% of caregivers whose residents were not enrolled in a UHCI sniff.

16:46
The central message here is obviously not to memorize every number on this chart.

16:50
It's that caregivers are judging quality through consistency, competence, responsiveness and respect.

16:57
And an ISNIP cannot replace the facility, staff or culture.

17:01
But a model that adds clinical support and help staff respond more proactively may reinforce the dimensions of care that families notice the most.

17:13
The second theme is equally important.

17:15
It's communication.

17:17
Most caregivers communicate with either their resident or family staff very frequency, very frequently.

17:24
I was surprised by this, actually.

17:26
41% do so several times a week, and another 39% communicate daily or multiple times a day.

17:33
That means families are not just occasional observers, they're regularly interacting with the resident, the facility, or both.

17:40
So communication is part of the day-to-day experience.

17:45
Across the survey, 91% of caregivers agreed that they were informed about changes in their resident status.

17:51
That includes changes in health, medications and the care plan.

17:56
The same percentage said they knew who to contract when they had a question and that facility leadership was responsive to their quest questions.

18:04
Again, hats off to you all.

18:07
Prompt incident notification Notification is also very important.

18:11
89% agreed that they were notified promptly when an incident occurred.

18:17
For UHC ISNIP caregivers, 97% agreed that they knew who to contract when they had questions, compared with 90% of caregivers whose residents were not in a UHCI snip.

18:30
We also saw a difference in overall satisfaction.

18:33
49% of UHC ISNIP caregiver said they were very satisfied with communication from the facility compared with 44% of all respondents.

18:44
So recognize I said facility.

18:46
So there is a Halo effect that goes over to the facility level as well.

18:53
What facilities should take from this is that communication is not an added service.

18:57
From the family's perspective, it is at this point just table stakes or a baseline expectation.

19:04
Families want to know what changed, who's responsible, and whom they can call.

19:08
A care model that creates clearer ownership and more consistent clinical communication can therefore affect not only care coordination but also the family's confidence in the facility.

19:21
Caregivers also evaluate the residents quality of life, not simply their medical care.

19:27
The strongest results in this area relate to respect for the residents preferences and support for emotional well-being.

19:34
91% of caregivers agreed with each of those statements.

19:39
90% agreed that the facility offered meaningful activities, while 89% agreed that the facility was clean and 88% agreed that the resident was safe.

19:50
Social engagement was slightly lower but still high at 85%, and meals stood out as the weakest measure.

19:57
78% agreed positively with the statement about meals, leaving a noticeable gap between food and the other dimensions of quality of life.

20:07
This matters because meals are not a minor part of the nursing home experience, they occur every day, they affect routine and comfort, and they can be one of the most visible parts of care to residents and families.

20:19
Among UHCI SNAP caregivers, 44% said they were very satisfied with the residents care quality of life, compared with 39% of all respondents.

20:31
And the broader lesson here is that families evaluate the whole experience.

20:34
So of course clinical quality is essential, but so are all of these quality of life measures.

20:45
When we asked caregivers which insurance benefits they valued most, care coordination was the clear leader.

20:52
Cognitive support ranked second, followed by food benefits.

20:56
There it is food again.

20:57
Humans are humans at the end of the day.

21:01
Dental benefits and of life care and access to on site clinical staff also appeared among the benefits caregiver selected.

21:07
And these findings reinforce what we heard in the earlier questions.

21:12
Caregivers are looking to looking for help navigating a complicated care environment.

21:17
They want someone connecting the pieces, particularly when a resident has multiple medical, functional or cognitive needs.

21:24
They also value services that address the residents day-to-day experience, including food and dental care.

21:31
40% of UHC Iceland caregivers said they were very satisfied with their residents health insurance coverage compared with 33% of all respondents.

21:41
And that difference matters for nursing home operators because families don't necessarily separate their experience with the facility from their experience with the residents coverage.

21:51
When benefits are difficult to use or care is poorly coordinated, that frustration can become a part of how the family perceives the overall nursing home experience.

22:04
And then lastly, for survey results, and this is the one that I think would be the most interesting for you all, is we asked caregivers what mattered when they originally selected their residents nursing home.

22:19
The highest rated factor was cleanliness, which 90% of caregivers considered important or very important.

22:27
close behind was the ability to ask caregivers questions and whether the facility accepted the resident's health insurance.

22:35
Both of those were at 89 percent.

