Assisted living communities that have on-site primary care could gain a range of benefits — including advantages in battling Covid-19.
However, bringing primary care into assisted living is not for the faint of heart, according to Brian Cloch, Principal at Innovative Health.
“This is really, really hard,” he said, during a recent interview for the Senior Housing News podcast, Transform, sponsored by PointClickCare.
Cloch, an owner and operator of affordable assisted living communities in Illinois, recently forged a partnership with innovative primary care provider Oak Street Health. Though still in its very early stages, that partnership is off to a good start in four assisted living communities in Illinois that are managed by Chicago-based Pathway to Living.
The rise of companies like Oak Street and the shift away from a fee-for-service health care model toward more value-based approaches have opened up possibilities for senior living that did not exist in the past, Cloch said. He and Grace Chen, senior vice president of care services at Oak Street, spoke with the podcast at the recent National Investment Center for Seniors Housing & Care (NIC) conference in San Diego.
Shortly after that interview took place, the Covid-19 crisis swiftly escalated in the United States. In a separate interview for this episode of the podcast, SHN spoke with Pathway to Living Director Enhanced Wellness Laurie Geschrey about why she’s glad to have Oak Street as a partner in facing the coronavirus threat.
What are the origins of the Oak Street partnership?
Cloch: I’ve been in senior living/post-acute care for a long time, since ‘83 … The journey I’ve been on for a lot of those 36 years was trying to find ways to keep our residents happy and healthy and in our buildings. It’s never been an easy thing to do.
The challenge has always been the misalignment of health care service. When people live in custodial senior living, whether it’s assisted living or skilled nursing, it’s never been very good alignment in a fee-for-service model. So we’ve been looking for opportunities to create a different model and to bring more resources into our communities, that allow us to keep our residents happy and health and in our buildings.
… I met the guys who founded Oak Street before they opened their first clinic, and just had a huge amount of respect for what they were doing.
While they didn’t use these words, I told them what you should say is this: They were creating primary care in health care deserts. So, they were going into areas that were lacking primary care, and they were opening up primary care clinics. I get chills even now, saying that, because I think what they did is such great work.
They brought not just a primary care model, I call it free concierge medicine to people that had no access to primary care, let alone getting a robust care coordination/primary care strategy.
So, I met them before they opened their first clinic, and I begged them then to come into senior living. They were incredibly focused and disciplined — as they always are — and rejected my advances for many, many, many, many years until I think they finally saw some opportunity, potentially.
As the members of their clinics age in place, their moral compass is so high that they see an obligation to their members to follow them into whatever setting they live in … They’re starting to see need now for some of their members that have been around seven years, [saying], “Hey, maybe we need to start following our members into these environments. Because otherwise, we lose a member, and we just don’t do the right thing by a member. So, it’s better for us to kind of stick our toe in the water and figure out this out, and see if we can create a model and a sustainability to it, and see how it goes.
You used the phrase “free concierge medicine.” How is Oak Street paid for its services?
Chen: We do believe in full responsibility for the patient. So, it’s that full accountability, that does include quality and cost. So there tends to be relationships with payers.
Are we talking about Medicare Advantage?
Cloch: I’ll address the “free” part, because I said it. What I mean by “free” is that to the residents and members, they’re not paying extra for it.
You know, I pay $2,000 a year to a concierge doctor … to the seniors that join Oak Street or use Oak Street as a primary care provider, they’re not paying extra for that service. In many cases, it’s just included in their Medicare benefits, and they’re maybe even paying less because if they’re a Medicare Advantage patient, they don’t have Medicare co-pays for supplemental [benefits]. So, for people that have that, it’s actually costing less to get better care and more services. That’s what I meant by “free.”
In our model, the third leg of the stool is a company called MoreCare. It’s owned by MHN, Medical Home Network, and they have a whole set of plans. An I-SNP plan, and IE-SNP plan, a Medicare Advantage plan and a C-SNP plan. We’re utilizing the IE-SNP plan for the members that live in our buildings … it’s an institutional equivalent special needs plan, since our communities are not defined as institutions, because they’re residential.
