Perspectives in Long Term Care

In this episode of Perspectives in Long Term Care, host Debbie Stadtler welcomes Hilanie Hauk, executive director of Oasis at 30th in Indianapolis, for an inspiring conversation about resilience, leadership and the power of serving others. Hilanie shares her remarkable journey from growing up with limited resources in the Philippines to building a career in long-term care, beginning as a certified nursing assistant and eventually becoming an executive director. She reflects on how determination, education and the encouragement of mentors helped her overcome obstacles and embrace new opportunities. The conversation explores her people-first approach to leadership, the importance of balancing compassion with accountability, and why creating a true sense of community requires more than meeting operational and regulatory standards. Hilanie also discusses the responsibility leaders have to recognize potential in others, invest in their professional growth and lead by example. Throughout her story, she emphasizes that where someone begins does not have to determine where they finish, and that meaningful success comes from helping others rise along the way.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Rising from humble beginnings and working her way up from CNA to executive director, Hilanie Hawk has lived her values of service and resilience in her career. Hear more about Hilanie's story in this episode of Perspectives in Long Term Care. Hi, I'm Debbie Statler, editor-in-chief of Provider Magazine, the flagship publication of the American Health care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long-Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long-term care and assisted living professionals about the opportunities and challenges impacting the long-term and post-acute care profession. My guest today is Hilanie Hauk. Hilanie serves as executive director of Oasis at 30th in Indianapolis. Rising from a bamboo hut in the Philippines to executive director of a facility, she has focused her career on serving others with compassion. Welcome, Hilanie.  Hilanie Hauk: Thank you, Debbie. It is my pleasure to be here. Debbie Stadtler: Well, I know you have a very unique background, and I really want to dive more into that. So tell us your story. How did you get to where you are today? Tell us about your background.  Hilanie Hauk: Yes. So my story really begins in southern Philippines. My father, who was a soldier, he passed away before I was born. And when I was only a few weeks old, a tsunami destroyed our family home. So I grew up with very limited resources because I was, like, raised by a single mother, and from an early age, I learned responsibility, resilience, and how to make the most of what I had. So with that being said, growing up, I can say that education became very important to me because I saw it as opportunity to change not only my life, but eventually the lives of others. So I earned my degree in education in the Philippines. Later on, I came to United States, entered health care as a CNA, became a nurse, then assistant director of nursing, then director of nursing, and eventually an executive director. And keep in mind, none of this happened overnight, of course. It was one opportunity, one lesson, one person believing in me at that time. Looking back, I think every difficult experience prepared me for the responsibility I have today.  Debbie Stadtler: With those circumstances growing up, I'm sure that you learned a lot. You mentioned resilience, relying upon education. How did those circumstances growing up shape your views on things? How does resourcefulness show itself in your life now? What's your view on hard work?  Hilanie Hauk: So growing up, we didn't have a lot of choices or resources, so I learned to use what I had. So with that being said, I learned very quickly that if you wanted something different for your life, you had to work for it. So there was time when continuing my education was difficult. I worked while going to school. With that being said, I have three brothers, so I had to care for my younger brothers and had to find ways around obstacles instead of allowing those obstacles to stop me. So it doesn't matter how hard life is, if you have that determination, it will push you through because you know that you have a goal, that you need to get through it And that is probably why education means so much to me today, because education gave me something circumstances cannot easily take away from you. And being resourceful taught me something equally important, that you don't always need perfect circumstances to move forward. Sometimes simply have to ask, "What can I do with what I have right now?" That mindset has stayed with me throughout my entire career.  Debbie Stadtler: I think those are some incredible lessons. I think the one you mentioned about you don't have to have perfect circumstances to move forward, that's so true, and something we all would do well to remember from time to time. Hilanie Hauk: Yes.  Debbie Stadtler: Your path in health care, you said you started as a CNA, you moved up to nurse, director of nursing, executive director. Was that pathway always your goal, or how did you know what the next step was at each level of your career?  Hilanie Hauk: Absolutely not. Being poor, you really didn't know what is the next day, right? So when I became a CNA, I wasn't thinking that someday I'm going to be an executive director, right?  So I was thinking about doing the job in front of me well. So do the job with your heart. This is what is important to me. It's not just, oh, I want that title because this makes my life better. It's just the nature takes its course, right? So as I became a nurse, I started seeing things differently. So I wanted to understand why decisions were being made, and how I could make things better for residents and staff So then as I moved into nursing leadership, I realized that I enjoyed developing people, solving problems, and improving systems. So with that, each step showed me that next one. So then eventually becoming an executive director made sense because I wanted to influence the entire community, not just one person. It's now the whole community that you are the operator, right? Okay, how can I make this better? So it's not just the clinical side. I wanted to understand the operation aspect with it, the finance, of course, staffing issue, because you need to make sure that you have enough staff to care for these people that need you. As a leader, you can't just say, "Okay, I have to follow my budget," but, "Oh, hold on a minute. Somebody's not really taken care of properly because we're short-staffed."  And the quality care is important to me because I was raised with my grandparents. So I want to make sure that these fragile individuals who are being cared by me and my staff are being taken care of properly. And it's not just the regulation. Yeah, I have to follow that because as a administrator, you'll get tags if you don't follow that. So the resident's experience and everything that comes together to create a successful community. I just don't want a building. I want a community that when somebody works and walks into my building and says, "Oh, it's a good place. I want my loved ones here." Yeah. "I want my mom, dad, my aunt," anybody that walks in, I want them to feel that they're welcome and it's their home.  That is also why I pursued my master degree in health care administration. So my career wasn't built from perfect plan. It was built by continuing to learn and being willing to accept the next challenge. Debbie Stadtler: I love that. And I love that you mentioned that you grew up with your grandparents. I find in talking to a lot of folks in long-term care that there's often a personal connection to this work for them that really makes it so valuable and such a passion for them. So I can clearly see that your passion for this industry just shows itself in your work every day. Hilanie Hauk: Yes. Health care to me, Debbie, is not money. It's more of caring the person who were there for us, and it can be anybody, because at the end of the day, they are your family.  Debbie Stadtler: I've heard you talk about your story, and at a couple of points in your story, you've mentioned mentors. Yeah. I know there were a couple of mentors that really inspired you, pushed you to that next level. So tell us about the role that those mentors have played in your life.  Hilanie Hauk: Of course. So to me, mentors have been extremely important in my life because sometimes another person can see something in you before you see it in yourself. It's like looking outside the box, right? So one of those opportunities came from someone who had previously been my assistant director of nursing, then she later became a director of nursing at another company. So she asked me if I wanted to be her assistant now because she's a director of nursing. So I said, "Okay." So when she took that position, she asked me to follow her and become her assistant director of nursing, and that was an important step in my career because she had already worked with me. She knew my abilities, and she believed that I was ready to take on in a leadership role because she knows that I am determined. So with the same company, we have my administrator, which is, her name's Kay, and Kay had enormous influence on me. She is also a nurse. She had decades of experience as an administrator, and she saw leadership potential in me. So she kept following me. And I said, "What do you want from me?"  She said, "Can I have a minute?" I said, "Yeah," because I was doing my rounds. And she said, "I need to sit down with you." She said, then she said, "I see leadership potential in you." So she encouraged me to continue my education and pursue my masters degree in health care administration, and she said, "And I will be flexible with your hours, and I will pay half of your tuition." Debbie Stadtler: Wow.  Hilanie Hauk: And I said, "I'm too old for that." And then she said, "No, never too old." I said, "Okay." So again, here I am willing to take on another challenge, right? So what I learned from Kay or from people like Kay is that mentorship isn't just giving someone advice. It's seeing their potential, challenging them, and sometimes pushing maybe in what I can be capable of doing. At that time, I said, "Am I going to do this?" That's the first time I'm going back to United States school. So and I said, "Can I do this, Kay?" She said, "Yes, you can." So with that, somebody that I look up as my mom, it really pushed me to my limit because keep in mind, English is my second language, and for her to do that and willing to give that to me, that is something that I can never forget. So that is something that I try to do for other people now. If someone invested in me, I have the responsibility to invest in the next person as well, because I'm paying it forward. That is my goal, and that is the legacy that I'm willing to leave when I die.  Debbie Stadtler: I think that's so powerful. Like you said, mentors, because they're outside of your box, can sometimes see so much more than you can see in yourself, and sometimes you do need that little push to go move to the next level, and obviously it worked out very well for you, but what a blessing to have had those mentors in your life to really help you move to the next level and take those next steps.  Hilanie Hauk: That is correct, and again, anything that comes your way, never say no until you try, because to me, that is something that God really guides you to be there. There's a reason for everything in my life, and that's how I look at it.  Debbie Stadtler: You've obviously lived according to your values of service and excellence. Yes. Tell us more about what those values mean to you.  Hilanie Hauk: Yes. So for me, service means remembering why we are here, right? So to me, leadership isn't about title. In my community, you can see me wearing scrubs because I am a nurse in nature, so I can be your housekeeper today. Tomorrow, I can be your dietary. So it's about what happened to people because you are in that position. So you have to lead by example, to me. So service means being willing to listen. You’ve got to listen, or else your ship is going to sink. Being present, helping someone when they need you, and remembering that the people we care are for someone's mother. It can be your mother, Debbie. It can be your father. Yeah. It can be your husband. It can be my brother and my sister. It's everybody's loved ones I'm taking care of. So excellence means I don't want us to simply meet the minimum requirements. I want us to continually ask, how can we do better? So with that being said, you can have compassion without lowering your expectations. In fact, I do believe that the two belong together really, and we should care deeply about people while also holding ourselves accountable for providing the highest quality of service we can. Debbie Stadtler: Absolutely. I think that's a brilliant way of putting it, that every person that you care for is someone's loved one.  Hilanie Hauk: Yeah.  Debbie Stadtler: And so bringing that idea that you're caring for someone's loved one just really makes it obvious how important that excellence and that quality of care are as you're going through each day with them. Such an important reminder.  Hilanie Hauk: These people need us, and they are our family. And when they come to you, you just have to know that this is your mom, this is your dad.  Debbie Stadtler: You've said that health care is people. I think that's super evident in everything that you've talked about so far. How has that philosophy shaped your time as executive director and your facility overall? Hilanie Hauk: So when I say that, because sometimes health care becomes focused on numbers, regulation, state surveys, budgets, our staff ratios, and paperwork. All of those things matter to run a building, to be able to have people work for you. But ultimately, health care is people. It's the residents who want someone to sit down and listen to them. When that one person's dying and there's no family, you're it. You have to be there to let them know that they're not alone dying. You have to hold their hand, let them know it's okay. It's the family member trusting us with someone they love. So when a family is screaming at you because you're not delivering the quality care that you promise, so never overpromise and underdeliver. Always be transparent. So it's the CNA who has been working hard all day. We can easily point what they did wrong, but keep in mind, they're human, they're people as well. So always remember that they all have a bad day like everybody else. So understand that situation. It's the nurse trying to make the right clinical decision. Sometimes some nurses make a mistake. Don't judge that right away. Know what happened first. And it's the housekeepers. Every day, if you don't have housekeepers, your building looks nasty and filthy. And the dietary, who's feeding your residents, right? And the maintenance people, and all the department leaders, everyone contributes to that resident's experience. So as executive director, I try to remain visible and accessible because I don't believe leadership happens only from an office. So when your people know you are there, that you will listen, and you will always hold everyone accountable, it changes the culture. Policy guides us, but relationships are what make a community feels like home. Debbie Stadtler: I think that's so true. And your point about everybody working together on the resident experience, you don't always think about all the different roles, but they're really all important in their own way, and there are people there trying their best in each of those roles every day. So it's a good reminder to focus on the people part of it, not necessarily just the data technology piece. Hilanie Hauk: Yeah, we follow the corporate metric. But I also have metrics in my community. My people are my metrics.  Debbie Stadtler: Absolutely.  What is the one piece of advice that you'd like to leave with us?  Hilanie Hauk: So for me, don't allow where you started to determine where you finished. Be willing to work hard, stay teachable, and don't be afraid to take an opportunity simply because you don't feel completely ready. There were many times in my life when I could have decided that my circumstances were too difficult or that something wasn't possible for someone like me. Instead, I kept taking the next step. And when you become successful, remember the people who help you to get there, and turn around, open that door for another else. Success means much more when you use it to help another person to rise.  Debbie Stadtler: I love it. Once you have moved through a door and taken that next step, turn around and help the person come up behind you. That's a brilliant lesson that we all need to remember, for sure.  Hilanie Hauk: Yes.  Debbie Stadtler: Thanks again for joining us, Hilanie. Hilanie Hauk: Thank you, Debbie.  Debbie Stadtler: Visit the AHCA/NCAL website at ahcancal.org to learn more about how to get involved and develop your leadership skills. And thanks to everyone for listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler welcomes Irene Borgen, PhD, MBA, MSN, MJ, FACHE, RN, vice president of innovation and clinical partnerships at Sunrise Senior Living, for a conversation about why value-based care represents an important inflection point for assisted living. Irene explains how the shift from fee-for-service to outcomes-focused care aligns with Sunrise’s wellness-first approach and the evolving expectations of residents and families. She shares how Sunrise established baseline measures around hospitalizations, emergency room visits, readmissions, falls, polypharmacy and satisfaction before developing a relationship-based model that brings clinical partners into communities while preserving residents’ choice of primary care provider. The conversation explores the realities of implementing this model, from change management and team training to consistent measurement and selecting the right partners. Irene also discusses how value-based care can benefit residents and families while strengthening care teams, referral relationships and business outcomes such as occupancy and retention.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Superior clinical outcomes for residents, increased family trust, and better metrics for your facility? That's the promise of value-based care in assisted living. Learn how to get started with Irene Borgen in this episode of Perspectives in Long-Term Care.  Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long-Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long-term care and assisted living professionals about the opportunities and challenges impacting the long-term and post-acute care profession. My guest today is Irene Borgan. Irene serves as vice president of innovation and clinical partnerships at Sunrise Senior Living. She is a registered nurse, a licensed nursing home administrator, a board-certified nurse executive, a certified professional in health care quality, and a fellow of the American College of Health Care Executives. Welcome, Irene. Thanks for being with us.  Irene Borgen: Thank you, Debbie. Thank you so much for having me.  Debbie Stadtler: Well, let's start at the beginning. Tell us about your career journey. What led you to get started in long-term care?  Irene Borgen: I joined Sunrise just over three years ago after spending more than two decades in the broader health care industry. I started my career as a clinician and gradually moved into hospital administration and executive leadership with an increased focus on operations, quality and safety, care transformation, population health, and most recently, value-based care. Over the years, I've worked across hospital, home care, skilled nursing, ambulatory, and health insurance settings, and have been very fortunate to bring that experience with me to Sunrise. Today, I have the opportunity to help advance Sunrise's strategy around innovation and clinical partnerships, and to think about how we can apply value-based care principles within senior living while continuing to strengthen our person-centric holistic approach to wellness.  Debbie Stadtler: So Irene, tell me about your organization. When did value-based care first come onto your organization's radar, and what made you realize this was something that assisted living could not afford to ignore?  Irene Borgen: Let me start with a bit about us and how this fits in a much bigger ship. Sunrise is one of the largest senior living operators in the US with some communities in Canada. We have around 240 communities currently. We offer independent living, assisted living, some skilled nursing, and are serving around 20,000 residents. Wow. And we've always been an organization focused on hospitality and wellness. That's in our DNA, and it's the promise we make to residents and families. But I would frame the value-based care itself as bigger than one company's decision. It's an industry-wide inflection point. Since the introduction of the Accountable Care Act in 2010, also known as Obamacare, the US health system has been shifting from paying for volume, also called fee-for-service To paying for quality and improved health care outcomes. And that shift continues to reshape every care setting, including senior living. In other words, value-based care movement aims to help people stay healthier longer, prevent unnecessary hospitalizations, improve overall health care outcomes, and contain escalating health care costs. And senior living is really uniquely positioned in that shift. Our teams don't just provide services, they truly know our residents. They notice when someone isn't quite themself, whether it's a change in appetite, energy level, participation in activities, just overall well-being. We know it long before those changes would be visible in a traditional health care setting. Those everyday observations, combined with close partnerships between our care teams, families, our clinical providers, create really unique opportunities to intervene earlier and support better health care outcomes. In many ways, senior living has always played an important role in helping older adults stay healthier and avoid unnecessary hospitalizations, whether we have formally described it this way or not. And families and residents have already been pointing the industry in this direction through decisions they make when they choose a community. They're actually telling us how much access to health care and wellness matters. Increasingly, we see that they're looking for communities that can help their loved ones maintain their health, independence, quality of life, not just to provide a place to live. So value-based care wasn't something we had to be talked into. Our mission, the evidence, and our residents and families really all pointed in the same direction. It felt less like a trend and more like the natural next chapter in how senior living can support residents.  Debbie Stadtler: I think that's a great point, that this was something that generally you were already doing, and this just formalized it and really gave it a name and a direction, but you were already providing that better life for longer, better health for longer kind of thing. As you began exploring value-based care, what convinced you and your leadership team that this was something your organization needed to embrace? How did you know your organization was ready to take the first step?  Irene Borgen: Honestly, in addition to the feedback from residents and families, the peer-reviewed published evidence did a lot of the convincing. There's a really large and growing body of recent peer-reviewed research linking primary care to longevity. Most recently, in 2025, a study was published by Harvard Medical School and the Harvard School of Public Health that included nearly 11,000 of older adults aged 65 to 84, and they found that access to primary care was associated with roughly two additional years of life expectancy. That reframes primary care from a nice-to-have into a genuine longevity lever When the evidence shows access to primary care adds years of life, then the conversation stop being, should we? It becomes, how fast can we? The other thing that made us ready was recognizing that this wasn't a pivot for us. It was a natural extension of what we were already doing, an organization where we have our wellness-first mission, culture, and the infrastructures to support it. So bringing value-based care, focused primary care on top of that just felt natural. It fit really well with Sunrise's vision of creating the preferred lifestyle for enjoying longer, healthier, happier lives. And the last piece of readiness is a mindset shift that's available to any operator. You don't need to become a medical group to do any of this. What you need is the willingness to bring in the right clinical partners, collaborate with them closely, and collectively drive better health care outcomes, and ultimately, greater longevity for our residents.  Debbie Stadtler: I love that. You don't have to have a fancy system or change everything. It's really collaboration and working closely for the best outcomes. That's great.  Once you decided to move forward, where did you start? Walk us through the early days. What were the first priorities? What capabilities did you have to build? And also, what were some of the challenges you encountered along the way?  