22:38
88% prioritized the facility's safety record and the availability of counselors.

22:45
87% considered online quality reviews and whether the cost fit their budget.

22:51
The table includes many other factors, but the main pattern is clear.

22:55
Caregivers are looking for evidence that the facility is safe, responsive, and affordable.

23:02
Some of the factors that facilities may assume carry the most weight actually ranked lower.

23:07
For example, whether the facility was independently owned or part of a large chain was not as important to most respondents and the same was true of placement on any sort of national ranking list.

23:23
Factors on the left are the ones that are most likely to shape the initial selection and the ongoing reputation of the facility.

23:31
If you have any questions about the survey, again, please put them in the chat for our Q&A at the end.

23:37
But that is the last of our survey results.

23:42
And next we will go to the meat of our presentation.

23:47
We have spent the first part of the presentation explaining how Isnips work and what caregivers value.

23:55
We'll now turn to what participation in an ISNIP can actually mean for you and your organization.

24:02
So we'll begin with the financial model because to be honest, this is often the question I get first from sniff operators and Marika as I go through some of this research.

24:12
I mean you're seeing this on the ground every day.

24:14
So please, please, please jump in with your thoughts throughout that is going to add the color that brings this research, these numbers to life.

24:26
Will do.

24:26
Thank you.

24:28
Of course.

24:30
OK, So one potential financial benefit of an ISNIP is the ability to choose a payment structure that aligns with the facility's resident mix and risk tolerance.

24:42
Let me say that more clearly.

24:43
In a fee for service model reimbursement works much like traditional Medicare.

24:47
That facility is paid through skilled days.

24:53
That structure may be financially attractive for a facility with a high share of skilled residents or frequent skilled episodes.

25:02
On the other hand, a capitated structure works differently.

25:05
Instead of being paid only when a resident is receiving skilled services, the facility receives a per member per month payment for all attributed residents regard, regardless of acuity.

25:17
For a facility with a larger custodial population, that could create a more stable and predictable revenue base.

25:26
Neither model is automatically right for every facility.

25:30
The value is in having the flexibility to select the structure that more closely reflects how your organization operates.

25:38
And who knows, that choice may actually change overtime or year over year.

25:43
A facility could begin with one structure and adjust as its resident mix, as its capabilities, or as its strategy evolves.

25:53
ICE net participation therefore offers more than a more than an additional payment source.

25:59
I get paid to speak for a living, not that you would know it.

26:03
So ICE News can provide a controlled way for a facility to test and scale value based care while preserving their own flexibility and without feeling like they're being forced into it.

26:16
Marika, what do you hear on the ground?

26:19
Yeah, Sally, I believe it begins with selecting like the right contract and really being able to understand what your contract means to you.

26:28
And so in my role, the first thing that I do is I sit down with a nursing home administrator to really understand what their business strategy is.

26:37
So you already touched on that a little bit, but that helps me understand a little bit more about what their goals and aspirations are and what and how they want me to show up for them as a partner.

26:48
In addition to that, understanding a little bit about the resident profile and who they serve will help us help with the process of of what would work better for them, whether it's fee for service or capitation.

27:02
And then in addition to that, I also look at what are the staff's capabilities and tenure in the community.

27:10
You know, you talked a little bit about risk, but it's also what type of care do you provide?

27:16
At what level of care do you provide at the community?

27:19
You know, do you provide trach and vents?

27:21
Are you more traditional?

27:22
Are you focused on behavioral health?

27:25
And so these are very important for both your isnet partner to understand and for you to partner together.

27:32
And absolutely, as a best practice, you should be checking in with your isnet partner at least annually on whether or not your contract is meeting your business needs because as we all know, this industry is very dynamic.

27:47
Yeah, I love how you mentioned flexibility and quality.

27:52
Would be remiss if we weren't talking about that.

27:55
So actually, beyond the base payment model, many Eyesnip arrangements include incentives tied to quality and total cost performance.

28:04
And one common structure of that is pay for performance, which you see on the left hand side.

28:09
Under that approach, facilities may receive higher per member payments or bonuses when they achieve strong quality results.

28:17
Performance is often tiered, so a facility with good results may earn 1 level of payment, while a top performing facility could earn meaningfully more.

28:27
On the right hand side.

28:28
There's another model called shared savings.

28:30
In a shared savings arrangement, the facility receives a target for a total medical spend.

