The art of admissions: the admissions coordinator plays a large role in the resident's well-being, the family's morale, and the facility's financial success.

The admissions department is where impressions of your nursing home are made. This department needs to shine with its presentation, knowledge, helpfulness, and understanding of all the complexities involved in the decision to place a loved one in a nursing home. Blending the emotional, financial, psychosocial, and medical aspects of an admission requires a solid knowledge of the facility's marketing, social work, nursing, and business departments.

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Timing an individual's readiness for admission--usually along with the family's--with room availability in the facility often requires the proficiency of a circus juggling act. Art is defined as "requiring sensitive understanding," according to the Oxford English Dictionary. If we look at admissions to our nursing home facilities in this light, the idea of admissions strictly being about completing paperwork and obtaining specific documentation takes on a very different meaning.

The American population is aging. Baby boomers are nearing the age where long-term care becomes a possibility--and many of their parents are already there. Statistics and research show that the need for long-term care facilities and the services they provide will increase. (1) Assuming that the upcoming explosions in the elder population will lead to a facility's security, though, would be premature, at best. With Medicare and Medicaid cutbacks, the changes caused by the Prospective Payment System (PPS), the nursing shortage, and the higher acuity of residents, each of these factors on its own can cause facilities to overextend themselves to the point of no return. These elements combined, if not handled with well-designed alternatives, pose a real threat to a facility's survival. In a study conducted by the American Association of Homes and Services for the Aging (AAHSA), more than 200 nursing facilities closed from 2000 to 2001. Nursing facilities must analyze how to be cost-effective in all departments throughout their organization. What better place to start than with admissions?

Get Involved Early

Advanced planning is the key to long-term care placement, which means that the admissions department's work begins long before a person even sets foot on the property. The facility needs to have early involvement with those who are just starting their research on long-term care. (2) You can't wait for them to call you based solely on a few fliers or local newspaper ads. Start by making a personal care connection to show that your facility understands each applicant's unique circumstances and will honor his/her individuality. If this connection is not made prior to admission, there will be no admission.

Admissions personnel must earn individuals' or families trust to be able to convince them that your facility best meets their needs. Even a violation-free facility must show its merit and distinction and, most importantly, have someone to show it to. There are many ways to initiate this connection: offer tours and open houses, and provide facility-specific information packets and even information on specific specialized units, such as the dementia care unit, if applicable. Also, offering general information on long-term care and related topics, such as advance directives, estate planning, understanding Medicare and the Medicaid process; and health-related issues, such as Alzheimer's disease, glaucoma, or diabetes, will position your organization as a good source of information and referrals.

Admissions personnel must be knowledgeable of overall healthcare issues. Hosting informational seminars for the public is a good way of demonstrating this knowledge. Not only does it get people in the door to see your facility, but it also shows you are concerned about matters of interest to them. When administrative staff are present at the event, it connects faces to the organization--happy, supportive faces who are there to listen to the needs of the community and, let's face it, be given the once-over. Informational, supportive "meet and greets" show the public that your facility is an excellent resource center for addressing their long-term care needs.

Types of Admissions

Admissions generally fall into two distinct categories. Each requires a different approach, takes different paths to gather information, and creates different issues.

Long-term/planned admission. This admission is planned by an individual or family usually living in a private home (either alone or with relatives), or it may originate as a referral from an assisted living community, where the client now requires more care than the current facility can provide.

Families are usually involved with any type of admission, but transitioning from home to facility care requires the most serious counseling. This type of admission forces the family to face the fact that their loved one's needs are so great that he or she cannot remain at home, which is why meetings in the admissions office are regularly tearful scenes. Up to this point, placement has only been an option, but when the paperwork is actually signed, it becomes a reality. Admissions staff must be equipped with skills to handle such delicate emotional episodes.

Serious family disagreements on what is best for a loved one also transpire in the admissions office. The admissions coordinator must facilitate among the differing opinions and help the family reach a mutual agreement on behalf of the client. Always remember, though, that a competent client or his or her durable power of attorney for healthcare is the decision maker.