Irene Borgen: Great question. I think, like always, we started with data because you truly can't manage or prove progress on something you haven't measured. Before you change anything, you establish your baseline. Things like what we looked at was emergency room visits, hospitalizations, 30-day readmissions to the hospital, falls, polypharmacy, multiple medications on res- with residents, the distribution of primary care providers across our communities, and finally, resident and family satisfaction with primary care. That baseline became what we hold ourself accountable to, and later, it really becomes your proof. From there, it's the care model. At the concept level, it's consistent relationship-based clinical support embedded in the community, focused on prevention and proactive chronic disease management rather than reactive care. It's predictable, timely access and coverage, so concerns can be identified earlier, can be better coordinated, and resident can continue to thrive in place, at home. One part that I do want to make concrete because families feel it so directly, residents always have a choice of who their primary care provider is. And even if they choose to stay with their existing provider with whom they have a long-standing relationship, the embedded value-based care focused clinical partner could still cover them for an urgent clinical escalation. So a small change on a Sunday night when their primary care doctor is not available to respond doesn't automatically become a trip to the emergency room. Our residents and families loved it. Loved it. No one wants to go to the emergency room with mom or dad ever, especially not on a Sunday night, right? And clinical escalations are unpredictable. You never know when this will happen. So that was really something that we learned through the process. Now, I wouldn't pretend that this was all easy, okay? The biggest challenge was the change, right? Change is always hard for residents, families. Introducing a new primary care provider, it's really personal. People have relationships with their doctors going back years. So we had to lead with choice and let the experience and the results win them over. It is always their choice. Another important consideration was supporting our teams through this transition. Any new care model introduces new ways of working, new opportunities for collaboration. Our team members embrace the vision, but like any meaningful change, it required thoughtful training, clear communication, ongoing support to help everyone build confidence and consistency over time. And third, and I'm kinda like coming back to it, was data, right? Standing up measurements and reporting is a little bit harder than it sounds. You have to define your metrics, capture them consistently across every community, and make sure everyone is looking at the same numbers. And the fourth was really finding the right partner. Really critical point. Not every clinical partner is willing or able to actually meet a high bar, and we were asking a lot on purpose because that's what delivers the best experience and support to our residents. So finding partners who could deliver on all of it really took time and vetting. None of those were reasons not to do it. They were just work, and working through them is what turned this from a good idea into something real and meaningful.  Debbie Stadtler: I like how you mentioned sort of the different parties and groups that are involved. It's not only the residents, it's not only the staff, it's also changing maybe how you measure your data and metrics, the partner that's involved. There's really so many pieces, and so working through each piece and getting everybody going in the same direction, I could see how that would be the important part of it for sure. For providers who are skeptical, what's the real business and clinical case for assisted living to engage in value-based care? What tangible benefits have you seen for residents, families, staff, partners, and your organization?  Irene Borgen: Sure. I think the first thing I would say to a skeptic is that this isn't a trade-off. Clinical outcomes and business objectives move together. In this particular instance, they're not competing goals. Both come out of the same thing: providing holistic, wellness-focused care and a great experience for our residents and families. On the clinical side, I would speak directionally. Communities with value-based care, outcome-focused clinical support consistently trend towards fewer hospitalizations, fewer readmissions, and fewer emergency room visit- visits compared to their peers. And the model itself is really, if you think about it, concierge-level clinical support without the concierge cost, and we are converging health care and hospitality. That's our bottom line. We are an amazing hospitality company, and now we're bringing health care to their doorsteps. When you look at people, at various partners like you mentioned, so... Or even everybody who's involved. So if you look at residents stay healthier longer with a clinician who actually knows them and sees them often weekly on-site in their apartments, truly concierge medicine. Yes. Families, right? Families get peace of mind in one coordinated team instead of fragmented set of providers, and that builds trust, which is everything in our business. Health care system in general is very uncoordinated and fragmented. If you are able to get a partner, a provider who is coordinating care, because that's what they do best, it's incredible. It's so helpful. It's somebody who will help me schedule appointments for my mom when I also have a full-time job and other things I need to get done. And they will coordinate among all of the providers, so everybody knows what medications my mom takes and what other clinical conditions she has. I think it's incredible. Care teams, they gain efficiency and a predictable point of contact, so instead of chasing down multiple physicians during clinical escalation, there's one number to call, one number, 24/7. For referral partners, hospitals, health systems, skilled nursing gain a post-acute partner that help- helps them keep their own outcomes and readmission goals. Hospitals and SNFs, they are penalized on readmissions, so they know that by sending their resident, their patients to us, we will keep them out of the hospital with, in collaboration with our clinical partners The organization itself, us, we see the metrics leadership really trends, right? Tracks and trends. We see occupancy improving, we see retention, we see length of stay. So the skeptic's real question, does this actually move the business? To me, it has a very clear answer, and the answer is yes. It improves clinical outcomes and business performance at the same time, because in this model, they're one and the same goal. Debbie Stadtler: I love that. It's a win-win situation, clinical and business. If you were speaking directly to an assisted living executive who's still on the fence, and you've given a lot of evidence why they should move towards value-based care, what's your elevator pitch? What's your quick speech to convince them?  Irene Borgen: So my elevator speech would be something like, value-based outcomes focused primary care helps residents stay healthier longer, and everything else from, flows from this. Families have greater peace of mind, care teams have stronger clinical support and coordination, and the operators see the benefits reflected in outcomes they already measure, such as resident experience, retention, and length of stay. Just as importantly, it doesn't require senior living operators to become health care providers themselves. The opportunity is to build strong relationships with clinical partners that share accountability for outcomes and resident well-being. It is truly concierge medicine without the concierge cost, converging health care and hospitality. The larger point is also that health care is steadily moving towards rewarding improved health care outcomes rather than volume of health care services provided, and the question isn't whether this shift is coming. It's already here. It is really about how prepared are we to actively participate in it.  Debbie Stadtler: I love that. What capabilities do you think every assisted living provider will need over the next five years, regardless of whether or not they're participating in a formal value-based care arrangement? What do you see? Irene Borgen: Sure. I think if an operator... even if an operator never signs a single value-based care contract, the ground is shifting under all of us. CMS and payers keep moving toward awarding quality outcomes over volume. So a few things become table stakes. First, data and benchmarking. Every operator will need to be able to track its own outcomes, emergency room visits, hospitalizations, readmissions, falls, polypharmacy, satisfaction, and be able to compare them credibly internally today and against peers over time. That's the hope. Second, strong clinical partnerships across the care continuum because in the next chapter, the strength of your partnerships will matter more than any single operator's internal clinical capabilities. Third, a workforce equipped to notice. Team members trained to catch subtle clinical changes early and escalate them appropriately. And here's, I think, the bigger picture that I would love to leave people with. Senior living hasn't yet fully quantified or told the story of the cost it's already helping take out of the broader health care system by keeping residents healthier and out of the hospital. That's a collective opportunity, not a competitive one. If we can prove it consistently and credibly across the industry, it could open a much broader conversation about how senior living is recognized and valued within the health care system, so that over time, this value is reflected in how CMS care models are designed, so more seniors can access the kind of support that keeps them healthy and independent longer. Debbie Stadtler: I love that collective, and it really does impact the whole health care system. Avoiding that is so critical. For assisted living providers listening today who may be where you were a few years ago, what advice would you give them?  Irene Borgen: So a few things. I would say first start with data, not a finished model. You don't need the whole thing figured out to begin. You just need a baseline, and that baseline is both your roadmap and your future proof. Second, don't try to build clinical capabilities internally. Use your scale and the power of partnership to bring in the right partners. Coordinate with them closely and hold them accountable for real results. Third, expect a learning curve. The early friction isn't a sign you're doing it wrong. It's a sign you are early, and that's okay. Give it time and let your data and your residents' experience show you that what is working. Finally, lead with the mission. This is about helping residents stay healthier at home longer. When you frame it this way, your team, your families, your leadership all move in the same direction. The business case is real and it's strong, but the mission is what gets everyone around the shared purpose, the rest follows.  Debbie Stadtler: Beautiful. I love that. And then even if you do encounter a couple of challenges or speed bumps along the way, keep going and it's really worth it in the end. Thanks. Thanks again for joining us, Irene. This has been a great conversation.  Irene Borgen: Thank you so much for having me.  Debbie Stadtler: Visit the AHCA NCAL website for more value-based care resources.  And thanks to everyone for listening to this episode of Perspectives in Long-Term Care. Join us each month as we discuss issues that impact the long-term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler welcomes John Kane, senior vice president of reimbursement policy at AHCA/NCAL, to discuss how reimbursement policy directly impacts the resources providers have to deliver quality care and the challenge of keeping pace with an ever-changing policy landscape. Kane explores the development of the Patient-Driven Payment Model (PDPM), its shift from volume-based reimbursement to a model centered on patient characteristics, and the challenges states face when adapting PDPM for Medicaid populations. He also examines major Medicaid changes under H.R. 1, ongoing Medicare Advantage challenges related to access and payment, and the growing regulatory demands facing facilities. The conversation highlights why staying informed and engaged is increasingly important as reimbursement continues to evolve toward value-based care.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession. My guest today is John Kane. John is the senior vice president of reimbursement policy at AHCA and NCAL. Prior to this, he spent almost 15 years at the Centers for Medicare and Medicaid Services. Welcome, John. Thanks for being with us.  John Kane: Thank you very much, Debbie. It's a pleasure to be here.  Debbie Stadtler: We like to start at the beginning. So tell us how you got involved in long term care. How did your career lead you to where you are today?  John Kane: A combination of things probably. I think one part of the journey started back years ago when I was studying philosophy of all things... and had every intention of becoming a college professor: teaching, publishing, sipping wine. And but I found that as I was talking with my colleagues, and I would be asking questions that they didn't seem to really care much about. We would be talking about health policy, and I would ask questions like, "Well, how are we gonna pay for that?" Or "How are providers going to implement this?" And they didn't really seem to care, and I realized at that point I wanted to do something that was more applied and less theoretical. And at the same time, as a matter of coincidence, I was actually working at a facility in Blacksburg, Virginia, Five Stars Warm Hearth, shout out. Nothing glamorous but very important role. I worked in the kitchen. And I'll tell you that trying to make a soft liquid diet palatable takes a lot of skill. But my experience there also helped me to see the daily struggle of the people that were working in that industry and the amount of passion that they brought to it and really just dedicating their lives to valuing the lives of seniors. And I loved being a part of it, even a small part. And as I was there, I felt like there was more that I could do, and I wanted to get deeper into it. And so that eventually led me into the deeper areas of health policy and eventually led me to CMS. Debbie Stadtler: I love that story. A little hands-on kitchen experience really leads you to your greater purpose in health policy and helping those in long term care. I love that story.  John Kane: I like to think that I've done more not burning people's food than-  Debbie Stadtler: Always important. Your background includes years spent working at the Centers for Medicare and Medicaid Services, what we know as CMS. What's that like working on the government side of reimbursement, and how did that time kind of influence your views?  John Kane: My time at CMS was some of the most formative and memorable time of my life, especially my career. I can't speak highly enough about the people that I worked with at CMS and that continue to work within CMS. They are dedicated public servants, all of them, and it was also just an incredible feeling to be at the genesis of policy development. It was hard to not feel as though you were doing something that was impactful and you were making a difference every day. At the same time, I also felt a certain disconnection from the industry that I had grown to love. I would go to visit facilities, whether it was because my dad was in a facility or just to get back out in the field and go and visit with residents or visit into the various homes, and it felt different. I was no longer just a person walking through the halls. I was CMS now. And so conversations became more focused on policy than on people, and I missed it. And moreover, I think being at CMS, you develop a level of specialization that is nurtured by the, the siloed nature of the agency. While I was there, like you said, I was there for about 15 years, and while I was there, I primarily worked on Medicare Part A SNF payment, and every word of that is relevant because if it wasn't SNF, if it wasn't Part A, if it wasn't payment related, that belonged to someone else. Okay. And good policy just isn't made in a silo. It's made usually at the intersections of those different silos, where quality and payment and innovation come all together. And that's actually something that when I've spoken with my former colleagues at CMS, I've actually tried to emphasize is to begin meeting more at those intersections and to really be thinking about the downstream effects of policies within one silo on, on other areas. And so it's something again that I've really enjoyed of my time here, being able to think about that in retrospect.  Debbie Stadtler: That's an interesting point, though. From the government perspective, you really are at a very impactful position to influence the policy. At the same time, there are, layers of bureaucracy and silos because it is the government, and that kind of works against you a little bit. So it's like a push and pull situation. One of your major accomplishments at CMS was developing the patient-driven payment model, like you said, for the skilled nursing Medicare Part A, all the words are important, benefit. How hard was it to develop this whole new reimbursement model, and what did you learn along the way? John Kane: Yes, I think I'll start by saying, I am incredibly proud of the work that we did in developing PDPM at CMS, and I was honored to be trusted with leading that effort. The shift under PDPM, away from volume-driven metrics ... and focusing more on patient characteristics and the specific needs of patients that often drove cost. Couple that with the massive reduction in administrative burden, the realignment with quality, and really just getting the payment model out of the way, if you will, of providers being able to decide how best to care for their residents, rather than any sort of weird artifacts of the payment model. It was incredibly difficult, but it was also very, very rewarding. I think one of the most rewarding aspects of developing that payment model, though, was the interaction and engagement we had with groups like AHCA and other advocacy groups. It wasn't just us at CMS in a back room crafting policy. It was a dialogue. It was sometimes a tough dialogue with AHCA and other industry advocates, and so much that when I remember back when CMS actually proposed PDPM, most of the comments that I remember reading at that point from the most respected, outspoken members of the community were just basically saying, "Okay, yes, that's the model we discussed. Looks good."  And it was the best example of collaborative policy development that I'd ever experienced, and I think that the success of PDPM, particularly with how it worked during the COVID pandemic of all things, is a real testament to the value of that collaboration. It's not to say that everything's perfect with the model. There's definitely room for the model to grow and change but I think it's working well overall, and I think that it reflects the importance of focusing on patient characteristics versus focusing on the volume of services that those patients are provided.  Debbie Stadtler: That's a really good point, because you're crafting policy and this model that's going to affect the whole industry. And so by really harnessing that collaboration of industry groups and the government and providers, all of that together really formulated the successful model. So that's, kudos to you. I can only imagine that process, but a great result from it.  John Kane: Thank you.  Debbie Stadtler: Now PDPM is being adopted by many states for Medicaid. How's that going, and where are some of the challenges?  John Kane: Talk about operating from within a silo and ... the potential downstream effects of that type of approach. Again I feel a great amount of pride for how we constructed and implemented PDPM, but I have to admit a complete and utter blindness to the impact that this was going to have on states. And I think this really goes back to the structural siloing of CMS and its impact on policy development. To put a really fine point on it, I didn't really have a lot of conversations with the Medicaid side of CMS until PDPM was about to be implemented. The states, I mean, that was someone else's job. Because it wasn't, it was mine, and it was the responsibility of those of us who were developing this policy. And we were warned. AHCA, other groups did warn us about the potential impact of this change on reimbursement on state programs.  And in that, I think lies the truth about our sector that I think makes us unique among our partners in the post-acute community. Our providers don't serve a single population, and I think that's what you usually find throughout health care. There are really two distinct populations that are residing in our facilities. The short-term post-acute population, that was the primary focus of building PDPM, and then there's the long-stay population about whom PDPM was never contemplated. I think PDPM is effective for the post-acute care population, but it doesn't really accurately reflect the needs and relevant characteristics of the long-stay population. Really, what CMS did was that there were so many states that were basically given a square peg and then forced it to fit it in the round hole that is their Medicaid program, which would be a daunting task before you consider that CMS withdrew support for legacy models and put states on a relatively short clock to come up with a solution to this problem. That's why I really think it's important that states have the flexibility and really the support to design reimbursement models that reflect their unique populations that are served by their providers within that state and that reflect the population's unique care needs from within that state. Debbie Stadtler: You could not have said it better about changes on a short timeline, for sure. And speaking of many changes on a short timeline there are really big changes coming to Medicaid because of the One Big Beautiful Bill Act, or what some are calling the Working Families Tax Cut, H.R.1. What's happening and when, and then how does the long term care sector protect Medicaid funding through all of this change? John Kane: Absolutely. You could not overstate the massive impact that this new law is going to have on our providers for years to come. And I think it goes without saying that across this country and for far too long, Medicaid has, has short-changed long term care, and any additional cuts within this sector would be devastating. I think there's a lot of changes that are coming as a result of this new law, but I think that the areas that are probably the most impacted would be restrictions and new regulations for how states finance their Medicaid programs increased scrutiny, burden, risk associated with Medicaid application processing, and I think just a significantly increased workload for state Medicaid agencies at a time when resources are already tight, and our ability for our providers to be able to seek review and relief from those agencies when it comes to issues like change of ownership or other issues around reimbursement are already hampered. With that said, I do think that there are some causes for optimism. I think that, first and foremost, we were pleased to see that, that Congress saw fit to shield nursing homes and ICFs from the provider tax phase-down that was included in H.R.1. Additionally, I am always heartened to see just how deftly and passionately our affiliates are continuing to engage in conversations with their state policymakers to prioritize long term care residents and the Medicaid resources needed to invest in their caregivers and access to care, and it's something that we will continue to support them in. It's something that our Medicaid guru, Grant Beebe, often says, that we are always prepared to stand next to and behind our affiliates.  Debbie Stadtler: Absolutely. And I love that AHCA/NCAL provides that support on several issues, but these payment issues are high priority for sure. Speaking of priorities one of AHCA's policy priorities is reaffirming the promise of Medicare Advantage. What does that mean, and why has this become a problem?  John Kane: Yeah, without a doubt Medicare Advantage is appealing to a lot of seniors because it offers a variety of different perks.  Debbie Stadtler: Absolutely. My mother is enrolled in it.  John Kane: And there's gym memberships and-  Debbie Stadtler: Yes ...  