28:35
Performance is then measured against that target over time, and if the facility delivers care below the spending benchmark while still meeting quality expectations, the plan and the facility share the resulting savings.

28:48
So the important distinction is that the financial opportunity isn't from reducing services.

28:55
The facility must manage costs while maintaining the quality performance, and together, these structures give skilled nursing facilities an opportunity to capture part of the financial value they help create.

29:09
That's huge.

29:09
That's actually a lot of the reason why Snips even contemplate starting their own Isnips.

29:16
In this way, the facility can gain a stake in total cost management and premium dollars without necessarily assuming the full responsibility and complexity of operating an insurance plan themselves.

29:30
Marie, good.

29:31
Did I get that right the the two models here?

29:35
Yeah, absolutely.

29:36
And I think similarly to as we discussed under the contract slide, selecting the right incentive plan or participating in those incentive plans were largely largely be based on your operational practices and your business strategy.

29:52
And so you can look at some historical performance around how you your utilization has performed historically.

30:00
And, or I would want, I would also say that as a partner, I want to make sure that I understand how I can support the sniff in maximizing their, their earning potential.

30:12
And So what that means is that you know when you are being paid for performance, everybody wins because the members getting the care that they deserve, the facilities earning more and also benefiting from the quality outcomes in the metrics with CMS and then also the health plan is also saving money.

30:33
So I always refer to this as a partnership should be mutually beneficial.

30:38
And so when we are aligned and have the same goals, everybody wins in this scenario.

30:49
So are those calculations done every year but also before the initial contract starts?

30:54
I assume no, it's something it's a great question.

30:58
I feel like you can kind of do some pre work and I encourage administrators before before choosing an incentive plan to participate in to be able to look at some historical data to be able to inform their choice.

31:14
Again, like the contract, your, your participation in your incentive plan can be can be flexible.

31:22
So you might learn that as you start getting to your partnership and your communication is, is it is consistent that you are able to lean in more and your partnership with the ISNIP organization then really becomes 1.

31:40
So you start to really say like maybe I'm ready to transition to a shared savings because you want to go a little bit deeper into the program.

31:50
So it really has to be a fluid conversations.

31:54
I think there's some great key performance indicators that are out there that can help guide administrators and and keeping a pulse on how you are performing a scorecard if you will.

32:07
Thank you.

32:08
I used presenter privilege to sneak in a question before the Q&A.

32:16
OK.

32:17
So lastly for the financial Section 1 of the clearest or maybe fastest ways an ISNIP can affect both cost and care is by making it possible to manage more clinically appropriate care inside the nursing home.

32:31
So under traditional Medicare, a resident generally needs a medically necessary inpatient hospital stay of at least three consecutive days before receiving the sniff benefit.

32:41
But for a nursing home resident, particularly someone with cognitive impairment or behavioral health needs, that transfer can be disruptive and stressful.

32:51
So also if sent, a hospital may focus primarily on the immediate acute problem that could potentially disrupt the ongoing management of the resident's chronic conditions and expose the resident to additional lab tests, imaging or procedures.

33:10
So under an ice NIT model, a resident does not always need to go to the hospital to qualify for the Medicare benefit.

33:16
If the resident experiences a changing conditions, such as a UTI, let's say, the on site clinician could evaluate the resident and determine whether a skilled event is medically necessary.

33:28
When it is appropriate, the clinician can authorize that Part A or Part B skilled event within the nursing home that allows the resident to receive covered care without an unnecessary transfer, preserving continuity and reducing disruption.

33:43
The medical necessity qualifier is very important here, and ISNIP is not intended to prevent an acute hospital admission when that admission is necessary.

33:54
The objective is instead to avoid transfers that aren't because the resident can be safely and effectively treated within the facility with less disruption to his or her life.

34:07
Marika, how have you seen this play out in real life?

34:11
Yeah.

34:11
So, you know, philosophically, Isnips are all about early detection.

34:16
And so we say Rye care at the right time in the right place.

34:21
And I think that that's really important.

34:23
Our model of care is collaborative.

34:25
And so that means that we work very, very closely with the nursing home team, the resident and the families and of course, the PCP to really detect those changes in condition.

34:36
So early detection coupled with, you know, advanced care planning and can help mitigate that risk of hospitalization, which is what everybody's goal is because we know how disruptive it can be for residents to go to the hospital.

34:51
It is important to know that not all hospitalizations are avoidable because we take we take care of such a frail population.