How does the Oak Street model translate into assisted living?
Chen: Our traditional model in our centers is frequent visits, availability and access of the providers and the care teams for our patients. It is clinical services plus wraparound services — behavioral health needs, social workers, addressing transportation and any other barriers that might be hindering their care. So, this holistic approach to treat patients.
What we’re doing in senior housing is very similar, it’s an extension of that. We have a care team, they’re seeing patients in the community with additional services on top. I would say we’re very much additive to the wellness coordinators and wellness teams, many times alleviating some of the work and headaches that they have, because we can coordinate a lot of the services, ensure that the patient’s getting the care that they need, not more and not less.
Cloch: And the value we’ve seen as an operator, having a provider like Oak Street do what they do, it’s been exactly what Grace is describing. It’s just a tremendous value-add to the residents and our communities. They’re literally saving lives. No exaggeration, we’ve got stories in the last seven weeks of people whose lives are impacted and changing based on the approach of really good care.
Again, look at at the fee-for-service world. It just doesn’t align with custodial long-term care, and people’s needs. Most assisted living communities, they’ll talk about these vans. Come live here, we’ll take your mom or dad, grandma or grandpa to the doctor. So, these people are moving into buildings because they have to and they need more services coming to them. It’s not safe for them to go in a van, let alone the breakdown in communication. What happens when they go in that van, go to the doctor, who’s going with them? What the doctor says or does, how does that get translated back to the record in their building? How do we know what to do? How do we change the meds? It just doesn’t work. While I feel bad about things I’ve done over the last 30, 36 years, we didn’t have any choices. You couldn’t get this model fo care in these communities.
How many communities is Oak Street in right now?
Cloch: Four. Three, pretty solid. We have challenges in one of our buildings that we’re trying to work through, which is a good comment. This is really, really hard.
For everybody, it’s a change. It’s a transformational change to the payer. Enrollment — for members who live in this environment, it’s totally a different way of enrolling. It’s the same as what happens in the general community, but you have to change your approach. So, that’s hard. Then, the next step is providing the care. That’s really hard. Oak Street’s working really, really hard and trying to figure out if this is a model that’s sustainable financially for them. And for the operators, it’s hard, because it really impacts every vertical in the building.
We’ve made the mistake, until now, that we look at this as a clinical program. It really isn’t. It’s an all-encompassing program. It impacts every vertical in the building. Clinical, activities or life enrichment, marketing, business development, sales, dietary … as an operator, we have to think about changing. How do we change our ways of doing business to align with providers like Oak Street, so that we can keep them in our buildings?
I wake up every day fearful that they’re going to call me and say they can’t do this any more. And I know the benefit to me as an operator, I know the benefits to residents. So, we want them to do really, really well and succeed in our building.
Chen: I’ll just add, I think the really great part about the relationship is we have [communication between] the three entities. We’re on calls every week to talk through some of the challenges, and challenges aren’t necessarily bad. It gives us the opportunity to work through it, and we’re all willing to adapt, and I think speak freely about what’s best for the patient. You don’t always get all those players at the table. We don’t have specialists who are meeting our demand from an access standpoint, the payer is willing to have conversations of adding specialists to the network. Brian and his team are operationally open to calling us and changing some of their processes from what they’re used to. We’re making adjustments to work with the facility teams.
If assisted living providers reduce health care costs through on-site primary care, that’s saving the payer money, it’s increasing length of stay for the senior living provider, increasing quality of life for the resident. Am I missing any benefits?
Cloch: I would tell you that you get that and more. The hard part of what you described — you need an operator that understands they’ve got to change the way they do business. We’re still struggling with that. So, it’s not a slam dunk. Grace and I had great discussions in the last 24 hours on this exact topic. We as an industry, coast-to-coast, have a challenge with personal injury lawyers, plaintiffs’ lawyers … we’ve got a lot of these cases in assisted living, in nursing homes. Many, many organizations have behavior changes where somebody trips and falls in the hallway, or we find a resident on the floor, we just automatically call 911 and send them to the hospital to get evaluated, out of that necessity to protect ourselves from — god forbid — a future lawsuit that might show up in the next four years.