John Kane: I think I heard once at one point tanning option. There's all kinds of different perks that, that MA plans can offer. Unfortunately beneficiaries, providers face persistent challenges from, especially the larger MA plans, and especially within skilled nursing and post-acute care, and this comes in the form of gaining timely admission to just get into the building, being able to stay in the building for a medically necessary stay, and then for providers to be able to receive appropriate and timely reimbursement once the care has been delivered without subjecting the providers to massive paperwork rules. Okay. I really feel like seniors have earned the right to make a decision as to how they receive timely access to care, and that in consultation with their doctors, their families, and in consideration of their goals for their overall care, they should be allowed to dictate the course of that care, not an insurer, not certainly some AI program. As you said we want to be able to reaffirm the promise, the advantage of Medicare Advantage, and make sure that it's fulfilling its promise to our seniors, and this is a very important priority for the work that we do in reimbursement. And we're actually very lucky to have people like Nisha Hammel that are on our team, who's done an amazing job working closely actually with our government relations team here at AHCA to develop and advance meaningful legislation on that front. There's really not a lot that the parties in Congress agree on but this is one of them, and I think it's something that we're optimistic that we're going to be able to see something passed by Congress, hopefully even by the end of this year.  Debbie Stadtler: Wonderful. Yeah, that's great news because Medicare Advantage is so popular and has such a large uptake that really making it work for those seniors is such a critical, important aspect to all of this. I know you're not on the regulatory team, but how can rationalizing the regulatory environment, which is another AHCA policy priority, how can that support reimbursement and quality?  John Kane: There was a phrase that we often used during my time at CMS, and that was patients over paperwork, which is a laudable goal, it's an important goal, but it's also one that I think is easy to get lost in the pursuit of things like accountability and transparency, which is also an important goal that we do support. We spend a lot of time and resources on reporting things to various state and federal agencies, and that's appropriate, but we need to find a sustainable balance between transparency and administrative burden.    I think this is what we mean when we talk about rationalizing the regulatory environment. It doesn't mean eliminating all regulations or any measure of accountability. It means having targeted regulatory and oversight mechanisms that are focused on our collective goal of ensuring the delivery of high-quality care to our residents. I think an example of this would be the off-cycle provider enrollment process. This was an unprecedented attempt to revalidate all 15,000 some-odd nursing homes at the exact same time with new disclosure requirements regarding ownership. And not only did it overwhelm providers under a mountain of administrative burden, it even overwhelmed CMS's own data reporting systems. Yet, we do remain committed to reasonable ownership disclosure, and providers are even now continuing to submit this paperwork to CMS even though CMS had indefinitely delayed the deadline due to all of these various issues. We need to find some way to streamline reporting to what's important and actually drives quality improvement rather than just becoming overwhelming to our providers. I think ultimately we should be dedicating our time, energy, resources to where it belongs, which is to our patients.  Debbie Stadtler: It's another one of those push and pull situations. You need some sort of, you know, framework of paperwork for that accountability and transparency that you're talking about, but it also can't be so burdensome that providers and even CMS itself can't handle that. So it's really a balance is needed there, instead of just trying to do all the things in all the areas. John Kane: Exactly.  Debbie Stadtler: Where do you see the SNF and assisted living sectors headed when it comes to reimbursement and financial viability? And what do providers need to do to stay competitive?  John Kane: We talked earlier about silos, and I think that this is where the silos come crashing down because reimbursement is not simply a matter of just dollars and cents. Ensuring accurate, adequate reimbursement is a workforce issue. It's an access issue. It's a quality of care issue. Nursing homes cannot provide the level of care that our nation's seniors deserve without the resources to be able to pay competitive wages, maintain appropriate staffing, meet the increasingly complex medical and personal needs of our residents Now, reimbursement in this sector has always relied on a delicate but fairly pivotal balance between higher Medicare payment helping to offset what has traditionally been Medicaid reimbursement that simply does not cover the cost of care. So let's talk about each of those briefly. I think on the Medicare side, you look at the data, you listen to CMS, you talk to providers, times have changed. Traditional Medicare and its ability to subsidize reduced reimbursement on the Medicaid side of the ledger is shrinking. It is undeniable that the reimbursement paradigm has shifted. And even just a few months ago at our population health management summit, we were actually told by CMS directly that their goal is to have as many beneficiaries as possible in some form of accountable value-based arrangement. This means ACOs, this means alternative payment models, this means MA. This means that to survive and to thrive in this new world, providers have to be thinking not only in terms of the time that a patient comes into the building and the care that he or she receives while they're in those four walls, but providers have to be thinking episodically, globally about that patient's care trajectory. So understanding the alphabet soup of CMS with ACOs, APMs, ISNPS, MSSP, LEAD, understanding how our facilities can participate in this new paradigm and how they can form successful partnerships with up and downstream providers is really the key to this new chapter in reimbursement. To that end, I cannot recommend highly enough that you come to our convention this year in October and our population health management summit next May. It really is the best chance to make sure that you understand all of these evolving payment models and how you can turn each of those into opportunities for an organization. And then to the Medicaid front, it means fighting to protect every Medicaid dollar. Medicaid is the primary payer for most nursing home residents, and yet in many states, Medicaid reimbursement does not fully cover the cost of providing care. And when that gap persists, nursing homes face difficult choices. They may struggle to recruit and retain nurses and caregivers, invest in staff training, maintain their buildings, purchase equipment, or even sometimes the ability to continue to serve in their communities. Policymakers need to ensure that Medicaid rates reflect the actual cost of delivering care and are updated regularly to account for inflation, workforce expenses, and changes in resident acuity. The funding under Medicaid needs to be predictable so that providers can plan, invest, and improve their buildings. Ultimately, strong Medicaid funding is an investment in residents. It's an investment in caregivers, in families, and in the communities. And if we expect nursing homes to deliver high-quality care, we need to provide them with the necessary resources to do so. Debbie Stadtler: Absolutely, 100%. And what I really appreciate about AHCA and NCAL in this situation is that not only are we advocating with policymakers and stakeholders and regulators to get the systems working in a way that will help long term care, we're also providing education, conferences, explaining what all these payment models mean, what the changes are, when they're coming, and things like that. So we really strive not only to make it better in the future, but also help you in the moment, for those providers to make sure they're figuring things out and doing things as well as they can.  John Kane: Absolutely. The worst possible choice that one could make in this environment is to not ask questions and to not be engaged. You have to stay engaged, ask questions. There's not a dumb question. Ask your questions, ask for information, ask twice. Just be as informed as possible. Yeah, that information is going to pay dividends going forward.  Debbie Stadtler: Absolutely. This has been a great conversation. Thanks again for joining us, John, and we learned all sorts of things about reimbursement policy and changes that we need to stay aware of. John Kane: Thank you very much, Debbie.  Debbie Stadtler: Visit the AHCA/NCAL website for more reimbursement resources, and click on the reimbursement tile. Thanks to everyone for listening to this episode of Perspectives in Long term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession, and be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler welcomes James Carlson, senior reimbursement advisor at AHCA/NCAL, and Nicolette Reilly, senior vice president of quality at the Oregon Health Care Association, for a conversation about the evolution of assisted living over the past four decades. They reflect on the origins of the assisted living model, how the definition of quality has expanded to focus on resident experience and continuous improvement, and the balance between regulation and innovation. The discussion also explores the role of NCAL in advancing the profession and looks ahead to the future of assisted living, including emerging technologies, workforce development, personalized care, and changing consumer expectations.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Since its inception in the 1980s, assisted living has used innovation to redesign aging. Hear more about the evolution of assisted living, how quality has matured, and why the next 25 years may be the best yet. Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession. My guests today are Jim Carlson and Nicolette Reilly. Jim is a senior reimbursement advisor at AHCA/NCAL, and he spent 30 years with the Oregon Health care Association, including 23 years as the CEO. Nicolette is the senior vice president of quality at the Oregon Health care Association. Welcome, Jim and Nicolette. Thanks for being with us.  Jim Carlson: Good afternoon.  Debbie Stadtler: Well, let's start at the beginning. Tell us about your career journey. What led you to get started in assisted living and long term care? Jim, do you want to kick us off there?  Jim Carlson: Sure. I'd say probably my first interest really in health policy and all the issues related to Medicaid and Medicare and the economics and aging demographics was, I worked for an economics professor of mine in college when he ran for Congress. And we spent hours upon hours driving around the Fourth Congressional District in Oregon, and he had a particular interest in health care and health care economics. And since he was running for Congress, he had a particular interest in federal level issues, dealing with Medicaid and Medicare and health care economics. And so it piqued my interest. He ended up losing that race, but I ended up, after graduation, going to work for another member of Congress, and being low man on the totem pole on the staff, Medicaid and Medicare came into my portfolio. And so I really, from just a very young age, got very interested in federal health care finance and reimbursement programs and the economics, and I always had a real keen interest about demographics and the impact that had on the economy and society. Debbie Stadtler: Nicolette, how did you get started?  Nicolette Reilly: My path was very different from Jim's. When I graduated with my undergraduate degree, I had a business minor, and right out of college, I started working as a finance and business office manager for a new assisted living in Fort Collins, Colorado. And as a very young, new into the profession, I never envisioned that my career would be in long term care. It just happened to be this door that opened up to me from a business perspective. So in 1995, I started out as a business office manager in an assisted living, and just over the years went from a business office manager to an assistant administrator to an administrator, and then to a regional ops person, and then a vice president of operations. Even did a stint as an owner/operator of an assisted living company a while back. And then about four or five years ago, really wanted to find a way to take my passion of working with seniors and take my passion around driving quality in long term care, and try and find different ways that I could engage and influence the quality that was happening in long term care and how to drive that. And so I had a great opportunity to come over to the Oregon Health Care Association, where now I've been able to see long term care from a completely different perspective, more from the legislative perspective and the regulatory perspective and what goes into that, and the wonderful opportunity to advocate on behalf of providers in both of those areas. Debbie Stadtler: That's interesting. So both of you come at assisted living from a different perspective than normal. Usually I hear about people have a family member that inspired them, or they start as a caregiver, a CNA, and things like that. But you guys really come from, like, the business economics perspectives, and yet you've developed a similar passion and desire to serve in this industry. So it's really interesting the variety of ways people start these careers. Knowing that assisted living started in Oregon, I want to focus on assisted living. You both are from Oregon. What was the profession like when you started, and how has it changed to where we are now? Jim, do you want to start us off? Jim Carlson: Sure. So I joined Oregon Health Care Association in 1994, and came over to run their government relations program, and for the previous seven years, I'd been working on acute care and representing the Oregon Medical Association and doing a variety of health policy issues there. But I closely followed what was going on in long term care, really starting in the, the mid-'80s when I was working for a member of Congress from Oregon. And Oregon was the first state in the country to get a home- and community-based care Medicaid waiver from the federal government, and that happened in 1980. And after the state got that waiver, really it kind of took them until the mid to late '80s till they really started making a lot of serious programmatic changes. But one of those policy initiatives, if you will, was to kind of nurture this new growing model of care that a couple of the early pioneers who were based in Oregon had developed, called assisted living. And so you had people like Wendell White, who'd come from a long family history and background growing up in his mother's nursing home, and developed one of the very first assisted living facilities anywhere in the country. And then he and Karen Brown Wilson, who was another early pioneer... There's a lot of disagreement, or you could get a little argument on who, who had the first assisted living facility. Most of that conversation focuses around Karen and Wendell and some other folks who were early pioneers. Oregon had a Medicaid director at the time, a fellow by the name of Dick Ladd, and he wanted to kind of nurture this little care setting. And so using that waiver that Oregon had received from the federal government, he worked with some of these early developers of what we now call assisted living to come up with a Medicaid payment stream to essentially reimburse them for services in this model. And that led to what was the country's first licensed assisted living setting anywhere in the country. And so really from all that early pioneering work that was done in the '80s, you really saw it take off in the '90s. And as I was coming and transitioning away from an acute care focus into long term care and joined the Oregon Health Care Association in '94, assisted living was becoming a big focus, and the association and our leadership recognized that at the time and really made a heavy investment into trying to support and help guide that development and that growth of assisted living. Debbie Stadtler: Oregon has been a pioneer, and the growth of assisted living has really been impressive, even now, still on a big growth trend as well. Nicolette, how was it when you started, and what changes have you noticed over time?  Nicolette Reilly: I think I come... I look at this from a very different perspective. Jim is the all-knowing legislative, how these things started from a legislative perspective. But for me, coming from the operational side, when assisted living was first emerging, it was this exciting, new model that hadn't existed before. And so the goal was to move away from that traditional institutional model of care to create this place where older adults could actually receive support, but still maintain their independence, and their choice, and their kind of control over their individual lives. I think in the early days of assisted living, it was a lot about just knowing the person. It was a relationship-based care. It was focused on that home-like environment where residents were surrounded by people who knew their stories, and their preferences, and what really mattered most to them. But I also, because it was so new, there was a really strong entrepreneurial spirit too. Communities were, like, figuring out what worked, and they were learning each other, and they were building that foundation for what this kind of dream of what assisted living could be for the consumer. And so you had this great kind of fun, competitiveness, entrepreneurial spirit around who could build the better building, who could provide the best care, who could fill their buildings, and those types of things. And I think there was this great spirit of this new concept, really focusing on what the resident wanted and what the resident needed, and trying to create it all in this fun, social, home-like environment.  Debbie Stadtler: I love that. The entrepreneurial spirit really is so true, and everybody's finding their way and seeing what works and doesn't work. So I love that depiction of the environment where everybody's trying something new. Well, Nicolette, you work a lot with quality in assisted living. How has the definition of quality evolved since the profession's inception?  Nicolette Reilly: It's what I was saying before, when... I think when assisted living... quality in assisted living very first started out, it was really, was measured by the environment. Was the community beautiful? Was it safe? Was it welcoming? Were the staff nice? Those types of things. And then those things obviously still matter, but our kind of understanding of what quality is in assisted living has... it's expanded significantly. It's more about the resident experience. It's about whether someone feels known or valued or respected. Again, ability to live the life that they want to live and that emotional kind of wellbeing and engagement with others. I also think that kind of over time we've seen this quality evolve from simply responding to problems when they actually occur, to really embracing this culture of continuous quality improvement, this high-performing example, like where organizations recognize that quality's not just about fixing an issue after something goes wrong, but it's more about intentionally examining our systems and our processes and our policies, and really identifying opportunities for improvement before the challenges arise. And so I think that's this vision of quality that has evolved as we've continued to grow in the health care system really.  Debbie Stadtler: Yeah, I like that you mentioned the proactive nature of quality now, like you said, more at the process level of making sure those are all functioning as well as they can in assisted living to deliver that quality experience. Jim, what have you seen about quality as things have evolved?  Jim Carlson: Couple points. So first off- One of the things I love about assisted living and senior living is that innovation and that spirit and culture that Nicolette's touched on. And the model was designed to be more that social model, to be more that resident-centered model, and to allow them to live as independently as they're able to, but get the services and supports they need. And I've seen this with my own grandmother, my own family members, friends, others, when people are reluctant to make that transition and move and leave their home and maybe move into an assisted living community. And I've seen when people do that, I've seen them just blossom in terms of the social interactions, the better nutrition, the wide range of activities, and the fascinating and just fascinating, interesting people you meet in, in senior living communities and assisted living communities. I could tell stories all day long about just amazing people and amazing stories that I've heard from different residents. I think a concern I've got is that as the model has grown and matured and spread throughout the United States and become such a big sector of post-acute long term care services and supports, from a regulatory standpoint, I see regulators trying to come in and regulate assisted living in the same manner they did, let's say, skilled nursing or hospitals and others. And really what I think has always been at the core of assisted living has been that resident satisfaction, that family member satisfaction component, and I really think that needs to stay at the center of this, and that you don't want to come in and get prescriptive models overlaid. You want to allow for innovation. You want to allow for culture and community. And sometimes people to try to maintain their independence, yeah, there's some risk, and there's some, there, there's some things where you're not going to be living in a hermetically sealed bubble to keep you safe 24/7, but you've got the ability... None of us when we're out living our daily lives, we all understand when you're out in a part of the world, there's always some risk. And I think people in assisted living communities are still active and want to live and thrive. And so get concerned when regulators are trying to come in and get overly prescriptive, and I think that really will stifle innovation and chip away at a lot of the strengths of what makes assisted living and senior living so special  Debbie Stadtler: I think that's a great point. Yeah, the innovation, the entrepreneurial spirit, that, that sense of thriving is really so important to assisted living.  Jim Carlson: Yeah, and I've just seen it time and time again with, like I said, people I know in my family and friends when individuals go out into assisted living. And I've got a friend of mine, a gentleman in his late 80s, and he moved into a senior living community that has assisted and Alzheimer's and independent. And I was talking with him and asking him how he enjoyed the move, and he was telling me one of our former governors lives in the community that he's in. He says, "It's fascinating. At breakfast this morning, I was discussing a recent Supreme Court decision with a former governor." And so it's incredible because you can live and thrive, you know, in these communities. And I don't want to see regulators really get so prescriptive where people just don't have the freedom to, to get out in the community and do things.  Debbie Stadtler: Yes. Yes. Speaking of celebrating assisted living and that spark that it has, the profession celebrates National Assisted Living Week each year. This year it's September 13th through 19th, and the theme is Shining Through the Years. What does that mean to you as an assisted living professional? Nicolette, you want to start us?  Nicolette Reilly: Yeah, sure. When I think about- Shining through the years, I think about really our seniors and the incredible stories, the resilience, the contributions that those seniors have made throughout their lifetime, and the impact that has on what they bring to our communities and driving that vibrancy in the communities. But I also think, too, we're getting to the point, as Jim and I have talked about this morning, about just the emergence of assisted living, and it's now been around- Yes ... to the point that now we have these great team members that have been in the profession for 30, 40, 50 years. So now we're starting to see this fun blend of our seniors and their incredible stories and their decades of experience and wisdom and accomplishments, but now it's starting to mesh with these great team members that have built amazing careers from a very young age in community-based care and assisted living. And just seeing those kind of stories all mesh together kind of just represents that dedication of the professionals that have cared for the generation of these older adults. And I just think that's really profound, that impact of both our team members and our residents, and the stories and the joy and the connection that they have brought to the profession. I just think that kind of just wraps it up with that shining through the years, is looking at all of the things our residents have done, but really looking at all the things our team members have done, too, as this concept of assisted living has continued to grow across the country over the years.  