35:00
But again, the more eyes that we have honor, honor members on our residents, it helps set them up for success.

35:07
And so the meat and potatoes of an ISNIP is truly the model of care.

35:14
And so I say when our program is working correctly and is working well, we become an extension of the nursing home team, which optimizes the best outcomes possible for our residents and our families.

35:30
It's almost like you know what's coming because that's a perfect segue into our clinical section.

35:38
So that ability to manage care inside the facility as well as to help the staff in the facility brings us to the clinical benefits of our sniffs for sniffs.

35:48
So in the next couple of slides, we'll look at the outcomes associated with the model since I know you all care deeply about your residence care quality.

35:57
1st, a pretty data heavy slide.

36:00
Several studies from ATI Advisory and Medpac show that ISNIP enrollment is associated with improved clinical outcomes and lower acute care utilization among nursing home residents.

36:12
The most important number to notice on this slide is the reduction in emergency department use.

36:19
ISNIP enrollees were 50% less likely to use the Ed than the comparison population.

36:25
There are also 27% less likely to be readmitted within 30 days after an inpatient stay and 29% less likely to experience pressure ulcers.

36:36
Mortality rates were 21% lower than among members of other MA plans within a given year.

36:43
These outcomes appear alongside greater use of clinical care within the nursing home.

36:48
So it would be concerning if this is happening because folks aren't getting care, but the data doesn't show that.

36:55
I SNIP enrollees receive an average of 3.4 on site evaluation and management visits, compared with approximately 2.4 to 2.8 visits for other residents.

37:07
This is important because the story isn't simply that residents use the hospital less, it's that the setting and timing of care change.

37:15
So they're actually getting more interactions.

37:19
Higher Medicare Part D spending has also been observed among my SNIP enrollees, and that may reflect the clinical complexity of this population.

37:28
But it could also reflect the role of medication management in treating residents within the facility rather than relying on hospital care that might not always be necessary.

37:42
Continuing on, the clinical model depends heavily on having dedicated advanced practice clinicians who can work alongside the nursing home team.

37:52
These clinicians provide more consistent clinical coverage and can reduce some of the day-to-day burden on existing facility staff who are often overworked.

38:02
As we mentioned in the first challenges slide in the UHC Isnet model, the care team includes an Optum nurse practitioner, a registered nurse, and a patient care coordinator.

38:13
The team sees residents regularly and provides individualized care.

38:18
Residents with higher levels of risk receive more frequent visits and more comprehensive clinical reviews, so that repeated hands on engagement gives the team a better chance of identifying a change in condition before it becomes a larger problem.

38:35
Optum clinicians spend an average of more than 26 hours per year with each patient, and these clinicians support the facility more broadly than that.

38:45
So it's not just for those specific patients.

38:49
Nurse practitioners could work with staff to enhance on site care to coordinate referrals and improve communication with external providers.

38:58
Often times it's taking off a load of already overworked staff's plate, especially if it's things that they might not love doing.

39:07
Nurse practitioners could also support vaccination clinics, could help with patient and family communication, and even staff education on topics such as fall prevention and infection control.

39:21
Optima offers web-based courses that nursing home staff can use to meet continuing education requirements, and these courses are often provided at no cost.

39:30
And facilities don't need to be partnered with Optum even to participate.

39:37
The quote on the bottom here from David Dunn, who's the CEO of Shannon Grave Rehab and Recovery Center, describe the value this way.

39:44
It's not just the extra and community care that makes the plan so valuable.

39:48
It's the people often puts on its teams.

39:50
They go above and beyond.

39:51
It's the caring, the corporate support they provide.

39:54
They're very important members of our team.

39:58
Now, I'm speaking about this as an outsider, but Marika, I'm sure you can elaborate more here.

40:05
Yeah, I love that.

40:06
I love that quote because it speaks to what I just said.

40:09
You know, when it's working well in a in a community, we really become an extension of the team and and you know, I want to address to you from it's all about the partnership, right, And when you implement the program really well, you know what you put into the partnership, you actually you get out of it, you know, elementary there, but why wouldn't you leverage the collective wisdom of the team?

40:37
You know, you'll be a stronger operator for it and your residents or families will be cared for.

40:43
And so we're able you, you rattled off so many wonderful attributes of the program, but you know, by having and leveraging that expertise of the advanced practice clinicians and your whole clinical team, because it's more than just, you know, the APC.