Chen: Our goal is not to reduce hospitalizations, necessarily. It’s getting the appropriate care for the patient. Frequently, they don’t need the admission. They need something — eyes on them from a clinical perspective, or they may need some kind of intervention or treatment that’s available in another setting.
We can do a direct admit to a skilled nursing facility where they can keep a 24-hour hold on the patient to get eyes on them while they stabilize. It’s better for the patient. There’s less risk of some of the infections that we are exposing them to when they go to the hospital. We have better eyes because we have, potentially, SNF partners who are willing to intervene in certain ways for us and bring them back into the community so patients can be home, in the environment they want.
Preparing for Covid-19
Oak Street’s on-site assisted living services also could be beneficial in light of the Covid-19 outbreak that is worsening across the United States, Pathway to Living Director of Enhanced Wellness Laurie Geschrey told the podcast in a separate interview.
Describe your role with Pathway and how Oak Street fits into Covid-19 preparations?
Geschrey: I work with our partnerships, our health care relationships with different strategic primary care partners like Oak Street, but also different home health companies, physician groups, hospice, labs, all different types of partnerships that we create.
What we’ve been working on right now is enhancing our rapid response plan to Covid-19. It’s certainly been an interesting time. I can tell you that I’m really proud of our wellness team, our operations team, everyone who’s worked together to get that plan in place and operational quickly.
So far, we have no incidents of any outbreaks in our communities, in all the different states we’re in. I really think that’s a testament to not only our team members and how hard they’re working to initiate those rapid response plans, but the cooperation of the strategic primary care partners that we work with.
… We have daily calls — we’re working not only with Oak Street but all our strategic partners on a regular basis, keeping track, making sure we’re sharing response plans, making sure that we’re sharing protocols so that as different partners are entering our communities, that they’re following what we’ve set in place.
Oak Street is a great partner. They’re in four communities as we’ve been rolling out our value-based plan, but it’s been really a very positive experience. As difficult as the whole coronavirus or Covid-19 issue has been, it’s really showed the strength of our partnerships.
Does the Oak Street partnership give you confidence that if a resident or staff member displays symptoms, that could be caught and addressed quickly?
The more dangerous it becomes to leave a community, the more important it is for services to be available on site?
It’s key, especially for this population of vulnerable adults. Seniors. Right now, we are not allowing any family visitation. We’re setting up different FaceTimes and Zoom meetings, so that they can talk to their loved ones and they can see each other, but for right now, we’re doing our very best to ensure that we’re keeping our seniors safe. So, having on-site providers that are willing to come in and provide care is outstanding.
Do you think the Covid-19 situation could show the value of this type of partnership and accelerate them in the future?
Absolutely, I couldn’t agree with that statement more. Pathway to Living has always been at the forefront of a coordinated care model. Going back 12 years ago, we have always believed that our job is to provide these services and bring these services around our residents. Why have them go out in bad weather and risk a slip and fall on ice? And, to also be able to give family members their relationship back, to being the daughter or son as opposed to being a care provider. Our job is to do that. We do it well because we have these partnerships.
When Oak Street workers come into a community these days, what kind of work are they doing?
They’re dealing with the day-to-day issues of whatever residents need. Typically, they’re seeing residents based on the acuity of that resident. They see residents who have multiple comorbidities more often, to make sure they’re managing the exacerbations of those disease processes — keeping them out of the hospital, happy, health, and in their homes.
So, they’re on top of things quicker, they’re not letting things get out of hand, where if a senior just goes to the doctor, even if they go every quarter as most seniors do, things are already at a level that [they] are hard to pull back. So, it’s really important that we’re staying ahead of the curve and keeping these disease processes under control.
… We’re just really excited about our relationship with Oak Street — and, really, with all our care providers. They’ve been great partners for us. We continue to look forward, to see how health care changes because of this whole thing.
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