Debbie Stadtler: It's a great reminder. National Assisted Living Week is not only about the residents, but also about the staff and caregivers and even other parties like the families and the providers and all of that. So that's a great reminder that there's a great blend in this idea of shining through the years. Yeah. Jim, what does shining through the years mean to you? Jim Carlson: I really like what you just said about celebrating the caregivers and the professionals in the field. I can tell you through the years when you're out advocating on behalf of folks, and sometimes you'd get really frustrated dealing with elected officials or regulators or unfair media coverage and things like that. And whenever I would get a chance to engage directly with professionals and frontline caregivers, I would get such energy, and it would be a touchstone on really what the mission is, right? And the importance of that mission and how it touches all of us, everybody, in terms of our family and our friends and our communities, and how important that all is. And so I think celebrating that important role and that important mission, right? And what I love about the energy that I would get from that, right, is it, it makes me feel good too about all of us as we're on our own path and our own journey and what the future holds and all the, all the options and opportunities people have to live out their life and the way they want to. But I just think the celebration of, of the people in the profession and how far we've come on the professionalization of the setting and the phenomenal options that are available to people across this country. And so there's just so much to celebrate, and the mission is so important  Debbie Stadtler: Speaking of mission, the National Center for Assisted Living is dedicated to the profession of assisted living. NCAL is celebrating 25 years this year. So what does NCAL's work mean for the people who work and live in assisted living communities? Jim, tell us your thoughts.  Jim Carlson: I'm a big believer in people coming together around common goals and objectives and missions, and the power of that. And NCAL really is that guide star. And for the 23 years I was running a state association and representing hundreds and hundreds of different providers who are all out doing what they do in their organizations on a daily basis, we were out there, and I think to advocate on their behalf, advocate on behalf of the, the residents and the families. But also, I think we always tried to be thought leaders, and we tried to always help educate the elected officials, regulators, but also other operators and providers to be their best, right? And I think the role that NCAL plays, American Health Care Association plays, our state affiliates play, is really to be that convener, to bring together leaders from throughout the country, throughout the profession, and to advocate, to educate, and to lead really, and be that kind of guide star for folks. And I can tell you, when I ran one state, I would go and when I would talk to... I met Nicolette first when Nicolette was a board member for NCAL on her way to become the NCAL chair. And so at that point in time, she was working clear across the country, but we struck up a relationship that's continued to this day. And so the opportunity to meet and engage with people and to learn from them on what's happening throughout the country, and from other innovative operators and models throughout the profession, really NCAL helps make that possible and helps convene all that and curate all that, if you will. And I just can't imagine what it would be like if NCAL did not exist, right? Because there's just such a tremendous wealth of resources and value in all the work that's done  Debbie Stadtler: Absolutely. Nicolette, what does NCAL's work mean for you in your role?  Nicolette Reilly: When I think of NCAL, I've been involved with NCAL really since its inception and grew up in the career with NCAL as a really close partner for everything that I did. And when I think about celebrating 25 years, I really think about just NCAL and the power of, as Jim said, bringing assisted living professionals together, giving our profession a unified voice, and it's elevated the importance of assisted living on a national perspective too. Obviously advocating for our residents and our staff and our, and the organizations that are working really hard every day to provide these services for our seniors. But I also think that NCAL does an amazing job of kind of shaping those conversations with the appropriate parties around quality and workforce and leadership, not only from the organizations all coming together and collaborating together and learning together, but also advocating for us with the federal government and with federal agencies and with consumer groups and those types of things to help them understand the provider perspective that sometimes gets missed when we're doing these huge policies and advocating for seniors. There are all these great ideas, but actually implementing these ideas is always not the easiest of tasks. And so having NCAL there to really advocate for professionals across the country and creating this safe space to share those ideas, to learn from each other. But I also think that what NCAL does really is they remind us as providers on a continuous basis that it's not just about the building. It's not just about the regulations. It's not just about a service. It is truly this amazing profession where individuals are, are working in these communities every single day trying to make a meaningful difference in the lives of our older adults, and there's that passion there. And NCAL understands that passion and does an amazing job sharing that passion with all of those different groups there and helps them understand what we're all about  Debbie Stadtler: Passion, it's at the heart of what NCAL does, and definitely the professionals in assisted living. I love that reminder. Pull out your crystal balls. What are you most excited about for the next 25 years in assisted living? Nicolette, give us your thoughts.  Nicolette Reilly: I think if I had to think about what I was excited the most about with assisted living, I think I'm really excited about this continued evolution of assisted living and the opportunity to redefine what aging looks like. I think we're going to see a lot of innovation, new technology, stronger workforce development programs, and even more kind of personalized approaches to care. As Jim mentioned earlier on, I am just really hopeful that we continue to move toward models that are flexible and creative and centered around the individual resident, not just focusing on the needs that they have, but really the person that they are, and not over-regulating this sector so much to the point that we forget that this is a service industry providing services for real people and caring for real people.  I'm also excited about this kind of next generation of leaders that are entering the profession, where the workforce is really tight right now. We're seeing some amazing youth, this next generation of leaders entering the profession, and the future of the, of assisted living as a whole really depends on these individuals, depends on them to have that same passion and belief in the mission of what assisted living is. And we're also seeing this generation of people that are Asking the question of how can we do this better? How can we improve upon this? I feel very fortunate in my two older children, whom I never thought would follow in my path by any means, are both now working in the profession as an administrator and as a med tech. And it's really fun to get those mom calls where my kids are like, "Mom, this is what happened today, and how does this work with the regulations, and how would you handle this?" And it's just been fun to see this next group of leaders. I have been so fortunate to be involved in the OHCA and Quality Award program, and just doing fun pilot programs with them and bringing these young, new leaders into the program as not only applicants, but as examiners, and just seeing the fresh passion that they have for quality in our profession just makes me really optimistic and really hopeful. I think NCAL has done this great job of building this foundation, and I think the next chapter of assisted living just has great opportunities to be really impactful, not only for our seniors, but for our team members in the profession.  Debbie Stadtler: That's a great point. Sometimes folks can get a little skeptical of the coming generations and that they'll be able to step up when the time comes, but it sounds like the next generation is really developing that passion, like you mentioned, and that desire to kind of take assisted living to the next level. So I think that's such a great point Jim, what are you most excited about for the next 25 years of assisted living?  Jim Carlson: I just think it's an amazing time to be alive because I think we're witnessing how we're redesigning aging and what that looks like. And I love Nicolette talked about the evolution, but this kind of confluence of technology and innovative design, the talent that we're attracting into the profession because they see this as an area with tremendous opportunity. In the marketplace, we're attracting capital from capital partners, allowing owners and operators and developers to create amazing places to live and to enjoy life. And so I just think it's an opportunity to redesign what aging looks like, and it's a very exciting time. There's innovative operators all across the country. I get super excited when I go out and I meet with people from the Springs Living or Oakmont or Human Good in the not-for-profit sectors, and you start talking with these folks about what it is that they're doing and the innovation and what they're looking at on trying to essentially envision what the future is going to look like and the innovation that they're trying to bring. And I think it's a wonderful time for folks because they're going to have these choices and these options that I think it’s really going to allow people to live a fabulous life along their journey. And so it's all coming together now, and for a lot of years everybody was waiting for that kind of demographic wave to hit and everything. We're here right now. We're on the cusp of that for the next 30 years. And so I think it's just a tremendously exciting time, and it's fascinating to watch folks kind of painting their own masterpieces out there in the innovations. And I'm sure for Nicolette, when she gets out and she tours communities and she gets a chance to experience firsthand the programming, the services, how they're doing that, how they're harnessing technology, and then some of the design elements on just these beautiful communities and places to live. And it's hard to imagine going back into the '80s and going into the '90s and then looking at the options that are available for people today. So I think it's a wonderful thing for people, for families, and communities  Nicolette Reilly: I think our consumers changed too. Yeah. Our consumer... Now that assisted living has developed, as Jim's saying, you have these developers that are just getting very creative around the physical plant. Yeah. But I also think our consumers have changed. What our consumers want in a community are very different now. They're not just the beauty shop that can do their hair, but they want manicures and pedicures and massages and facials and all of these different things. And they want the coffee shop in the building where they can go down and sit in kind of this fun coffee shop environment, and they like the multiple dining rooms, restaurants, activities, and the community space in and of itself, the rooftop gardens and real fun. Yeah. It's amazing to me. Nice ... that this fun development.  Jim Carlson: Yeah. I'm going out and visiting communities, and it's... This is way cooler than where I live. You know? So I want to hang out with these guys and join their scotch tasting club or, you know, play cards with these guys on, on Wednesday nights. So there's a lot of really cool things happening all across the country, and it's really exciting just to be able to see it and experience it. Debbie Stadtler: It's a great summation really. Everyone wants to live a fabulous life, and assisted living has grown so much, and it's only going to grow more, and there's so many exciting things on the horizon that it's really an area we should all be optimistic and looking forward to. So thank you for joining us today, Jim and Nicolette. This has been a really great conversation, and I am excited about the future of assisted living. Visit ncal.org, that's N-C-A-L.org, to learn more about assisted living, and visit N-A-L-W.org for more about National Assisted Living Week, September 13th through the 19th of this year. Thanks to everyone for listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler sits down with Barry Carr, chairman and co-founder of Ignite Medical Resorts, and Randi Carr, Ignite’s chief of staff, to discuss the importance of advocacy and relationship-building in the long-term care profession. As they celebrate 40 years of marriage and prepare to receive the Joe Warner Patient Advocacy Award, Barry and Randi reflect on how their involvement with AHCA/NCAL inspired them to become more engaged with policymakers at the local, state, and federal levels. They share practical insights on building lasting relationships with elected officials, emphasizing the value of consistency, education, and offering solutions rather than simply highlighting challenges. The conversation explores how facility tours can help policymakers better understand the realities of long-term care and why providers must stay engaged on issues ranging from Medicaid reimbursement and staffing mandates to federal regulations. Barry and Randi also discuss current advocacy priorities, including Medicare Advantage obstacles and the ongoing challenges surrounding the three-midnight rule and observation stays. Throughout the episode, they highlight how proactive advocacy helps strengthen the profession, improve patient care, and ensure policymakers have a clearer understanding of the vital role long-term care providers play in their communities.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Politicians are people too. Learn more about building relationships with policymakers and advocating for our profession from Barry and Randi Carr in this episode of Perspectives in Long term Care.  Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession. My guests today are Barry and Randi Carr. Barry is chairman and co-founder of Ignite Medical Resorts. Before founding Ignite, he spent years growing new care services from roughly 1,000 to nearly 5,000 beds. Randi serves as Ignite's chief of staff and engages regularly with state and federal policymakers. Barry and Randi met at the University of Michigan and are celebrating their 40th wedding anniversary this year, which deserves a hearty congratulations. Welcome to the podcast, Barry and Randi.  Barry Carr: Thank you.  Randi Carr: Thank you. Glad to be here.  Debbie Stadtler: Well, tell us about your career journey. What led you to get started in long term care? How did you get to where you are today?   Barry Carr: I started about 41 years ago. My father-in-law was an investor in a group of facilities, and they needed an assistant administrator, so I came on board, said I would do that for a year or two, and they ended up selling the company a few years later. And then I got back together with his old partner, and we grew that company together. His family was getting involved. There was a nice growth. I left after 27 years and then broke off and started Ignite with my partner, Tim Fields, about eight years ago now.  Randi Carr: When Barry and Tim, in 2018, when they were starting up the company, Barry had one facility on his own. They were trying to acquire more properties, and Barry said to Tim, "The company doesn't really have any money yet, but we do need someone to help us out, and Randi's really organized, and we don't have to pay her." So that's how I got my job. In the beginning, he always had such a really busy work life, I was in charge of the kids and the house, and I was a stay-at-home mom, but I also was a substitute teacher for 20 years. So that overlapped a little bit with when I started with Ignite. But then when COVID shut the schools down, it just kind of got busier at that time, and it just evolved.  Barry Carr: Yeah. Timing was right.  Randi Carr: Yeah.  Debbie Stadtler: You're both receiving the Joe Warner Award. Again, congratulations. For those who don't know, the Joe Warner Patient Advocacy Award honors members who embody compassion, service, leadership, and an unwavering dedication to the elderly and people with disabilities. What does this award mean to you?  Barry Carr: It's a great honor. It surprised us both.  Randi Carr: It really surprised us. We weren't vying for it. Yeah. We didn't even really know much about it.  Barry Carr: But we don't do things for the award. Our focus is really on people and making sure that the patients are taken well care of, the families are happy, the staff is happy. So really for us, it was, it's just a Randi Carr: Bonus ...  Barry Carr: it's a bonus, yeah, on top.  Randi Carr: I mean, it's really, we're very honored. It's very nice to be recognized, but again, we just do it for helping people out.  Debbie Stadtler: The name of the award has advocacy in it, and we know that you guys are very deeply involved in advocacy work. How did that get started? What kind of got you interested in doing advocacy and speaking up to policymakers?  Barry Carr: I think, again, over the 40 years there's always been a lot of regulatory issues and a lot of issues that are coming up. We just started seeing just more and more over the last few years and decided that we would get involved with talking to people who we've met along the way, know along the way, and try to just get in front of people who could help make changes that could make things better for us. There, there's so much in the news about our industry and so many bad things, and there really are some really great things that we do and not a lot of people recognize it.  Debbie Stadtler: Yes.  Barry Carr: So we just got into it, I wouldn't say accidentally.  Randi Carr: But I think a lot of it was because of AHCA and NCAL, like really when you were on the independent owners council, when we only had a couple buildings, and we just learned a lot about it through AHCA.  Barry Carr: The people were great. At that point I had met Mark Parkinson and Phil Scalo and Phil Fogg and Chris Wright and of course-  Randi Carr: Clif,  Barry Carr: of course ... Clif Porter and LaShawn Bethea. So when we started talking to them, started realizing just how many resources they had and how many ideas that they had that really were pro-care. And we decided that was just something we liked. Randi Carr: Yeah, we really clicked with the organization, like right away. It just felt really comfortable for us.  Barry Carr: And Randi's gotten involved with me in that because she's so organized and-  Randi Carr: And going to Congressional Briefing, it's a lot to manage and especially when we became operators over several states. There were like quite a few meetings all in one day, and so we tried to organize and we realized that we could get to people. Barry Carr: There's a synergy there that the two of us created a much bigger circle than each individual could do. So it worked out really well for us.  Debbie Stadtler: I love that you mention the positive aspects of long term care and the work, because I agree, sometimes things get focused on the challenges and the problems, and the positive side of it, the great things that are happening get a little lost along the way. So I'm glad that you guys focused on that and really feel that's a good story to tell, because it really is.  Barry Carr: No, it's... We're a punchline to a joke sometimes, our industry. My mom used to joke with me all the time saying, "Ah, bet you one day you're gonna put me in a nursing home." And is that bad? Exactly. But again, her take on it was that it was the worst thing that could possibly happen to you.  Randi Carr: And also Ignite's model is a little bit more upscale, and that's another positive thing that Barry and Tim have really tried to make it a place where you wanna be and you can get amazing therapy and-  Barry Carr: Yeah, live in a boutique hotel. Randi Carr: But there are plenty of facilities that are people on Medicaid and they're serving... We definitely always advocate for those facilities as well. Medicaid doesn't necessarily always affect us or our guests or patients, residents, but  Barry Carr: But we do advocate strongly for it because it's so important for the industry. Debbie Stadtler: Absolutely. Very vital. You've been doing this kind of work for several years, and through a couple different administrations, through a few changes of policy makers at CMS. How has the advocacy work changed over time? What has changed about how you interact with policy makers?  Barry Carr: I think we've really decided to really get to know the policymakers rather than just showing up once in a while saying, "Hi, I have a problem. Can you help me?" We've spent a lot of time now getting to know the policymakers, especially the ones in our areas or in other areas that are important for the different states.  And in doing that, I think they start to realize that we are human. We're not just there to always ask for something. Sometimes we're there to offer help, and we've also learned that if you show up with solutions to problems, much better than just showing up with a problem. Randi Carr: Complaining.  Barry Carr: Complaining. So we've kept in touch when there are things we'd like to talk about. We've kept in touch when there's nothing to talk about, and I think when they start seeing that you are real and that what you want to do is real and it's important, that changes. So that, I think, has changed for us at least over time. Yeah. The different administrations, it's sometimes you're dealing with Democrats and explaining to them why your piece of legislation's so important, and the next day you're talking to the Republicans and explaining to them why it's so important. So it changes from topic to topic, from administration to administration, but I think the one thing that's been constant and that we've learned is a good relationship goes a long way. Debbie Stadtler: Yes. Absolutely.  Randi Carr: And I feel like, I, I know Barry said less synergy, but sometimes I feel like do we get a little bit more noticed because it's the two of us together instead of just a guy showing up in a suit and another guy showing up in a suit. It's just, I don't know.  Barry Carr: Yeah. I dress Randi up like a clown. Yeah.  Randi Carr: But I, I feel like the guidance from AHCA helps us along with the different administrations, and it's just invaluable-  Barry Carr: AHCA's been huge ...  And the state execs have been amazing, and the states that we operate in, states we don't operate in, I've talked to a lot of them, and they're very good about just giving you feedback, telling you what's important, and I think that's just such a big piece of it. Randi Carr: And they can advocate all they want, but they appreciate when we go in as operators, it makes more of an impact on policymakers than just a lobbyist or a state exec showing up. And Barry's on a couple of the state boards where we operate, so he has contact with them also.  Debbie Stadtler: That leads me right into my next question. How is it different interacting with folks at the local level versus the state level versus maybe the federal level? Obviously, there are different issues, but are the relationships different or how you do your interactions different? Tell us more about that.  Barry Carr: Yes and no. You're still dealing with people and still they have a lot of different things on their plate. Local, it's more direct community relations. We try to be good stewards in the community. We try to make sure that we're doing what's proper for the people who live there in our buildings, plus dealing with what's important to the local government there.  Randi Carr: Like staffing and things like that  Barry Carr: And everything else. Randi Carr: So it's definitely more casual. Barry and Tim and a few people went to meet when we were opening of one of our buildings in Illinois, and they went to meet with the mayor of the town, who's very involved in his town. He's an amazing mayor. So they got in their suits and went and met with him, and the guy was amazing, but he was wearing sweatpants, and so it wasn't really what they expected. But he's an unbelievable mayor. He's just more casual.  Barry Carr: And the state, we focus a lot on Medicaid and regulations and things that come up with things that affect the state more directly. And when we go federal, it's, it's a lot of just national mandates, like the big staffing mandate. Like a state may have their own staffing mandate, so that's... We talk about that. But then when we're going to talk to the federal regulators, you're talking about staffing mandates and legislation that affects all of health care and everybody else. So it changes. The conversations change, but the message is very often the same. It's just how do we make sure that the seniors are being taken care of? How do we make sure the staff's being taken care of? How do we make sure that the facilities can function?  