41:01
It is also, you know, our care navigators that are, are a part of it, our patient care coordinators, our RNS, our provider engagement representatives.

41:11
You have a whole team that can help support the overall operations in your community and the satisfaction at the heart of it.

41:20
ISNIP is a member benefit, you know, so we are able, we prioritize being able to care for the resident.

41:29
However, there's so many wonderful things that that you benefit as a facility operator for.

41:35
If you think about your surveys, you think about leveraging all of the documentation that we have and are available access to pharmacist to be able to assist in problem solving when it comes to, you know, complex medical needs that are going on.

41:54
And so again, like I said, leverage the expertise of the team, lean into the program and everybody will be stronger for it.

42:06
Wonderful.

42:06
I, I love how you said that it's a member benefit because that is where we're going next.

42:14
And we're going to experience last, but it's certainly not least this matters because the residents experience the family's confidence in the facility and eventually the facility's reputation are all closely connected.

42:30
So I think this still counts as a benefit for the facility as well.

42:36
So one concern a facility may have when considering an I snip partnership is whether the plan will insert itself between the nursing home and the resident or family.

42:45
But as you can see on the slide, the facility continues to remain at the center of that relationship.

42:51
There are actually clear rules governing enrollment discussions, and I didn't know this before I started this research, but only licensed plan reps or agents may market the plan or discuss enrollment in a way that could influence a beneficiary's decision.

43:05
And they may do so only after the beneficiary has initiated contact or given permission.

43:13
So sure, our plans can support passive outreach through educational materials or being there on site, but they cannot directly market to residents without prior consent and without consent from the Sniff administrator.

43:27
So for Sniffs, that means that the partner provides clinical support and plan benefits, but they're not trying to take over the facility's relationship with the resident and family.

43:39
Marika, have you heard this concern before?

43:42
Absolutely.

43:42
And I would, I would say this is one of the, the biggest concerns that we get on the front end of saying like where did where does your staff and where does my staff begin and end and how does that work?

43:55
And again, we should truly be complementary of each other.

44:00
And so like any, like any relationship and every partnership, it takes work, right?

44:06
And so you need to be intentional about your communication.

44:11
Of course, we need the honesty of the communication as well.

44:15
So we need to sometimes dig a little deeper to be able to make sure that we're having the right discussions.

44:23
And then there's, I always say we have to something will go sideways at some point and you want to always make sure that we extend that grace to each other.

44:30
But we should be there to lift each other up and focus on the resident.

44:35
Again, at the end of the day, we we all want the same thing, which is outstanding clinical care.

44:42
And so with that being said, I love that you talked a little bit about, you know, the license plan representatives, because as we go through the implementation process, we talk about compliant outreach and that can be such a scary word when we say compliance and people say, oh, I don't want to sell insurance.

45:04
And you know what, we don't want you to sell insurance either.

45:07
We want you to be able to say we partner with a great program and we think that we think that this, this might be beneficial for, for your mom or your dad.

45:19
Would you like to learn more about it?

45:21
And it's really just that simple.

45:23
I would also encourage you to ask your Isnip provider customize what feels comfortable for your community.

45:31
Do you like we can do meet your your nurse practitioner?

45:35
We could have events there where it's as simple as learn about your Medicare Advantage program, ask questions and you know, insurance.

45:46
Sometimes it's just a very scary word for folks and being able to destigmatize that and, you know, have a presence in the community and ask those questions, I think really helps break down those walls and really it enhances the partnership.

46:03
Mm hmm.

46:04
Yeah, definitely on insurance being a sometimes a scary word, but there are actually a lot of perks of having insurance as well, right.

46:14
So absolutely to that's again a perfect segue.

46:19
Thank you.

46:20
Marika Isnips can provide benefits that directly aligned with the priorities that caregivers said that they care about in our survey.

46:29
So care coordination was the highest ranked benefit among caregivers and Isnips addressed that through coordinated care management and a structured model of care.

46:38
Caregivers also placed a high value on cognitive support, which Isnips respond to with behavioral health integration and services designed around residents with complex cognitive needs.

46:51
And then food benefits.

46:53
Another leading priority.

46:54
Depending on the plan support may include meal delivery or grocery allowances.

46:59
And then plans may also offer vision and hearing coverage, prescription drug benefits, non-emergency transportation, over the counter allowances and palliative care support, just to name a few.