Skilled/acute admissions. Skilled admissions require extensive medical knowledge, so that the extent of a person's skilled care needs and the subsequent cost to the facility are understood. Although Medicare covers skilled care, at times expensive nontherapy ancillary services are needed and it is the facility's responsibility to provide them. Admissions personnel need to anticipate accurately the level of skilled care required and the predicted ancillary services, and properly communicate this information to the other departments involved, as well as letting administration know the financial responsibility entailed. This is a difficult task and is learned only through experience.

Whether or not admissions staff are responsible for entering data into the Minimum Data Set (MDS) system, they need to understand how their admissions will be reflected in that system. It is important, therefore, that they are familiar with the Resource Utilization Groups (RUGs) and the RUG case mix. In April 2002, Medicare rates were significantly reduced to $35.42 per day per Medicare Part A resident across all RUGs. For an average SNF that is a deficit of approximately $100,000 per year. (3) Although all admissions are important, this particular type of admission can significantly affect reimbursement and revenue.

Timing the Admission

Remember the familiar phrase, "Timing is everything"? Well, in admissions, it is certainly relevant. First, a bed must be available and, if your facility has rooms certified with particular licenses, they must be matched to prospective residents. Second, you generally are filling a recently vacated bed. Often the vacancy is the result of the death of its previous occupant. Removing the deceased resident's belongings is a sensitive issue that must be dealt with. While a family certainly needs time to grieve, time is not on the side of the admissions coordinator.

This sensitive subject can be approached in various ways. Some facilities have a policy that establishes a time limit for removing personal property (usually 24 or 48 hours), after which the facility will remove the deceased resident's belongings and put them in a holding/storage area. Also understand that once the room is cleared, some families might feel less responsible for those items. If the personal effects aren't important to the families, they might not be claimed at all. If these are large items, such as furniture, the facility might incur a cost for disposal. This policy should be clarified upon admission. Although you want to avoid upsetting a family in its time of sorrow, a clear policy statement at the outset avoids the risk of damaging a relationship with a family and leaving them with a negative impression of your organization.

Waiting Lists

A waiting list is a wonderful vehicle for long-term placement admissions. It provides a pool of prospects to draw from when beds become available, especially nonskilled beds. But a waiting list also means that the admissions coordinator must manage the needs, issues, and problems of those on the list. Usually clients have paid a fee to be on the list and, based upon its length, numerous problems possibly will arise and need to be resolved. For example, a waiting-list client might have insurance that is not accepted by your facility. In that case, the admissions coordinator needs to explain other insurance options and choices to the client to avoid any delay at admission.

Also, families might need help to continue caring for their loved ones at home while waiting for a vacant bed. Admissions staff should be able to provide information and referrals to other agencies that focus on in-home support, such as the Cuyahoga County Passport program (in Ohio), private home healthcare services, Alzheimer's Association resources, and adult day centers.

A waiting list doesn't necessarily guarantee a quick turnover of beds. Even with a significant amount of advance preparation, no one knows what an individual or family will do when a room becomes available to them. Often, when a room is actually offered, admissions staff will be told that the client and/or family is not ready (mostly emotionally) for placement. At this point it is critical that admissions personnel provide support and understanding concerning their emotional difficulties in placing a loved one in a nursing home. The family might not be ready now, but they may need your services down the road. Even though this means that a scheduled admission has fallen through and that you will have to start the process from scratch, the family needs reassurance that their relationship with the organization has not been damaged.

On the other hand, every day a bed remains open, revenue is lost. This fact presents another concern for an admissions coordinator: gathering documentation required by other agencies. PASSAR screens, level-of-care verification, physicians' orders, and Mantoux test results for tuberculosis are just a few examples of required documentation, some of which can significantly affect payment if not obtained properly. Occasionally, admissions staff have to explain to another agency that the individual's placement might be in jeopardy if the paperwork is not received within a particular time frame.