Debbie Stadtler: I wanna know where the rubber meets the road. You've talked about attending Congressional Briefing, which is a great way to get involved in advocacy. AHCA and NCAL are always talking about getting some policy makers and politicians out to visit your facility. That's a really strong way of connecting. But how do you engage with policy makers? What methods are successful, and what do you find works for you?  Barry Carr: I think consistency. These policymakers, they'll be talking to you one minute about health care and health care regulations, and two minutes later they're talking about energy and-  Randi Carr: With somebody else Barry Carr: somebody else, and 15 minutes later they're talking about agriculture. They can't be an expert in everything, but they try to be knowledgeable in everything, and they have good staff members who are knowledgeable. I think the more that you contact them, the more that you meet with them, the more likely they are to actually set up a meeting with you rather than one of their staffers. And once they get to know you, it makes a big difference, especially if they're getting to know you to the point where you're not asking for something every time.  Randi Carr: Yeah. You're just checking in, how's it going? And it just-  Barry Carr: And what can we do for you? And that doesn't always translate into you say, "What can I do for you?" People think, oh, they're asking for donations. Not, that's not necessarily it, but there are things like sitting at meetings in their districts and/or just meeting with them and helping them get their message across on something that's important to them. So you do it.  Randi Carr: Or there may be something that they don't know about, like that, that insurance issue that you discussed with one of them. Barry Carr: yeah ...  Randi Carr: that Barry just brought to the representative's attention because he didn't know that this. Barry Carr: All the managed Medicaid issues that have been affecting us, didn't, never realized that was a problem 'cause they never had a personal problem with it, and no one they knew had a personal problem with it. Randi Carr: But it was a big problem, so it was good that you were able to bring that to  Barry Carr: their attention. Yeah. So we educate them as well, as long as they'll meet you.  Randi Carr: I feel like when you talk to them, and a lot of them, especially if they're experiencing something with their own family, they just get it so much more. It just clicks for them. It's a huge difference if someone's experienced having to put their parent in for rehab or in a long term care facility or assisted living.  Barry Carr: Or went to a hospital and had a service denied because the managed care managed, the MA plan didn't think that they needed the certain service, so-  Randi Carr: Yeah Barry Carr: there are a lot of things, and there's usually an aha moment that helps with-  Randi Carr: I felt like we've experienced a lot of that recently where, and maybe just because we've gotten to know these people better, but they really, it, it does really click for them a lot more when they-  Barry Carr: Yeah.  Randi Carr: It's easier to have personal experience with it. Barry Carr: And getting them out to your facility so they can see that you're not these, you know, the butt of the joke like I said before,  Randi Carr: It's very eye-opening for them. Part of my job is that I try to get facility tours in all of our buildings, and we've had a lot of tours. Yeah. And I would say it's been very successful. Barry Carr: Yeah. They meet the patients and, or the residents if they will, and they see that, you know what, they're people, they're being well cared for, they're happy, they appreciate everything that's being done for them. They see the staff that's there working and happy and, and smart. They're not just what they imagined based on these stereotypes, and it's an eye-opening experience for them  Debbie Stadtler: Yeah, there really is no substitution for that firsthand experience, whether it's a facility tour, like you said, and actually meeting the people and seeing what goes on, or something that happened in their own family that they've gone through and now they have a familiarity with the process and the situation. So yeah, making those relationships and getting folks to come out is super important.  Randi Carr: I would've never believed it had the impact that it does. I couldn't believe how shocked the like our tour our people were when they came.  Barry Carr: Shocked in a good way.   Randi Carr: Let me throw that in. They were like, "Wow." And that we've had federal and state and local people out to our building. Sure. And it's nice for our staff to get to meet them, take a picture with maybe someone they've seen on TV. Yeah, for sure. It's  Barry Carr: great.  Debbie Stadtler: Yeah, that's a good point, too. Yeah. Staff as well, not just about the residents, but also staff make those connections and, and relationships as well. Barry Carr: Yes, I could say who it is. It was Representative Mrvan from Indiana came to one of our buildings, a US representative, and he started talking to a staff member. He was very wonderful about talking to everybody. Started talking to a staff member and he goes, "Oh," he goes, "How long have you been working here?" And he goes, "Oh, this is my first day." And he's, "Oh, that's great." He goes, "How long have you been a nurse?" He goes, "It's my first day."  Debbie Stadtler: Ever.  Barry Carr: So he grabbed him, he goes, "We're taking a picture." So he took a picture of them, and ... he says... And Representative Mrvan looked at him and said, "You're never gonna forget this day." Debbie Stadtler: That is true. That really makes it memorable.  Barry Carr: Yeah. So stuff like that, it's just fun for them and-  Randi Carr: Yeah, and we had Representative Sharice Davids was in one of our buildings in Kansas, and a couple of the people were coming up to her the staffers were saying, "Oh, I campaigned for you. I voted for you. I'm so happy to meet you," and it was really nice. Barry Carr: So it's a big boost for the staff... there's just, again, so many positives with that. The staff are so happy to meet them. The patients and residents are so happy to meet them, and they're happy to see what we do, so it really works well.  Debbie Stadtler: Tell us about a success that you've had, whether local or state level, but tell us something where you guys really put a lot of effort into it and gained that result that you were hoping for. Barry Carr: I would say a lot of it isn't necessarily just us as an industry- Yeah, very true ... that we've had pushing for, but not anything in particular to us. But the staffing mandate that was being pushed on us, for lack of a better word.  Randi Carr: We spent a lot of time  Barry Carr: with that. We spent a lot of time. And not that, that having a lot of staff is not important, but it was no way to do that without funding. There was no way to do that without the number of staff available that are licensed to do it, and it would've definitely affected our rural facilities more than city facilities. But there would've been closings and that would've been, that would just would've been terrible. That would've just decreased access to care. Randi Carr: But I think getting them into, people into the buildings to see, they really didn't realize. It sounds amazing. Yeah, get as many staff as you can.  Barry Carr: Yeah, but they did see patients being well cared for in buildings that had staffing levels that are normal and accepted.  Randi Carr: Another success I think was amazing for our sector was the, in the one big beautiful bill, the Medicaid carve-out for our, for nursing home skilled care. However they worded it, but like I said before, we don't have a lot of Medicaid patients or hardly any, but we know that's really important, so we still really push for that kind of stuff because it's important to the whole industry.  Barry Carr: Yeah. That's-  Randi Carr: Now we're working on the hopefully it will be successful tightening some of the guidelines on Medicare Advantage and the observation bill. Yeah. The three midnights.  Barry Carr: There's a bill regarding the three midnights and observation stays in hospitals, so that's, that's been a problem for people who think they're qualifying for Medicare, go to the facilities, and they find out that even though they were in the hospital for three or four nights, that they were under observation, and Medicare won't pay for them, so they're stuck with a bill. Randi Carr: Yeah.  Barry Carr: Which is terrible for the patients. So we're working on it. With AHCA, of course.  Debbie Stadtler: You make a really great point, especially with these issues that are larger and affect the whole industry, is that it's really not one person, one group. It's all of the folks in AHCA and NCAL pulling together and having really this unified voice on an issue. So you talk about working with AHCA and, and being united with other folks, but really that's so necessary for some of these larger topics.  Barry Carr: Oh, that's great. And the states have been fantastic. The state execs and the state associations have been just amazing at getting so much done. And through them and through AHCA, it's been... We fight the fight, and we are usually very successful. It always seems like there's another speed bump thrown in front of us. Yeah. But you do what you can.  Debbie Stadtler: We've talked a lot about relationships, and we know that relationships are vital in long term care, particularly as we've talked about in this advocacy work. And you two have demonstrated great skill in relationships, not only professionally, but personally, celebrating 40 years of marriage. What is your best piece of advice on sustaining strong relationships, whether professional or personal?  Barry Carr: Find a divorce attorney. Just joking, honey. Keeping in touch, I would say is probably one of the biggest things. Again, people don't like to only hear from somebody when they have problems. People like to hear from people when things are good and when things are bad. You earn more respect when you are in touch, helping, and offering some advice for them and asking for advice. Don't complain, I think is a big thing. If you sit there and complain, that's just... No one wants to hear that.  Randi Carr: Right.  Barry Carr: I think if you go in and you say, "Here's my issue, but I have a solution. Can you help me with it?" And it's a reasonable solution, I think it helps a lot.  Randi Carr: Yeah. I think just being friendly with them, like we just... I don't know. Yeah.  Barry Carr: Being friendly helps.  Randi Carr: I guess we have good banter, but it's just... It just, it does. They're just, they're people and they just maybe wanna breathe for a minute.  Barry Carr: Some people hate the industry, but like us. Not us necessarily, but us as human beings, and that helps, and I think if they could see where you're coming from, even if they dislike the industry or dislike something that happened to them personally, maybe 10 years ago in  Randi Carr: the industry. We've had a few of those.  Barry Carr: Yeah, that happens. I think it, it helps. But getting them out is so important. I think when they really see what's going on there and staying in touch with them, I think it's the biggest things that I would suggest.  Randi Carr: Getting them out to the building? Yeah.  Barry Carr: Out to the building. Randi Carr: Yeah.  Barry Carr: There's 200 or 150 or whatever, 300 people who are potential voters sitting there. So it is a nice thing for them to get out and meet people and be seen and shake some hands, and it makes a big difference.  Randi Carr: And we always ask, "Do you mind if we take pictures?" And they love it. On their social media. Oh, yeah.  Debbie Stadtler: It's a win-win situation for everybody.  Barry Carr: It works for everyone.  Debbie Stadtler: Yeah. Thank you so much for being with us today and sharing your knowledge and your experience on building relationships. We really appreciate it.  Randi Carr: Thank you for having us. Thank you.  Debbie Stadtler: And visit ahcancal.org to learn more and get involved with advocacy efforts. Thanks to everyone for listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession, and be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler is joined by Rachel Bunch, executive director of the Arkansas Healthcare Association, for a conversation about innovative approaches to addressing workforce shortages in long term care. Bunch shares her professional journey and discusses how the association responded to member needs by launching the Arkansas Healthcare Association School of Nursing. What began as a medication assistant program designed to help CNAs expand their responsibilities and allow nurses to practice at the top of their license evolved into a tuition-free, employer-focused CNA-to-LPN pathway. The discussion explores how the program incorporates accelerated coursework, coordinated work schedules, and wraparound student support to improve retention and completion rates. Bunch also highlights the school’s strong outcomes, including a nearly 92% graduation rate, ongoing expansion efforts across the state, a focus on geriatric care training and faculty development, and future plans to explore an LPN-to-RN pathway. She also reflects on the importance of listening to members and being willing to pursue nontraditional solutions to workforce challenges.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: We know that finding workers in long term care is a challenge. Learn more from the Arkansas Health care Association, who have seen great success in starting a nursing school to address that need. Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health care Association (AHCA) and the National Center for Assisted Living (NCAL). I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long-term and post-acute care profession. Today, my guest is Rachel Bunch, executive director of the Arkansas Health Care Association. Rachel also serves on the Governor's Council on Aging and the Alzheimer's Disease and Dementia Council. She is the president of the Arkansas Health Care Association’s School of Nursing, which we are going to talk more about shortly. Welcome, Rachel.  Rachel Bunch: Thank you very much.  Debbie Stadtler: Let's start at the beginning. Tell us about your career journey. What led you to get started in long term care?   Rachel Bunch: I guess you could say it's one of those... What's the quote about the best laid plans are not plans? So I actually started working at the Arkansas Health Care Association when I was in college back in 2008. Started working there and really enjoyed it. I, at the time, didn't know really what an association was or the role that they played, and really enjoyed my work there so much with them, and then did a lot of different duties with them. Started in my position at the end of 2013, and so I'm going on my 18th year now with the Health Care Association in Arkansas, which is really wild and hard to believe that it's been that long. Time flies when you're having fun, right? Definitely. A little bit of a non-traditional route.  Debbie Stadtler: We know that workforce challenges are top of mind for long term care providers, and the Arkansas Health Care Association decided to help address this challenge with a nursing school. Tell us more about it. Rachel Bunch: Sure. Thank you. So it's been a really exciting journey and something that has really, we've laid the groundwork over the last several years. We didn't necessarily seek out to do this. We've done education at the association for many years, just like a lot of the other state affiliates offer, and this really started with our medication assistant program in 2023. That was a, a level in our workforce, a licensure level that a lot of other states had, and we didn't, and worked to add that through legislation and with various state boards in Arkansas. And once we started offering that program, it really took off, I think because we were a little bit behind the curve on having those professionals in the state, but also the workforce shortage was so great. And the key difference that it made for us, it allowed us... The structure of our program, it allowed us to take existing CNAs and put them through this medication assistant program for higher wages, more responsibility, and they went through the program, and they were so motivated to go to school. The facilities really embraced it, and it went well because it gave our nurses on the floor got time back in their day to do other nursing tasks other than pass meds, and it really allowed those nurses to work at the height of their license, which made such a difference. And so that was the beginning, and we had a lot of motivated students, a lot of motivated providers that really had done some tuition reimbursement before but hadn't had a real structured process to be able to offer those things, and it took off from there. And here we are today, just finished our first graduation and looking forward to beginning our second cohort this summer.  Debbie Stadtler: It's really been awesome. The nursing school is quite unique because it's the first nursing school run by a state provider association, and you're training CNAs to become LPNs in long term care facilities, and students have a guaranteed position when they graduate. That's huge. So what other things make the nursing school special and just right for Arkansas?  Rachel Bunch: I think one of the biggest things is that we, through our work with a lot of our facilities and a lot of work with our students, we've really made this facility and employer-focused, and in turn, there's a lot of student focus that went into it as well. So we identified a lot of the reasons. Again, we did not start out seeking to do this, but it really made sense, and it seemed like a great service that we could provide to our members. So we identified a lot of the barriers with traditional programs. We don't believe that this competes with traditional programs. We think that we're serving a different population of people that would otherwise never go on to a traditional higher ed program. But we identified the barriers. What has held these people back? What has kept someone who's been a CNA for their career, and they've loved it and found meaning and purpose in that role, but they're willing and able to do more. They've just not had the opportunity. We identified a lot of those barriers and tried to eliminate those as much as we could with the program. I would say the biggest ones are that the program is tuition-free for students, which is a really big bonus, and what a gift for them and their families. The other thing is that the tuition-free is due to a combination of grant money, matching money from the facilities, and then some help from our association as well. It's a true group community effort to make them successful. The other thing that we do is partner with our member facilities to coordinate work schedules of our students. In the traditional school, you might be in class Monday to Friday, eight to five, but then you can't work nights and then go to school. It just makes it impossible to do. So our program, we have the students in school Tuesdays, Wednesdays, Thursdays, and then they work in the facility Monday, Friday, and then either Saturday or Sunday. And the employers help them with some wraparound supports and gap pay, and we coordinate those things together to make it possible for them. And it is fast-tracked, but we help them with things that we're helping the students with licensure fees. The facilities are helping reimburse us for the licensure fees. That's a common barrier. We looked at a lot of research, and we interviewed even a lot of our staff members that had attempted a traditional nursing program in the past, but they weren't successful for one way or another. And it was really interesting to hear their stories and understand why that didn't work. But here we have a great employee that is dedicated, committed to our facility locally. They want to do more and grow in their role, but there have been different barriers that have prevented that. And so we just, we really try to work hard to eliminate those. Debbie Stadtler: I love what you said about this is a different audience, and you guys tried to eliminate a lot of these barriers, because some of the things that you're talking about we've heard over and over about go to school and work at the same time and things of that sort. It's working out. The nursing school has had great success so far. Like, you mentioned the first class, it boasted a graduation rate of nearly 92%. That's amazing. And enrollment for next classes is growing fast. What do you think contributes to that success?  Rachel Bunch: It's one of those things that it's been a really hard journey, it's been a lot of work, but it's one of those things that is so worthwhile and paying off for our members. We're so excited about it. I think it's one of those things that we're going to look back and think, "Why in the world did we not do this 10 years ago?" It's one of those things, it's so obvious, but it was also so different at the time and hadn't been done, and we took a chance on it. I remember saying many times throughout the process, "This hasn't been done before, and I hope I don't figure out why." It was really just a very different approach, and just it took some time. But yes, 92% graduation rate for the first class. We had 66 students that graduated a couple of weeks ago. The ceremonies were so special involving both their families and friends, their children, but also their facility family, their, the facility staff, their administrators, their DONs, the facilities there to cheer them on. So just having all of that together was really special. So far, out of the 66 graduates, 51 of those have now passed their NCLEX exam. And so- Wow ... we have two students that are taking the NCLEX right now this morning, and some more later this week, and we've got more scheduled in the next couple of weeks, and so we're so excited to see the success. And I love hearing the stories about our students that are already working shifts on the floor as an LPN. They're going through orientation and starting to work as an LPN in their new role, and we're so excited about that. And then the next class will begin officially in July of this year, and our three locations that we've had for the first year, where we're going to have students at all of those again, but we are doubling the enrollment at our Little Rock class, and then we are adding an additional location in the River Valley area of Arkansas. And so we have admitted, we have 113 students that will begin their journey with us in July.  Debbie Stadtler: That is quite a story of growth. And I love how you mention the successes and the celebrations, because that's really just so personal for folks and gives you that satisfaction of seeing this journey of Arkansas Health Care Association pay off. Rachel Bunch: Absolutely. These students are not numbers to us. They are people with names and stories and families and facilities, and we've been involved and try to do our best to support them through the process, and we were so excited to celebrate with them.  Debbie Stadtler: That's awesome. You mentioned a new location and an expanded class for the coming year. What are some other plans that you have in the works for the school? I foresee great growth for the school. Tell us more.  Rachel Bunch: Yes. So I would say two things on that. We are working with our state agency. I think most people are familiar right now with the Rural Health Transformation programs. So we are very hopeful and optimistic that we might be able to benefit from that program in Arkansas. Our application there focuses on growth and sustainability of the program. That would be a grant. But the other thing that I'll add that we are doing, that I think is meaningful to our facilities and model for others, we are focusing highly on geriatrics for our faculty and for the training. We cover all the traditional things, of course. We have to cover infant and pediatrics, mental health, a lot of other things that we don't typically see. Some, a lot of the things that aren't necessarily long term care, because our curriculum has to align with the NCLEX test plan. However, I do think we have a really great opportunity here to really focus on geriatric training. You hear a lot about specialty nursing schools and medical schools that focus on maternal newborn or just different things, and we think that's great for those populations. But I think it's such a disservice that we are the largest collective national employer and state employer of LPNs, and yet we are sending people to work in long term care facilities that have a unique set of regulations, patient population, and expectations, and I don't feel that traditional programs equip them to be fully trained in geriatrics. And so part of our application to the Rural Health Transformation program is to purchase a lot of equipment, so geriatric simulation and equipment. And then I've just heard from things from our members, we've polled our members a lot, we just really want to make this member-centric and focused, polled them on things that, what do you feel that new grad nurses that you see all the time, what do you feel that they're lacking in long term care? And sometimes I heard that might be higher competency on IVs and things that they can do on assessments to try to help keep patients out of the hospital. And so we're working on equipment and materials to be able to better equip them as well. I've also had a number of conversations with my friend Dave Kylo at AHCA, working with him on the GeroNursePrep program. So the GeroNursePrep program is something we've known about in Arkansas, we've promoted it to our members, but we thought recently what a great opportunity to take that information and material, and it's our goal that before the next cohort begins, that all of our faculty members at each of the locations will complete the GeroNursePrep program to help better equip them to teach our students on the areas that they need to know more about working in long term care. Debbie Stadtler: I think it's really interesting that you're still keeping it very employer-focused by asking, "What is it that you need more of," kind of thing. Really specializing in geriatric and the GeroNursePrep program, we have research that shows how beneficial that is, so it's great to hear that's the direction that you're headed. This connection that you have with members and with employers, what have you heard is really the largest pain point in the workforce challenges? Is it recruiting? Is it hiring, retention, maybe something else? What are some other things that you're hearing from folks?  