47:11
One thing that I thought was very small and specific but had high impact was some Isnips also cover items such as specialized cushions or hygiene products or adaptive equipment beyond the standard room and board items covered through Medicare and Medicaid.

47:31
OK, to close us out, we've been talking a lot about Isnips and I know we've mentioned the UHC ISNIP in the survey results and in Marika's comments.

47:42
But for nursing home leaders interested in the model, the next question that is probably on your minds is should I build an ISNIP in house or should I partner with an existing plan?

47:53
So building an ISNIP provides the facility with greater control over benefits, services, quality, and the overall care model.

48:01
But it also requires significant capital and enough covered lives to support the economics.

48:07
The organization must also build the model of care from scratch and assume the financial risk and operational complexity involved in running a health plan.

48:17
Partnering.

48:18
On the other hand, it offers a very different path.

48:21
The Isnet partner would provide the resources and infrastructure needed to scale the care model and the partner also brings the care management support and on site clinicians.

48:32
That allows the nursing home to participate, but with less direct financial risk, and they can use flexible arrangements that evolve over time.

48:41
Of course, as Marika mentioned, a partnership will only work if the organizations are aligned philosophically.

48:47
So if both parties are committed to improving outcomes, reducing unnecessary hospitalizations, and treating residents within the nursing home when medically appropriate, then the relationship is more likely to succeed.

49:02
Let me close the didactic part of the presentation with these three key takeaways.

49:08
First, Isnips are MA plans that combine Medicare coverage and supplemental benefits with individualized care planning and clinical support embedded in the nursing home.

49:19
Second, caregivers place the greatest value on consistent care, clear communication, competence, responsiveness and respect.

49:27
And 3rd, Isnips can help reduce avoidable acute care utilization and improve clinical outcomes while creating potentially new financial opportunities for sniffs.

49:40
OK, Jim, I took up a lot more time than I thought I would, and I'm glad Marika had a chance to share all her color commentary as well.

49:51
But that brings us to the end of the formal presentation.

49:54
Did we get any questions in the chat?

49:55
I hope?

49:56
Oh, did we get questions?

49:58
This was, first of all, fantastic presentation, and I'm glad you took the time.

50:02
And because it was so good, I really firmly think that's why we've got these questions.

50:06
So we're going to get to as many as we can, intense speakers, but those that we don't get to in real time, please realize we'll get you answers afterwards right away on that.

50:17
So that said, I'm going to jump right in.

50:19
Marika, I've got one for you.

50:21
From we'll go, let's see to Catherine's first, who hires and pays the nurse practitioner caring for the Eyesnip and rollers.

50:32
Great question.

50:33
So our Isnip nurse practitioners are employed by Optum and so we hire and we train them.

50:43
And then in addition to that you should.

50:46
And because of that I will say they get to spend as much time as needed with each of the members.

50:53
And so that's important to know because a lot of times practitioners or providers have to go in and they have like have to see a certain number of caseload.

51:05
Our our practitioners are able to spend as much time as needed to be present with each of our members.

51:12
So they are employed.

51:14
Yeah, employed by us.

51:16
Excellent.

51:17
OK.

51:18
Another one to you, Marika, Jill asks what criteria do you use to determine quality performance criteria?

51:27
I know that can be a big broad thing, but can you give us a few seconds on that?

51:32
Sure, 2 seconds.

51:34
So we try to align as many of our quality indicators with CMS.

51:40
So that aligns with the nursing home administrator.

51:43
So the big one that we look at is, is hospital readmissions.

51:48
So we, we, we look at that as a key performance indicator.

51:51
We also look at medication adherence.

51:55
That's another key performance and polypharmacy is another one that we look at.

52:02
All right, very good.

52:04
Now, Sally, I'm not sure if you, you maybe you can Russell Marika for this one or not, I don't know.

52:09
Renee asks what happens with the Medicaid LTC residents.

52:15
Do you get paid by Medicaid or would it change to the Isnet payment?

52:21
Oh, that is a financing question.

52:23
Marika, do you happen to know that off the top of your head?

52:26
Do so because we focus on long term care residents.

52:31
So the the community will continue to collect the custodial rate for long term care.

52:39
And then if there is, depending upon your skill, your contract methodology, we if someone is skilled, then that flips from Medicaid being the primary source to Medicare being the primary payer source.

52:57
So as long as they're in there, you can get capitation, collect capitation as well as being paid the custodial rate.

53:05
Does that answer your question?