Qualifications for Admissions Coordinator

In view of all this, who exactly should be an admissions coordinator? Because this job is a combination of several stand-alone positions, it's difficult to say which aspect of the job is the primary focus. Getting people into the facility for open houses and tours and creating name recognition in the community are marketing and sales aspects of the job, but the admissionsd coordinator also needs to have the background to handle the community referrals and counseling aligned with the social work portion of the job description. Social workers who also have admissions responsibilities need to manage their time between admissions duties and their traditional social work roles. Because social workers are also generally the discharge planners, they need to be careful not to fall into a "get them in, get them out" routine. Also, the required understanding of residents' acuity levels falls within the nursing and medical aspects of the position, but it can be costly to employ an RN in the admissions department.

Admissions coordinators need to be self-motivated, able to work independently with little supervision, be well organized, and work well under pressure. Flexibility is also a key attribute. The more flexible an admissions coordinator can be with his/her schedule, the better chance he or she has of reaching potential clients. For example, some people may need to arrange evening meetings or tours to accommodate their work schedules.

An administrator should be cautious when considering an inexperienced or non-degreed applicant for this position, because he or she will make the first impression for the facility and will promote the facility on a variety of levels. This person must be well-versed in every aspect of your organization and be able to answer questions quickly and accurately.

Another important quality that successful admissions coordinators have is their ability to interact and directly affect the adjustment of new residents to their surroundings. If an admission does not go smoothly or if the resident and/or family does not feel supported or adequately informed, animosity can arise between the resident and the staff. Staff will then have to play catch-up in trying to reestablish trust and emotional security. Generally, when an admissions coordinator can create a positive outlook on an admission, the resident's and family's adjustment period will be smoother and shorter.

Future Trends

In the future, most jobs in any industry will rely more on technology, to the point of eliminating some positions entirely. The nursing home industry is no exception--and admissions departments, too, will have to expand their use of technology. "Information sharing and networking between organizations through a centralized referral source may be a trend for the future," says Martha Kutik, president and CEO of Jennings Center for Older Adults in Garfield Heights, Ohio. She explains that the workforce landscape will look very different in the next 20 years.

Kutik explains that currently for every person 65 and older there are 11 people 65 and younger. In 20 to 25 years, that ratio will become one to four. "It's not just that the elder population will rise dramatically, but that the population 65 years old and under will severely decrease, which means there will be more people to take care of and fewer people providing care," she says. "Technology and its tools may have to play a part filling in the workforce gaps."

Creating a database of potential clients and their specific needs that an admissions coordinator could pull up would help as a referral source and result in better placement. As potential clients become more knowledgeable about the Internet, facilities will have to make sure they are easily accessible on the Web and properly use the Internet's avenues of access, or they will risk being overlooked by computer-savvy customers.

In other areas, admission methods and procedures can have a major effect on revenue for a facility and the psychosocial adjustment of its residents. Managing the duties related to marketing, social work, nursing, and business affairs needs to be understood as interrelated. Nursing home administrators should examine the efficiency and effectiveness of their admissions department--whether it's an entire department, a single position, or a function within the context of another department. Overlooking the department's unique position and its effect on your reputation could be damaging to the overall well-being of the organization.

Admissions needs to be viewed as more than just a paperwork-signing department. It requires a "sensitive understanding," the specialized art of recognizing the needs of residents, their families, the greater community, and your facility. It is critical that the admissions department has sufficient support to allow it to develop the skillful expertise that, for the sake of your facility, it must have.

References

1. Alzheimer's Disease Education and Referral Center, National Institute on Aging. Progress report on Alzheimer's disease, 2000. Available at www.alzheimers.org/pubs/prog00.htm.

2. National Citizens' Coalition for Nursing Home Reform (NCCNHR). A Consumer Guide to Choosing a Nursing Home. Available at http://nccnhr.newc.com/public/50_155_3274.cfm.

3. Polniaszek S. Study of Profit/Loss Margins For Not-for-profit Skilled Nursing Facilities. Washington, D.C.: American Association of Homes and Services for the Aging, 2002.

BY SARAH FOX, LSW 

Sarah Fox, LSW, is the social worker for the dementia care unit at Jennings Center for Older Adults in Garfield Heights, Ohio. For more information, phone [phone] or send an e-mail to [e-mail]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].