Rachel Bunch: Unfortunately, I think it's all of it. I think it's probably a little bit of all of those things. I think it's a lot of those things, that retention is a problem, that staff members that jump around in different health care sectors or even different long term care facilities. You hear about recruitment, that is such an issue. I think the shortage in Arkansas is great. The traditional programs in Arkansas over the last decade have produced 40% less LPNs this last year than they did a decade ago. And so I think those programs, we've got a lot of really great ones in Arkansas, really great programs that serve our members and serve them well. But the numbers show that the overall number has declined by 40%, and I think the shortage is the biggest pain point there, and we hope to be able to help address that  Debbie Stadtler: That is really a surprising statistic. I can see why the School of Nursing has had such success in that situation when there's fewer graduates coming out that are needed. What other ways is the Arkansas Health care Association helping providers to recruit, hire, and retain? What other programs and things do you have to offer?  Rachel Bunch: That's always a work in progress for us, and definitely a more recent focus for us in Arkansas. But I'll say that we are piloting a new partnership in Northwest Arkansas with a high school. One of our nurse instructors that does CNA work is currently, we have a daytime and an evening program at a high school where we're doing CNA program, and there've been a lot of CNA high school programs for years. That's not necessarily new in itself, but we are doing it as the association. That's new for us, and then what we are doing with that program is connecting those students with local long term care facilities that might be closer to their home address for them to get part-time jobs. And then this summer we are hosting a high school-based medication assistant program for any of those CNAs who are working at the time in long term care facilities. And so we're excited to see the outcomes there. It's been a little bit of a different challenge with high school students than you do with 34-year-olds like our other program, but still meaningful and exciting. So we're excited to see where that goes and where we might be able to apply that to other places in the state. The other thing that we are working on in addition to our traditional kind of education and work that we do at the association is helping to develop some co-branded collateral and material. It would be my goal that for any of our member facilities in the state, my vision would be that they use the association, they use us as a vehicle to help them with some of their workforce needs. We want to be responsive to our members, and we want to be able to help them with these things, and I would, I'd love for, to have a more seamless process when they have applicants come in, someone who's never been a CNA before, who's maybe never been to a traditional higher education program before, where they come in and ask for a job and our facility could easily lay out for them, "Here's a career," not a job, but, "A career opportunity that we have for you," and to be able to show them, if you show up and work hard, this is where we could take you over a matter of just a few years, and it could be tuition-free. And so I think helping our members to connect those dots for applicants will be really important and will be really important in the coming days. And I should've mentioned this earlier, and I didn't when you were asking about growth, but the other thing that we are exploring is an LPN to RN pathway. That seems like the next logical step. I don't know exactly what that will look like yet, but if we could take someone who comes in without experience and show them, "Here's a pathway for you to do CNA to medication assistant to LPN to RN. You can work the entire time, and we'll have this program that supports you and wraps around you, and you're guaranteed employment at this facility in your hometown, in your community here all throughout the program," I think that's going to be a game changer for our members. Debbie Stadtler: How could anyone say no?  Rachel Bunch: Yeah.  Debbie Stadtler: It's such a great career ladder, and the fact that you have those supports and wraparound at each stage of the game from someone who has never even done this type of work to becoming a CNA to a medication assistant, LPN, eventually RN, to just have that path laid out and everything coordinated so beautifully, I think that's really going to be so important. What advice do you have for an organization that maybe wants to launch a new program to address workforce challenges? Any sort of advice from your learning as you guys have set up the school of nursing?  Rachel Bunch: Sure. So I think the biggest advice that I would have is to really listen to your members. Start by listening to your members and hear their concerns. I'm not a nurse. I'm not an educator, but I try to be a good listener. I probably am sometimes more than others, but try to be a good listener. And I think just talking to the members and hearing their pain points from them and not going and making the traditional excuses really. You can look at the different traditional models, and if that doesn't fit, don't be afraid to try something different. Try something different, and it might just work out. But we had to create a unique pathway here. It was not without some pushback and not without a lot of doubt, but we knew that we were doing right by our members, and we had enough data that was on our side to show the need, and then enough feedback from our members. And then the results are just, they're speaking for themselves, seeing the NCLEX pass rate. And then the biggest thing, I think, to me on the other side have been just hearing the stories from those students that have completed the programs, those single moms, those non-traditional students. We've had several students in their 50s that thought, "I'm going to be a CNA my entire career, and I want to give to my facilities and residents," and look at them now. They're LPNs, which is so exciting, and I know that they're going to be really great LPNs. So it's so good to hear and to see, but just don't be afraid to invest in those people and don't be afraid to listen and try a really non-traditional route, because it can pay off.  Debbie Stadtler: Absolutely. Expanding the vision beyond just the traditional folks that you might be looking to recruit and hire, but really being open-minded about non-traditional students and things of that sort. Really a great place to look for folks in our industry. Thank you so much for being with us today, Rachel. I really appreciate it, and I'm sure that we will see big things from the Arkansas Health Care Association School of Nursing in the future.  Rachel Bunch: Thanks so much for having me.  Debbie Stadtler: Visit ahcancal.org or careersincare.org for more workforce resources. Thanks to everyone for listening to this episode of Perspectives in Long term care. Join us each month as we discuss issues that impact the long-term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler sits down with with Renee Ridling, Executive Director of the Gingerbread House, to explore quality improvement and the AHCA/NCAL Quality Award program. Ridling shares her journey into long-term care—from marketing to licensure—and her experience helping organizations earn Bronze, Silver, and Missouri’s first Gold award. They break down the progression of the program, from defining an organization’s identity (Bronze), to documenting processes and data (Silver), to achieving results through a rigorous Baldrige-based framework (Gold). Along the way, Ridling highlights common pitfalls—especially focusing too much on “what” instead of “how”—and underscores the importance of repeatable processes, team engagement, and using feedback reports as a tool for sustained improvement. Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: Improving quality is always a goal in long-term care. Hear more about the ins and outs of the continuous quality improvement journey in this episode of Perspectives in Long-Term Care.  Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Healthcare Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long-Term Care, a monthly podcast produced by AHCA and NCAL. Each month we'll talk with long-term care and assisted living professionals about the opportunities and challenges impacting the long-term and post-acute care profession.  My guest today is Renee Ridling, executive director of Gingerbread House, a nonprofit provider for high acuity, medically fragile, developmentally disabled individuals in Rolla, Missouri. Renee has served as a silver and gold level examiner for the AHCA and NCAL Quality Award program for eight years. She joined the quality award panel of judges in 2018 and continues to serve as a judge for the program. She has also successfully led two skilled nursing facilities to two bronze and two silver quality awards, and in 2014, her facility became the first facility in Missouri to achieve the gold quality award. Welcome, Renee. Thanks for being with us.  Renee Ridling: Thank you for having me.  Debbie Stadtler: Those are some awesome accomplishments, and I want to talk much more about the Quality Award program. But first, tell us about your career journey. How did you get into the field? What led you to choose this career?  Renee Ridling: I actually got into long-term care by accident. I'd always wanted to work in healthcare, and I had a background in marketing. I interviewed for a position in marketing with a long-term care facility and I fell in love with it. And I worked at that time for Beverly Enterprises, a company that had over 200 facilities nationwide at that time. And I was asked if I would be interested in the AIT program and. It was intriguing, so I said yes, and the rest, as they say, is history. I obtained my license in late 1992, early 93, and I've been working in long-term care consistently since then. I just fell in love with everything about the people that we care for and the challenges that we face as an industry every day.  Debbie Stadtler: It's amazing, and as I talk to folks about their career and how they get started, it's so evident that there is a love and a passion for the industry and for the people that are in it. So I can see that is reflected in your career as well. But let's talk about the quality improvement journey. You have a unique perspective because you've seen it from both sides, both as an applicant and recipient, but also as an examiner and a judge. So give us a quick overview of the program and your experience with it. Renee Ridling: Well, I actually became an examiner after we received our bronze quality award in 2008 for my facility here in Missouri. And I wanted to learn more about the criteria, wanted to be able to help my organization to understand the process better and just to do a better job of learning and finding out what the quality improvement journey was all about. So that's when I became an examiner. I've stayed an examiner because I found it to be helpful in learning about my organization, how continuous improvement can benefit all aspects of the organization, not just the leadership part of it, not my job, but quality improvement continuously. Looking at opportunities to get better can help everybody, my residents, my staff, and really just became a student of that criteria. I really enjoyed the silver. And then I became a gold examiner. I've been a team lead at both levels. And then I was approached to be a judge, and that was a really interesting term. So it's been a really great opportunity for me not only to learn about myself, but to also learn about the organizations that I've had the opportunity to work with. Debbie Stadtler: I love how you mentioned that becoming an examiner was a way for you to learn the knowledge for your facilities, firsthand knowledge of seeing what they're looking for. But that's a great point though that each level of the quality improvement journey and each level of the Quality Award program are looking for different things. And so what advice would you give to those aiming for each of the three levels or applying for each of the three levels? What's the difference there?  Renee Ridling: I think beginning at the level we're really asking: What is your organization all about? Who are your customers? What are your key services? What challenges do you face? What advantages do you have over your competition? Then you take that piece and you move it into silver, and then we start digging into those questions about, okay, we, we know who you are and we know what you do, so tell us now how you do it. I think that's probably the biggest jump from bronze to silver. So those questions are how do you lead your organization? How do you make sure that you are focused on your customers. And then moving into the gold, that's a big trick. You go from the bronze, which is five pages, and then you go into silver, which is 26, and starting to be asked for some data, and then you open up the Baldrige framework for healthcare criteria and then you're asked to provide 55 pages of  a response.  So you now have basic questions and you have overall questions just like you had in silver. But now you have those multiple levels that really dig in and help you to identify gaps within your organization and opportunities to get better. It's just, it's, wow, I've never thought about that for my organization, but now I am, and I think we need a process for that.  And so I think the biggest difference is just learning at each level what is expected, how to address what is expected of you, and then moving into gold. It's really challenging for your whole organization to become better, the results throughout your goal. But what's presented in category seven is really a visual representation. You're like, wow, we did that. We really are getting better at what we do. For me, the biggest thing is just that moving from face to face along that journey and seeing at each level how we can grow and get better.  Debbie Stadtler: I like how you described it, that each piece builds on the previous one, so you're not just thrown into the deep end on day one, where you start with the bronze and it's more introductory, basic questions, a shorter application, a good starting point. And then by the time you're ready for silver, you have more data, you have more information, more details, things of that sort, so you're building. And then by the time you're ready to stretch for that gold, then you really can put all of that on display and showcase your organization.  Renee Ridling: Yes, I think that's a good summary. It is just the only way we talk about the journey, and I know sometimes people look at us strangely, but the honest truth is that it really is a journey and really you're moving from step to step. I think that's one of the great things about the AHCA/NCAL Quality Award program is that it is progressive. As a Baldrige recipient at the national program level for Baldrige, you start at the top. You start with that full criteria. You don't get that opportunity to start small and grow. And I think that the way AHCA in has developed this quality award program over the years has been really well thought out and just phenomenal in that it gives organizations an opportunity to move through those progressive levels and gain understanding throughout.  Debbie Stadtler: I always hear people describe it as a journey, and I think that's really the most accurate word there. From the examiner and the judge side. What are some common issues with applicants? What are some sticking points that a lot of folks get caught up in?  Renee Ridling: I think probably the biggest thing that we see at the silver and the gold especially is we know what we do as organizations. If we ask someone a question, how do you do something? They can tell us what they do. They can tell us we do this, but the real question is how do you do it? So the how question is really indicative of process steps. First we do this, then we do this, then we do this, and then we achieve an outcome. So all of those what things, those meetings that we have and that interaction that we have with one-on-one, with that resident or that family, all of those things that we do. Those what things. Go into the how, but the steps have to be there. And the important part about those steps is that they need to be well ordered. They need to have a first, a second, a third, a fourth. They need to be repeatable, they need to be consistent so that you're doing things the same way all the time to produce consistent results. Because that's really what we want, is we want those outcomes to be consistent and we want them to get better. And the way we get better is we have a process and that process helps us to get better. And then we look at the process and say, maybe if we tweak this, we could get even become even better. And I always tell people when I train other people like on the criteria and to try to differentiate between the what and the how. I said think of what do you need to make a peanut butter sandwich? I know that seems like a really silly example, but tell me what you need to do that. And they can list all of the things I said. Now tell when we do it, what do you do first? What do you do next? And then your outcome hopefully is a sandwich that is edible. So I think what we want everyone to see, that's probably the sticking point, is the difference between what and how. I think we see that at Silver and Gold a lot. We see a lot of connected activities of what we do, but not necessarily how we do it. And I think that's really critical for growing as an organization is having consistent processes that are well ordered, repeatable, systematic. They're effective in achieving the outcomes that you want at the end.  Debbie Stadtler: Yeah, it makes me think of showing your work on the math test that you took in school. Like it's not just about getting to the answer, it's about the process systems. Really the mindset behind it. Because like you said, these processes, we want to repeat and get better at. This isn't just write it down and put in the application. This is like continuous evolution of quality, and we want to be able to take those processes and systems and grow from them. So I think that's a really great point between the what and the how. What has surprised you or impressed you throughout your time as an examiner and judge? Are there any special moments that stand out to you in your memories?  Renee Ridling: I can honestly say that the one thing I miss being a judge is getting to do site visits. As an examiner, as a gold team leader and examiner, we get to go to locations, to facilities across the country who've earned that site visit because their application met the criteria level that we needed them to do, met the site visit characteristics, and getting to go to those facilities and see them in action. I think that was so amazing is I never went on a site visit that I didn't come home thinking: I learned something from that organization that I can apply to my organization, and that was always the so fun for me. So now as a judge, I don't get to do that, but I love being a judge. So I live vicariously through my teams. When I go outside visits, I'm like, okay, what did you see today? Tell me what you saw today. Did they really do that? How did they do that? What did that look like? Because it's really fascinating to see how we all do the same job. We're all providers of long-term care. We all are administrators or directors of nursing or whatever. Our role within the organization is, we all have the role and the basics of that role are the same, but every facility makes that happen differently. We do things that work for our organization and make it successful, and we can all learn from each other. I love that we are now asking our applicants to tell us about how they share and use best practices. How do they identify those best practices? How do they make those refinements of those best practices? Because man, there's some brilliant people in our industry,  Debbie Stadtler: Yes.  Renee Ridling: And you can learn so much from other people and it was always fascinating to go on site visits. So I love that. I miss that. But like I said, I get to live vicariously through the tease that I'm the lead judge for. So that's always nice. But I just think that's really great to see that everybody that I ever encountered in the facility was so engaged, so positive about what they do, and that just really means a lot. Debbie Stadtler: I love that you emphasize how different each facility is and how they do things with their own flavor and their own process, but still aiming towards achieving the same goals. From a staff member perspective, we only get a little snippet of that when we see pictures and the winners and the recipients and things like that. And we're always so impressed at the passion that everyone has throughout the organization. Everybody there is pulling in the same direction, and it's just so different for each one, but it's so exciting and fascinating, so I can completely see that the site visits would be super fun.  Speaking about individual differences, each facility being different. What kind of underlying principles or mindset shifts can folks use as they work through this process?  Renee Ridling: I think team engagement is critical. It's not a process that's just about the administrator or the person that's writing the application. The things that we're doing, those processes have to be deployed. They have to be shared in a way that the team understands the role that they play. How that process is deployed to senior leaders is going to be significantly different than how it gets deployed to the people that are doing direct care or the dietary person. That's most giving person. But all of those people are critical to having a process well deployed. I think the other thing that that sets applicants and recipients apart is that they use that criteria not as just something to get an award. Because if that's why we're doing it, that's probably not the best reason. We need to use that criteria as a management tool. We need to take each of those Baldrige core values that that AHCA/NCAL embraces in the quality award program, that leadership and strategy and customer focus, the knowledge management, and all of those key criteria processes, and use those as a tool. In other words: use it to identify where you have process gaps within your organization. Use it to help you overcome those process gaps within your organization. If you step back and you're like, yeah, our strategic planning is maybe not where it needs to be. Get these things from our parent company, which a lot of organizations do, that's very common,  But how do we take those? Goals and objectives that our parent company says, okay, here it is for this year. How do we take those and internalize those, make those part of our strategy at the facility level so that we're getting the best outcomes for the people that we serve? It isn't just about corporate said, do it this way. It has to be, well, corporate said do it this way, but you know what, we're already there on pressure ulcers and reducing pressure ulcers. So what do we do beyond that? How do we make that goal and move forward and continue to have success? I think just using that criteria, well, you don't have to do it all at once. We always tell people I, when I look at an application, I look at leadership, which is category one. I look at category two, which is strategy, and I look in category six to see how we're doing with work process, and those are areas that we as long-term care providers maybe are not the best at. So those would be the categories where I would say become students. Learn what's expected at senior leadership, learn what strategy and strategy, development and implementation is about learn about work processes and support processes and the requirements for those things. Become a student of how to articulate that and deploy that back out to your workforce and to the people that make it happen. Because I can sit at this desk all day long and I can write a beautiful application, but if my staff can't articulate and isn't really doing it, then it's just words on paper. It's really important that everybody becomes the ball. That team is engaged and the whole process, not just the person writing the application. So that, I think is the biggest thing. Use the criteria as a management tool throughout the organization.  