53:08
I think that does.

53:09
I mean, I'm telling I'm reading what the they're sending in here because they're coming fast and furious here, right?

53:15
So, OK, great.

53:18
We've got an interesting question.

53:19
Sally, I'm going to send this to you too because spot percentages says the data say 909090 to 91% felt they received communication, but only 49 stated they were satisfied with the level of communication.

53:34
Do you have a thought or two on that?

53:38
Oh yes, definitely don't be concerned that it's in the 40s.

53:41
They're completely separate questions.

53:43
So it was because we only took out the very satisfied.

53:47
There was a large contingent that was also satisfied.

53:50
So if you added those together, it would be very close to that 80 to 90% we were seeing for the specific measures.

53:59
OK, very good.

54:00
Marika.

54:01
Cynthia asks how are Part B services that the patient needs like doctor visits and rehab therapy needs of the patient handle?

54:10
How does the facility pay for those or save money on those?

54:15
Yeah.

54:15
So again, I'm going back to that contract.

54:18
So depending upon how your contract is, but you know actually in a nice NIB access to Part B services, it doesn't get any easier.

54:28
We we do there's no authorizations.

54:30
And so if somebody needs to be able to get access to physical therapy, whether whether they see a change of condition and they and it's medically necessary, you just all you need to do is work with your nurse practitioner and we can get that person on services.

54:48
Financially speaking, there are a ton of carve outs that a facility can can bill for on an ISNIP as well.

54:58
So think of it is that Medicare covers it.

55:00
So does an ISNIP very good.

55:04
OK, JC Marika, JC has one.

55:07
What's something in your experience that really moved the needle in reducing hospitalizations at the facility level?

55:13
Good question.

55:15
That's a great question.

55:17
So honestly, collaboration.

55:19
So we use this word a lot, Sometimes we overuse it, but you can never over communicate.

55:25
And so being able to one have aligned care goals and understanding the disease trajectory so we can all become aligned to be able to support that resident.

55:39
So that when I'll say when bad things happen and if we get that phone call, we're able to triage that to help support and see if we can treat in place when appropriate.

55:52
And that will help mitigate the risk of of hospitalization.

55:59
Also leaning into your diagnostics, ensuring that we have access and training for your team.

56:07
And so making sure we can help support you with starting Ivs and just making sure that we can help triage those patients in real time.

56:18
OK, very good.

56:19
Sally, I'm going to give you put you in a tough spot real quick.

56:21
One Michael wants to know any studies or surveys on operators and a capitated arrangement and the volume of therapy being reduced.

56:30
Oh, that's a good one.

56:32
So really quickly.

56:33
None that are public, I assume because the sample size would be too small.

56:38
But I in conversations with Marika, that's something that you could calculate for yourselves or use a blinded past example without having a without having a large sample size.

56:52
OK, excellent.

56:53
Now, toughest question because I'm going to push it to the metal here quickly.

56:58
Marika, what's the one thing you have to have people leave this presentation with?

57:03
You've talked about so many great things.

57:04
What's the one thing they have to leave with?

57:09
I say that if you want to reap the rewards of an isnip.

57:15
So all of the fantastic things that we talked about today, it starts with partnership.

57:21
So you need to lean into the partnership.

57:23
You can't just dip your toe in an eyesnip and expect to have all of the great rewards.

57:29
Very good, very good.

57:31
Well put, Sally.

57:33
All the stuff we've talked about, what's the one thing you really need them to leave with today?

57:39
Yeah, mine would be to just remember what folks said that they care about in a facility.

57:45
I know you feel very stretched thin trying to do everything, but keep doing what you're doing well, like cleanliness and you can focus less on things like getting on national ranking lists.

57:58
Outstanding.

57:59
And again, really so many great points for today.

58:02
Really wanted to thank our special give.

58:05
Our special thanks to Marie Carousa and Sally Kim, our Steam speakers today.

58:10
Thank you so much.

58:11
And we also want to thank our session sponsor, Optum.

58:15
Find them at optum.com.

58:17
And we want to thank you our attendees.

58:19
You've been a big part of the success today with excellent questions.

58:23
We look forward to seeing you again at future Mcknight's webinars.

58:26
You can keep track of what's coming under the live and virtualeventstab@mcknights.com.

58:32
Once again, thank you for tuning in.

58:35
This is Jim Burkland from Mcknight's.

58:37
Wishing you good health and outstanding days ahead.