Finding your post-acute care niche: when traditional skilled care is no longer enough for market survival. Some facility success stories.

Nursing facilities continue to face more challenges than ever before with competition from assisted living centers, dwindling reimbursements, and daily operational obstacles. Today, providing quality skilled nursing care is often not enough to maintain bed-hold and remain profitable. With increased scrutiny from federal and state agencies and easily accessible, but often misleading, state department of health surveys and other government data offered online for families to peruse, many facilities face an uphill battle to retain their image and share of marketplace while remaining fiscally viable. As a result, many facilities are moving away from traditional skilled nursing care and adding clinical specialties to enhance revenue streams and maintain or build census.

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As a nursing facility marketing professional for more than 20 years, I have consistently seen that those facilities that take the leap to find their niche are those that move forward with greater census and profitability. Whether it is short-term rehabilitation, subacute care, bariatric care, hospice, or wound care, nursing facilities are creating and packaging niche areas of expertise to enhance referral sources and case mix and increase census. All facilities, regardless of their present census, should consider specialty clinical programs to remain competitive.

Before embarking on a clinical specialty, however, a facility must examine its strengths, financial resources, physical plant, and staffing. Many facilities do not recognize their own potential in certain areas. I have observed that a professional consultant can often find strengths in a particular area of clinical service that has the potential to be packaged and marketed to a distinct audience. Begin by asking hospital case managers what diagnoses they have difficulty placing to identify services not offered in your area.

What follows are early progress reports from facilities that I have worked with along these lines.

Port Chester Nursing and Rehabilitation Centre, a 160-bed facility in Westchester County, New York (figure 1), had been offering quality nursing care and wanted to stay competitive by expanding its referral base to reach desirable Manhattan hospitals. In a brainstorming session with the owner, administrator, and director of nursing, we strove to identify the facility's clinical strengths in order to build an effective, cohesive, and marketable niche.

Administrator Carol Spedaliere remembers, "We had always had great success with wound care. Our facility had a low incidence of residents developing wounds and had consistent success with incoming hospital wounds. After discussing our potential in this area, we felt we were ready to move to the next step."

The facility began using "wound vac" equipment, trained its staff, and had the director of nursing become certified in wound care. Along with the interdisciplinary team and medical director, staff evaluated and adjusted protocol to accommodate patients with more difficult wounds, specifically by increasing flexibility in wound care product selection depending on individual resident needs. This program was named The Wound Healing Program; brochures were created in both English and Spanish and the marketing began.

The facility received an immediate response from local hospitals that didn't know where to send difficult wounds--including, yes, the desired Manhattan hospitals, which now refer patients with a variety of diagnoses, not just difficult-to-treat wounds, on a regular basis. Spedaliere's advice to others: "Before beginning a niche program, you must have a history of success and know that your staff is up to the challenge."

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Island Nursing and Rehab Center, a 120-bed nonprofit facility in Holtsville, New York (figure 2), decided to keep a short-term rehab census at 25 to 30% of its total population, as it felt it had the physical space and staffing to meet a growing community need. The facility's existing rehabilitation room, in excess of 3,700 square feet, looks more like a professional gym than a nursing home rehab department--and that doesn't include a transfer training car located outside the rehab area or the separate, fully equipped activities-of-daily-living kitchen. The facility recognized the need to hire more staff and added a full-time physical therapist and a COTA (certified occupational therapy assistant), as well as additional RNs and CNAs for the subacute unit, where the facility, to ensure continuity of care, implemented a restorative nursing program for residents discharged from rehab to ensure continued mobility and independence. Staff teamwork is emphasized as essential to this level of service.

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David Fridkin, Island Nursing and Rehab Center's administrator/CEO, says, "Our patients come to us sicker and requiring more acute care because hospitals are discharging them earlier because of their own reimbursement issues. We can handle this level of acute and subacute care and, clearly, at a lesser cost than hospitals can. Our healthcare community knows that when they need rehab, they can count on us."

Island Nursing and Rehab currently discharges approximately 30 to 40 patients a month, most going back to their homes, including several recently discharged patients over 100 years old.

When Daleview Care Center, Farmingdale, New York (figure 3), decided to offer short-term rehab in addition to traditional skilled nursing care, the owners built a large rehabilitation room, purchased state-of-the-art equipment, and renovated the area. Short-term patient satisfaction surveys had indicated that, while patients were extremely pleased with the care they received at Daleview, they would have liked rehab to be available on weekends to facilitate a quicker return home. Simultaneously, the facility was receiving and tracking numerous phone calls from the community asking if it provided rehab on weekends. With these two pieces coming together, along with increasing competition from rehab providers, Daleview Care Center decided to offer rehab seven days a week and hire additional staff for the weekend--one day for physical therapy and the other for occupational therapy, each provided by an individual therapist. Daleview's rehab management vendor works with the facility to train staff for this role.

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Daleview Care Center Administrator Mary Ann Mangels says, "While the cost of extra staffing is high, we are now one of the only facilities to offer seven-day rehab. We have begun to increase our volume of admissions and are inundated with phone calls from area hospitals interested in referring patients. We are pleased to be able to respond to this need in our community."

Daleview also went the extra step to add phone service and DIRECTV in each patient room, along with computer availability.

Ken Ruthinoski, administrator of Riverhead Care Center in Riverhead, New York (figure 4), says that attracting new post-acute patients requires a team effort. "The entire staff must be on board when adding specialty programs, particularly because you are often dealing with a younger population with different needs than the traditional geriatric patient." Ruthinoski adds, "We have found that our staff has risen to the challenge and become more skilled and experienced in different clinical levels of care." Specifically, by adding wound care, IV therapy, out-patient dialysis, and amputee rehabilitation, his facility has found its staff becoming more motivated and elevating their skill levels, with additional training provided by nursing administration, wound care product manufacturers, and other specialized resources, as they implement protocols that were previously only executed in the hospital setting.

None of this means that these facilities have ignored trends toward more modern resident care environments. Many have gone to great lengths to offer a hotel-like atmosphere and all the amenities deemed necessary to woo prospective families away from other facilities and neighboring assisted living communities. Some facilities have put down beautiful wood floors and added expensive lighting and window treatments to rehab areas. Others have created family visiting rooms and overnight-stay suites. Even more creatively, some facilities have added aromatherapy rooms, waterfalls, rock gardens, greenhouses, computer centers, cafes, and coffee bars. Others have added private bathrooms, in-room phones, cable, and satellite or DIRECTV, some on flat-screen televisions. However, while families are duly impressed by this, the bottom line for these facilities remains excellence in patient care.

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This is no time for traditional facilities to be intimidated. There are affordable opportunities for every facility to provide niche services, as long as you have a strong staff, adequate clinical expertise, and a commitment to well-researched and -developed programs.

Sharon Jarchin is President of Sharon Jarchin Health Care Marketing, Huntington, New York. For more than 20 years, the firm has specialized in nursing home strategic marketing, advertising, public relations, and census enhancement programs. For more information, phone [phone]. To send your comments to the author and editors, e-mail [e-mail].