Debbie Stadtler: I think that makes so much sense. Like you said, someone in the corporate headquarters or senior leadership, they're going to see the strategy and the goals and digest and internalize them one way to be able to put those down through the organization so that really the folks that are in facilities or dining or, you know, interacting one-on-one with the residents every day, that they're also internalizing and getting those strategies and processes. So important. And like you said, always keep learning. I just think that's so important as it's a continuous process. There are always things to do, tweaks to make all of that. So to continually be a student, I think is great advice. What closing thought would you get to everyone who wants to start or is in the quality improvement journey? What's your closing idea?  Renee Ridling: If you haven't started, begin, begin this journey. It is awesomely beneficial. I would say if you've started, continue, don't get discouraged because sometimes you write that application, you get that feedback report and you're like, huh, didn't get it this time. Keep working. Use that feedback report. Examiners spend hours as a team, as independent examiners. Writing feedback to help you understand what's missing, what are those gaps, and then use that criteria to address those gaps, those opportunities for improvement at every level of the criteria. It gives your organization an opportunity to get better, and I think if you're not there yet, get started. And as you do, embrace that culture of becoming or continuing to be. An organization that is continuously improving. It is ongoing every single day. I've done this many years now, and frankly, I learn something new every single day. I never stop learning And every year I have been involved with the Quality Award program is always a learning experience. I learn from my peers, I learn from my judges, peers, I learn from the examiners that we work with. It's fascinating to have so many people come together from so many different walks of life. One of the things that's always been fascinating to me is that not every examiner works in long-term care. I think that's something that many of our applicants don't realize is that they come from different industries, they come from different walks of life, different countries. I have a team right now that has an examiner from England and one from Thailand, so they're all over the world, and the fact that these people are willing to give their time to help our industry continually improve is phenomenal.  Debbie Stadtler: It really is such a great feedback mechanism and one is so personalized to your facility, so it really is a great opportunity for that one-on-one advice. Well, thank you so much for being with us today, Renee. This has been a great conversation.  Renee Ridling: Thank you for having me.  Debbie Stadtler: And visit ahca.org/qualityaward to learn more about the quality award program. And thanks to everyone for listening to this episode of Perspectives in Long-Term Care. Join us each month as we discuss issues that impact the long-term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler speaks with Nisha Hammel, Vice President of Reimbursement Policy and Population Health for AHCA/NCAL, about the rapid shift from fee-for-service to value-based care and what it means for long-term care and assisted living providers. Nisha reflects on her journey from geriatric social work to national policy leadership and explains how CMS has introduced roughly 11 new payment models in the past year. These models place increasing emphasis on prevention, provider accountability, technology-enabled care, and patient engagement, with more than 70 percent of payments now tied to quality and patient experience. The conversation explores several models that could affect providers, including the mandatory TEAM model, the state-based AHEAD and GEO AHEAD initiatives, and the forthcoming 10-year LEAD ACO model. Nisha encourages providers to stay informed, talk with clinical partners about ACO participation, understand their baseline utilization data, strengthen on-site clinical workflows to reduce avoidable transfers, and take advantage of AHCA/NCAL resources such as toolkits and the Population Health Management Summit. Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: [00:00:00] The transition from fee-for-service to value-based care is here. Learn the latest on new CMS payment models in this episode of Perspectives in Long Term Care.  Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Healthcare Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession. My guest today is Nisha Hammel, vice president of reimbursement policy and population health for AHCA and NCAL. She leads the association's policy and strategic initiatives on value-based care and innovative payment models. She brings 20 years of experience in post-acute care and senior living. Welcome, Nisha. Thanks for being with [00:01:00] us.  Nisha Hammel: Thanks, Debbie. Thank you for having me.  Debbie Stadtler: We'd like to start at the beginning, so tell us a little bit about you and your career journey. What led you to get started in long term care?  Nisha Hammel: My career journey really began next door with my maternal grandparents who were like second parents to me. I grew up in a home and culture that really revered old adults, so my passion for aging was shaped early. You could say, I honestly never stood a chance of choosing anything else.  Even when my peers would ask like, what are you majoring in? I stuck with geriatric social work as my master's program back when only a couple of schools in the entire country offered it as even as an optional major. From there, I started out as a social worker in a skilled nursing facility and moved [00:02:00] through a variety of operational and leadership roles in assisted living, home health, hospice, affordable housing. Really, I think each step taught me something new about caring for older adults with dignity. I really feel very blessed for that incredible journey. Eventually, I joined a state association where I helped lead providers in exploring new ways to work together that included some of our earliest conversations around value-based care and population health, and even how long term care could participate in Medicare Advantage in a meaningful way. It was an experience I still consider a privilege, and it has carried me into essentially the next chapter of my journey, which led me to AHCA, where I now have the opportunity to help advance models and policies that [00:03:00] transform care for older adults and support the truly exceptional providers who care for them every single day. Also, having the opportunity to advocate for some common sense policies to Medicare Advantage. I'd say each position has really felt like something I was called to do, and I am deeply humbled by this path and incredibly grateful that it all started with two grandparents right next door.  Debbie Stadtler: I'm always amazed at how many people have that personal connection, whether it's a grandparent or a family friend or a mother/father that really started them out in this profession. And I think, like you said, so many people feel it's a calling. It's really such a personal connection to this work, and I think that makes it really special. I want us to talk about value-based payments. Set the stage for us. [00:04:00] Where are we now? What has happened recently? What's going on in this area?  Nisha Hammel: Sure. I'd say value-based care has consistently received support from both Democratic and Republican administrations. While each may emphasize different elements, I think the overall commitment to achieving better quality and outcomes for every dollar spent has remained steady. What's happening now is that value-based care has accelerated pretty significantly in the last several years, and especially I think with this administration, it has been very highly active releasing or finalizing numerous models. In the last year, going to this year, there's been about 11 models. Wow. Which, yes, which aligns with broader CMS movement to test, expand, or retire models, all with the [00:05:00] goal of improving outcomes and containing costs. So if we think about some of the pieces that may be slightly different in this administration, along with kind of let's say the cost-cutting, improving quality outcomes, patient experience, there's also been a strong shift towards prevention. Also a greater focus on provider risk and accountability. So there's greater attention to having providers have some skin in the game. So not only upside, but also some downside risk. Technology enabled care is becoming much more central and there is a growing focus on the facts and benefits. Individuals are important partners in care. And so the growing focus on patient engagement, you've seen that become much [00:06:00] more key in recent CMS models.  Sometimes there's a sense of Medicare Advantage and just thinking about Medicare Advantage and then pure fee-for-service. But if we think about what's happening today, you've really got more than 70% of payments that are now linked to patient experience and quality outcomes in some way. And that's, I think, an important statistic that's that we may not often think about. Debbie Stadtler: I think that's a surprising statistic. I would not have guessed that it was that high, but it just clearly shows why the value-based care and the population health area is so important for providers right now. What do long term care and assisted living providers need to know? You mentioned 11 new models that have just come out within [00:07:00] the past year. Do all the models apply to them? What do they need to know at this point in time?  Nisha Hammel: That's a great question. In the effort of CMS to redesign and look at things differently, there are certain models that apply more directly and there are models that are a little bit more adjacent, but helpful for long term care providers to track because. The models, and I'd say the developments are important to monitor and understand because they could affect referral patterns. For example, care coordination expectations, and financial relationships.  Debbie Stadtler: Tell us more about the models that apply to long term care providers. I know there are several.  Nisha Hammel: So let's just start with the first model, which is TEAMs. And TEAMs is a mandatory model. So the other thing you'll notice with this administration, they've launched a [00:08:00] few more mandatory models. So TEAMs is a mandatory episodic payment model that really holds hospitals in certain core based statistical areas accountable for the cost of care for an episode that essentially begins with the anchor hospitalization of the procedure. And follows about 30 days post discharge for five. CMS considers high volume, high cost surgical conditions, and long term care providers and assisted living providers can often play a major role in patient recovery. And if you think about hospitals need strong post-acute care partners to help reduce readmission and ensure coordinated transition. This makes facilities part of the ecosystem of this model. Like I said, important to note though the good news is that AHCA has a [00:09:00] toolkit and resources and data available for providers to understand. Does it impact me, first of all, am I one of those facilities there are in those CBSA, right? And then be able to look at data through Trend Tracker that enables them to understand scope, impact and be able to make more informed choices about the path that they may want to go down.  Debbie Stadtler: That's a good introduction to TEAMs. What's the next model we need to know more about?   Nisha Hammel: The second model that I'd like to call out is the AHEAD model, which is the achieving healthcare efficiency through accountable design. And the uniqueness about this model is that it is a state level model. It was introduced under Biden administration and finalized by the Trump administration, and it is a voluntary state total cost of [00:10:00] care model, which started with Maryland. Starting this year in 2026 and is extended all the way to 2035, and you've got three different cohorts and participating states. You've got Maryland, Connecticut, Hawaii, and Vermont as cohort two, and then Rhode Island and Downstate New York, certain downstate, New York counties, I should say in cohort three. And some of the kind of key features of these is that states can receive up to $12 million to build infrastructure to help design the program. It includes hospital global budgets and like primary care, capitation, lag payments. So again, it's important to pay attention to the fact that it's certain states, but I think what is noteworthy in this is as part of [00:11:00] the states, CMS has also introduced Geo AHEAD, which is a AHEAD and a model, which essentially passively aligns any beneficiary that's not aligned to participating in another ACO program or Medicare advantage, or is in, for example, into the Geo AHEAD. And I think that's striking, and that's something different that I think providers participating in these regions need to be aware of because it will certainly automatically align these residents to ACO structures, and thus there could be corresponding care expectations. Debbie Stadtler: So AHEAD applies only to certain states, and Geo AHEAD is different. Is there another model we need to know about?  Nisha Hammel: The next one that we'll go to is LEAD. And LEAD [00:12:00] is the long term enhanced ACO design. And I think providers should really pay attention to this one. It is a new 10 year accountable care model set to replace ACO REACH. It's emphasizing stronger alignment, continues to focus on high need and complex populations, but it's also looking to engage providers that have not maybe previously participated in models, so safety net providers, rural providers. The model also includes CARA, which is CMS Administered Risk Arrangements, which essentially enables what's called like a shadow bundle pricing within ACOs, which may be an opportunity for long term care providers to collaborate in specialty and chronic care episodes. This is on the short-term care side, for example. So [00:13:00] we do see broader participation opportunities for providers. We're expecting the RFA pretty soon, and so something for our providers to track something provided that AHCA is tracking very closely. And we have provided some recommendations to CMS in a recently released LTC focused ACO white paper that encourages CMS to recognize the value and the distinct population and setting, setting specific pieces that long term care providers bring and how they may think about engaging long term care providers. Slightly different in the LEAD model. Debbie Stadtler: So LEAD focuses on high need and complex residents. What other models apply for long term care? Nisha Hammel: Then a couple of other models I'll just call out, which I think is good to know about the ambulatory [00:14:00] specialty care model. It's a mandatory model targeting high volume, specialty conditions, starting with heart failure and low back pain, and the goal is to really improve outcomes and avoid or reduce avoidable hospitalization. I know there's a ton of acronyms. But it would not be CMMI if it wasn't. All the acronyms are notable because it introduces prior authorization into fee-for-service for conditions that CMS notes are low value and at high risk for fraud, waste and abuse. One example being skin substitutes. You've also got the ACCESS model, which promotes essentially tech enabled chronic care management. It's emphasizing the use of digital tools, remote monitoring, and AI driven support. I think what's interesting with this model is it's the first model that pays [00:15:00] for outcomes known as outcome aligned payments versus defined set of services or model parameters. And then you've got MAHA ELEVATE, which is a model focused on chronic care and how lifestyle medicine can impact and moderate upstream drivers of health and like nonclinical supports and prevention. So I think a real opportunity for our assisted living providers to track and there've been, and then there are several other kind of drug pricing and pharmacy related models. Debbie Stadtler: I think you make a really good point about how providers are not on their own with this. You mentioned that AHCA has toolkits, articles, things to help folks learn about all of these models, understand them, educate themselves. So while it seems like a lot of acronyms and a lot of new things coming out all [00:16:00] at once, and AHCA is really here to help folks get their hands around this and understand what they need to be doing or start doing.  Nisha Hammel: I think the beauty of the association and the fact that the association is supporting our members is that they have an objective resource. So if they're trying to figure this out, noodle it. There are a lot of partners and providers and vendors out there, and sometimes it may be difficult to sort through rhe noise or all the options, and I would encourage providers, that's what your association is here for and this is how we can support you.  Debbie Stadtler: Absolutely. What do providers need to know who are starting this value-based care journey? What do they need to know to prepare for this journey? What do you recommend as some of those beginning pieces? Nisha Hammel: I [00:17:00] will probably sound like a broken record, but start by getting informed. Yes. If you don't already know about the models, explore it. Like we said, access some of the resources. Reach out. Attend AHCA’s Population Health Management Summit, which is the only conference of its type focused on long term care providers and assisted living providers meaningful participation in pop health. So I think this is, that's a fantastic, it's two days of the ability to get immersed, meet and network, meet some incredible folks that are doing some good things that have started that you've had some pioneers. So first of all, get informed. If you also don't already know, ask your physicians. Ask the clinicians, your nurse practitioners for example, or physician's assistants that are coming into your building and seeing your residents. Whether they participate in an ACO or the value-based care arrangements. I talk to [00:18:00] providers around the country and they may assume that they're contracting with an independent provider, and until they ask the question, they aren't aware that the provider may, even if it's an independent prep provider, may be connected to an ACO. And if they are, that means their beneficiaries are automatically part of that ACO. So get informed, ask questions. I would say understand your data. Know your baseline hospitalization rates, your emergency department utilization, your readmission rates. These metrics drive both quality and financial performance and value-based care. Then get an understanding or essentially assess your clinical capabilities, right? Determine whether your clinicians have the competencies, the workflows needed to support proactive early intervention rather than defaulting to [00:19:00] hospital transfers, for example. And review policies and protocols. There are sometimes inadvertently policies and protocols can move people to hospitalizations or ED referrals, which may not be necessary, may not make sense. Ensure you have structures in place that really empower teams to manage changes in condition on site whenever appropriate. It's so if something is unavoidable. You have to send a person out, but if it's avoidable, you want to make, be able to care for the person on side and then build, let's say internal alignment, engage leadership, nursing, medical staff early. So the shift towards value-based care is deliberate and consistent with the organization's overall strategy and leadership and where you want to head and go.  Debbie Stadtler: We mentioned that [00:20:00] AHCA and NCAL provide resources, support, education on value-based care, but how else are they involved in this sort of transition to value-based care? What is the association really advocating for in this space?  Nisha Hammel: Sure. AHCA is actively engaged and advocating on behalf of our members, and we are really advocating for value-based care models that reflect the true realities and the strengths of long term care settings rather than models designed for community-based populations. We are urging policymakers to adopt frameworks, I referenced the LTC focused, ACO model, for example, that recognized nursing facilities and assisted living's really unique capabilities, including the 24-7 clinical oversight, the interdisciplinary care [00:21:00] teams, the onsite supports, the focus on social supports and the fact of food, three meals a day, plus snacks that provided transportation opportunities for active social engagement and the ability to manage these high need, high costs residents effectively. So our global goal is to ensure, first that providers that want to be a risk-bearing entity have the opportunity to do that and have a pathway to do that. And for others that don't necessarily want to be the risk-bearing entity, but want to have meaningful ways to engage that reimbursement and regulatory structures can support them being able to effectively do so and support proactive timely care decisions made locally right in the settings where our residents live and where they call home. [00:22:00]  Debbie Stadtler: That makes a lot of sense. We really want to make sure that these models work well for AHCA and NCAL members, not the members having to squeeze themselves into models that are not quite set up for the specific populations and care that they give. So that makes a ton of sense. So you mentioned a little bit earlier that this transition from fee-for-service, where you're really focused on services into being focused much more on outcomes is the hallmark of value-based care. How does this impact how we think about and measure quality? It really seems like it's almost a whole new idea on how we do that. Nisha Hammel: The quality and outcomes is really at the heart of every value-based care model.  Debbie Stadtler: Yes.  Nisha Hammel: The challenge is that each model comes with its own set of quality measures. And those measures don't [00:23:00] always align well with the long term care population. Like I said, most of the models are designed for a community dwelling population, so that misalignment can create real barriers for nursing home and assisted living communities. However, I'd say there are some core quality outcomes that are important no matter. Who the payer is, what the model is, and whether it's not directly a quality measure. What you do to drive towards that has impact? So for our older adult population, let's say three of the most meaningful indicators are reducing avoidable hospitalization, minimizing unnecessary emergency department visits, and reducing inappropriate readmission rates, right? Because we know that when we keep our residents stable and cared for in place, that's better for their health. As a family member that's cared for a loved one, it [00:24:00] certainly makes a difference to my mental health and my kind of overall support, their experience and the overall system.  Debbie Stadtler: That makes sense. Quality is obviously our North Star and to really be honing in on those quality measures that we know and we monitor and we keep tabs of every day:  reducing the hospitalizations. That's what we know how to do. And so it's really great that this, even though it's a transition and some new things to learn, there's really still that focus on quality and we know what that looks like and how to do that well.  Nisha Hammel: That's exactly right.  Debbie Stadtler: What do you want listeners to take away from this? There's a lot to learn, a lot to know. What's your sort of bottom line takeaway right now?  Nisha Hammel: The most important takeaway is to be informed. Providers may ultimately decide [00:25:00] not to participate. Absolutely. Their choice. It should be a conscious decision, not a surprise. I'd say while the growing number of models can truly feel daunting and having been a provider, it seems very overwhelming. It also presents an opportunity by offering maybe more pathways that weren't there previously to participate.  So there could be different points of entry and different ways to engage all not requiring providers to assume significant amount of risks, which understandably is not for everyone. We also know if we think about assisted living communities, there's a huge spectrum between providers that are more focused on the social model versus more of a health care model. So really being very cognizant that many providers don't also [00:26:00] realize that their residents are already in ACOs. So where they are already helping manage, care and improve outcomes, they're just doing so without capturing the value that they're creating. And so stay informed, get educated, ask questions. Utilize your resources. Please call me. Please call my colleague Rohini, and we are here to help.  Debbie Stadtler: I love that. Make sure you are informed and AHCA/NCAL is here to help you with that. I think that's just the greatest note to close on. Thank you again for joining us, Nisha. This has been a great discussion.  Nisha Hammel: Thank you so much, Debbie. Appreciate the opportunity.  Debbie Stadtler: Visit the AHCA/NCAL website or providermagazine.com to learn more about value-based care and payment models and the Population Health Management Summit. And thanks to everyone for [00:27:00] listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler welcomes Heather TerHark, Chief Strategy Officer at Viva Senior Living, and Samantha Lawrence, Regional Vice President of Operations at Brightview Senior Living, for a conversation on redefining customer experience in long-term care. Together, they explore how organizations can move beyond traditional customer service to deliver more personalized, relationship-driven care. The discussion highlights the growing expectations of today’s residents, the impact of technology and AI on safety and engagement, and the critical role of staff training, empathy and culture in shaping meaningful experiences. The episode also invites listeners to get involved by joining the Customer Experience Committee to help advance resources and innovation across the industry.   Perspectives in Long Term Care is produced by Association Briefings.   Transcript Debbie Stadtler: [00:00:00] Is your facility making the best impression possible on everyone who walks through the front door? Learn easy ways to boost your customer experience in this episode of Perspectives in Long Term Care.  Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month we'll talk with long-term care and assisted living professionals about the opportunities and challenges impacting the long-term and post-acute care profession. My guests today are Heather TerHark and Samantha Lawrence. Heather is the chief strategy officer at Viva Senior Living and brings more than 27 years of experience to the table. Samantha is regional vice president of operations at Brightview Senior Living in New Jersey and has served seniors in various capacities for 26 [00:01:00] years. Heather and Samantha are the co-chairs of AHCA's Customer Experience Committee. Welcome, Heather. Samantha. Thanks for being with us.  Heather TerHark: Thank you for having us, Debbie. We're so excited to be here.  Debbie Stadtler: We like to start at the beginning. So tell us a little bit about your personal journey, your career journey. How did you end up where you are now? What led you to get started in long-term care? Samantha, start with your journey. Tell us a little bit about it.  Samantha Lawrence: So I was fortunate to know three great-grandparents and all of my grandparents and wow, when I was about 10 years old, my one great-grandfather had developed Alzheimer's. And at that time, communities like Heather and I had the opportunity to be engaged with didn't quite exist, so it was in a rural nursing home. I went to visit my great-grandfather and a woman that was a patient/resident there grabbed my arm and said, honey, will you get me a laxative? I did not know what that was at the ripe old age of 10. But I knew she [00:02:00] needed something. So I went to the desk and I said, excuse me, this woman over there in blue, she needs a laxative and that nurse turned my career path. Because she said, “Honey, she says that all the time. Just ignore her.” I didn't know what the right answer was, but I knew that didn't sound like the right answer. So I just went back and started talking to her and then you could not peel me out of there. I'm like, “Mom, this woman can't reach her cup. This woman is shaking and her food's falling off of her fork and we have to go.” Like I said, these people need help. So volunteering closer to my home, playing the violin at dinner for a local nursing home, and they needed a part-time receptionist when I turned 16. I did a paper application. I called my mom on a payphone. I said I was really nervous about my big interview, and she said, “You are the only 16-year-old that is stoked about working in a nursing home. I think you'll get the job.” And so then I never looked back. I grew my career in different frontline roles in reception activities, moved into management roles, got my administrator's license [00:03:00] in assisted living. Went into a subject matter expert role in dementia programming, but realized my heart was in operations, and been with Brightview now for the past 11 years, about six of those in a regional capacity, and was an executive director in Paramus, New Jersey, for them. Opening that community actually prior to this role.  Debbie Stadtler: It's amazing how many people that I speak with that the beginning of their journey has some sort of family connection to how they start in this industry. So it's really interesting. Heather, tell us a little bit about your journey.  Heather TerHark: Sure I wasn't quite as soon as Sam at the age of 10, but a woman in college. We all think we're going into college and we have this career path all mapped at, and I was working at a hospital as just more of that part-time job that you do in college and I got the opportunity to work with physicians, walking seniors on the track, some of them doing [00:04:00] stress testing. I got to teach water aerobics to seniors, and that was the start in college of my entire career because I knew right then and there, those were the people and I learned so much from a medical component being in the hospital going through surveys. So I got started right off at the age of 18. And I've been so blessed in my career to work post-acute rehab, skilled nursing, the entire senior living continuum, and also home health, hospice and pharmacy through just a few companies throughout my career, and my mother and my grandmother also passed away with Alzheimer's dementia. So memory care communities have a very, very special place in my heart, and I'm so excited both Sam and I have the opportunity to have either memory care communities or memory care neighborhoods [00:05:00] and know that we do things to enhance the lives of those that live. And so it's a personal journey. I tell people I don't know what it's like to work outside of the health care field because I've never done anything that wasn't part of the world that we all live in today. Debbie Stadtler: It's amazing that passion and that connection with people with seniors is really just so evident in everyone who works in the industry. So I love how your journey really highlights that as well, Heather. I want to jump into our topic today, which is customer experience, which is a little bit different. I think a lot of people are used to hearing the term customer service, which I think is a little piece of it. But start us off and get us all on the same page. What is customer experience and what is that encompass so that we know what that term really refers to? Heather, start us off.  Heather TerHark: Sure. So customer experience is everyone that comes into contact [00:06:00] with your community. It doesn't matter who it is, it could be a potential resident, a family member, a potential employee, but it also could be a fireman that comes in when there's 9-1-1 call. It could be the postman, the UPS that drops off. That is the experience because they're all our customers, because whether they're looking to work or to live in our community, they're part of that ecosystem that makes up that community and they form an impression and they have a feeling about that community of how the vibrancy or in the involvement or the heartbeat of that community. So truly that customer experience talks about anyone that interacts or has any kind of touchpoint with what we do.  Debbie Stadtler: I think it's such a broad amount of people. I understand what you're saying, that it's really anyone who comes [00:07:00] into contact and has an experience with your organization, your facility, but that's a lot of different groups, potential residents, families, current residents. Those are all different groups with different needs. How do you serve each of those groups? How do you make sure this experience is consistent or excellent across all of these folks? Samantha, tell us more.  Samantha Lawrence: So the joy and the challenge of serving so many different customers, that the experience is unique to every single person. Everybody comes to us with different emotions about being in that community or that facility. You've got prospective residents and families that are very apprehensive. This could symbolize to them a loss of independence. It could symbolize a big change. They live in the same home for 60 years. For that, maybe somebody that's a vendor or if the fireman, maybe this is their first day on the job, maybe they've never been to a community like ours before. There's a combination of personalized and generic things that we all [00:08:00] need to do to make sure that we're giving a great customer experience when individuals come through our doors. When it comes to residents in particular and that kind of thought of. It's scary to transition into communal living after so many years just pretty much doing your own thing, really getting to know them as individuals from the prospect to moving in. We try to ask so many questions to get at the heart of their current situation, if they're a prospect or once they move into our doors. What is it that brought them joy, brought them purpose in the real world, quote unquote, because this is their real world as well. It's just going to feel maybe a little bit different, but how can we as an organization, focus on the possibilities, independence and choices that they still have, and really focus on those possibilities rather than the limitations they may be feeling? So it's really knowing them all as individuals as much as we can, and infusing resident centered hospitality along the way as much as we can throughout that experience. Heather TerHark: Debbie, if I could add to [00:09:00] Sam's comment that when she talks about the hospitality, it's the really small details. How were they greeted the minute when they walked into the community? How were they greeted on the phone? Is there water out? Is there coffee? Is there someone saying, let me get someone for you? How do folks in the atmosphere feel when you walk through the community? But the details are really important because you don't know. As you said earlier, who your customer is, so you have to embrace 'em and make them feel like this is just a great place to be, even if they're the postman who's dropping off the mail for the day. Would you like some coffee? Can I help you somehow? All those things you're talked about, you and taught about with hospitality. [00:10:00] So I want to make sure that to everyone who's listening, it doesn't cost money, but it does take training. It does take time with the staff to really make sure that they know the ways to greet and welcome. Debbie Stadtler: Speaking of staff, I think that is a big question because if your customer is everyone you're coming into contact with, then you know, making this excellent impression isn't just the responsibility of the front desk or the intake person who's meeting the potential residents. This is everyone on staff. It's all the staff, it's the volunteers, it's the management. So how do you determine the skills or the roles that you're infusing into staff to support this customer experience? How do you teach or train some of this?  Samantha Lawrence: It starts, as you just said so beautifully, with [00:11:00] our associates. And at our organization, we firmly believe at the very foundation, if we're not as a company creating a great place for our associates to work, there's no way that they can in turn create a great place for our residents to live or all of those other vendors to walk through the door. So it starts at the kind of lower level Maslow's hierarchy of making sure that as an organization we are thoughtfully caring for our associates. Making sure we have meaningful benefits and meaningful appreciation for everything that they do, so that they feel great about what they do when they come in the door. And then when it comes to the skillset, before they even get to us, we're doing behavioral-based interviewing. We can teach them how to answer a phone or what they should say, or how they can take an order at the dining room table. But I can't teach them to have heart and passion for what they do. So we start out with a group interview process that tries to get at the heart of some of these customer experience or service types of questions to get a [00:12:00] feel for if there's an innateness in them in that regard. And if we can start there, then we can interview to the scale on a one-on-one basis and move on from there. And really make sure we actually have developed specific hospitality training to make sure that some of the things that Heather mentioned about answering a phone, eye contact. Making sure that if you don't know the answer, you don't end it there. You go and get somebody for you. And actually one of the things our committee did this past year for our members is develop some customer experience training with different scenarios that could pop up in different departments so that people have a resource to utilize for a quick hit in dining, in maintenance, and care with common situations that come up. And I think that was a great deliverable last year. That can just be a small touch if folks might not have some of those resources independently.  Heather TerHark: And I would just add exactly what Sam said. When someone walks in for an interview, whether it's an individual hiring manager or it's a group, if they [00:13:00] have passion, if they have heart, if they are there for the right reason and then you can train the rest of it. Yes, they may have to have their med tech or their LPN license or certain things. But you can have two people with the exact same resume and the exact same certification or degrees. But it's how they respond. Do you watch them before the interview sitting in the lobby? Do they interact with the residents? When you take them on a tour to the community, how does that potential associate employee, how do they interact with the residents? How do they talk to them when the residents talk to them? Because those are the folks that we want in our industry, because you can have a job description. But it doesn't really always encompass no job description. Say you have to turn the remote on for the resident. No job. [00:14:00] Best description says we, how many times are we going to look for the eyeglasses and the dentures kind of things that we do without thinking, because that's what's important to that resident that lives there and all the much more complicated things that they've made with the TVs and all of that. Now, who's going to do those extra little things when you talk to them?  Debbie Stadtler: Absolutely. You can definitely sense that sort of connection and heart. I think that's really a great way of putting it, of someone who wants to be of service and hospitable to folks. Sam, you mentioned scenario-based training as one way to help folks develop these skills. Tell us a little more about different types of training or different ways that facilities can help their staff be a little more open to this type of customer service and experience.  Samantha Lawrence: Sure. I think that one of the hardest things when you try to train to hospitality is it [00:15:00] often makes people feel they have to say yes to everything, and that's not necessarily a great thing either. So, it's important to communicate that a “yes mentality” is important. But as a team, we all need to set expectations of what is reasonable to expect and what's not reasonable to expect. And if somebody has something that they would like to do or there's always that one-off transportation request, I think we can all empathize with, or that one-off extra time with care or a dining request or something that we unfortunately just can't accommodate that day. So how do we say no without saying no? It's just as important as saying yes. Just saying, “You know what? While that's not something that's possible, I'd like to offer you this alternative, or maybe we can do this instead.” So just really having that yes mindset, but knowing that it might not always mean saying yes, and it's about offering some alternatives based on the expectations that we've all set forth from the beginning in a consistent way. Also, we talked [00:16:00] earlier about focusing on relationship-building with our residents and knowing their preferences, but also understanding that knowing those preferences is not, does not mean making assumptions. For example, if Mrs. Jones always loves her orange juice every single morning. While some might think, oh look, they have the orange juice preset, maybe today she feels like cranberry juice. But how do you show that you still know her and know her preferences and respect them, but give choice. You walk up and say, “Mrs. Jones, is it an orange juice kind of morning, or are we feeling like something different today?” Because maybe she'll say, “You know what? I'm tired of orange juice.” And maybe she's too polite to say no. And so there's a way you can confuse the world of choice, but also showing that our residents well, and it's just really continuing to focus on all of your interactions are based in that foundational relationship because if there's trust that you are able to build through that relationship development. Customer experience just gets that much easier. It all starts with relationships and trust. [00:17:00]  Heather TerHark: I absolutely agree. The other thing I would add is teaching our associates, our employees, that they have the ability to problem solve, that they have vision. To solve a problem that it doesn't have to go to a department head or the nursing home administrator or the executive director that they've been caught. These are things you can solve that are simple types of things, because a lot of times it can just be taken care of right there at that moment. To Sam's example of the transportation, you know, “Debbie, we cannot catch you up for transportation this afternoon. What does tomorrow morning look like for you? I see we already have some openings for that.”  Instead of saying, oh, no, I'm sorry, and just leaving it there. How can we train them to take the next step? How can we also train them to actively listen? It's something that all of us, no matter where we're at in our [00:18:00] profession, we think, “Oh, we're in a hurry. We're really going to move fast”. How do we make them take a breath and to see that this resident needs something and how do we help them? And sometimes that's so much harder than that sounds because there's another call light going off. Or they know that this resident, they're supposed to be in their room at this time to give them a shower and really, okay, let me repeat. Now, Debbie, is that what you said to me that you need, let me figure out how we do this. Let's go look for what's missing, whatever the case may be. And then just truly teaching them some emotional intelligence if they say something's wrong, not to take it personally. There's a lot that goes into what a family member says. That's because of guilt. It has nothing to do. But we sometimes take it personally because we have pride, we have passion, and we're doing the best we can. We're working as hard. How many times have we had to [00:19:00] teach them don't take anything personally, but we're here to solve that. We're here to create that best customer experience without worrying about what the issue is, how it reflects on anyone. And sometimes teaching them that empathy doesn't mean to Sam's point that we're going to solve all of the problems, because some of it we can't solve what they're emotionally going through.  Debbie Stadtler: I think those are such big pieces that you guys mentioned. Trust, relationship building, empathy, listening. Not to solve necessarily, but really to hear a person out in a lot of situations. Those are such important skills in work like this where it's so human-focused and so person centered to be able to bring those types of skills.  We all know that long-term care has changed so much over the past five years, 10 years, 20 years, and [00:20:00] with the baby boomers and the silver tsunami, there are expectations. How have the expectations around customer experience changed? What are some of the things that baby boomers are really focused on and look for as they have these experiences with our communities? Heather, what do you think?  Heather TerHark: Oh my gosh, Debbie. It has changed so, so much. Just as our worlds have changed with Amazon and Uber and Netflix and all their expectations changed. They're used to right-on-demand delivery. They're used to personalization. They are used to that responsiveness and. Going back to where we talked about earlier, hospitality, and whether it's post-acute rehab or it's senior living, they expect almost a lifestyle to it. Yes, they [00:21:00] need medical care, but they expect more than just good medical care now. They expect so much more and it's going to just continue to shift and evolve even more. And so how do we step up as organizations to serve today's customer is really, I think, a conversation that continues because the expectations aren't going to get less.  Samantha Lawrence: That's a really great point, and I think when you think about just our industry, and Heather and I have been in it for about the same amount of time. The nursing home residents that I started with back in the day is today's assisted living resident. And today's assisted living resident is the independent living resident. People are coming to us, often at a later phase of their journey, but they're still expecting that lifestyle that Heather described and we've created as a society, a very on-demand culture. So going back to that transportation example earlier, they're [00:22:00] used to going on their phone maybe and having themselves or their adult child or somebody help them get an Uber instantly or order. A meal on DoorDash or delivery with food, or I want to watch this TV show right now. I can turn on Netflix or what if they can’t work the remote? I'll get there. And so it's how do we find ways to anticipate needs so that we can try to get ahead of some of those demands or requests or desires or needs at the end of the day? I think one of the questions we get a lot is how are you evolving as a business? What are new tools, processes, services, programs? People want to know that you're thinking ahead and sometimes aren't even always interested in what you're doing today. They want to know where you're going with some of the offerings because the consumers at all ages are very well educated now about what it is that we do, and they very much want to continue their existing independent lifestyle [00:23:00] within our communities. Debbie Stadtler: I think that idea of evolution is so interesting and so much of what has changed in the world in general revolves around technology and the strides that it's made. So you know, what is the role of technology in this customer experience, hospitality service world. And how do you balance it with the things that are so human with that empathy and relationship building and things like that? What's the balance between the technology and the human touch? Samantha, tell us more.  Samantha Lawrence: Sure. I think one of the big things I know that we've done, going back to the pandemic, really leveraging some of the very basic tools that we have FaceTiming and not stopping FaceTiming at, okay, the pandemic's over, everybody's out. But if there is somebody that needs some assistance with connecting with a loved one, there's a way that I've built that relationship with that resident helped me FaceTime my loved one, and that's a great [00:24:00] customer service, customer experience piece. But it's also a way to leverage a very basic piece of technology on a broader scale. One of the things I'm really excited about is fall prevention or technology. I know our organization is in the process of rolling out safely you and our dementia care neighborhoods, and it's a fall detection software that detects fall motion and sends that alert immediately to our team. And our team is able to respond more quickly. What's been the greatest gift of this software is not only does it prevent an unnecessary hospitalization because we didn't see what happened in a different scenario, and we might send someone out of an abundance of caution. It's detected injuries that we might not have known happened because the resident got themselves back into bed before we got there quickly. But it's also been a great associate training tool because as we watched the video recording back of what happened, we are able to see body language and did we illustrate empathy in the way that we physically reacted to the [00:25:00] resident? And it's created great training tools, not necessarily that we even had to train to, but an associate watch it and says, “Oh my gosh, I would've gotten down at eye level next time I do that. I look like I was standing over that person.” And so it's a great way to illustrate the strengths that we have, as well as the opportunity areas we might have. So it's a great way to leverage technology to help us, but not in a way that eliminates the human touch and actually really enhances the human touch. Debbie Stadtler: I think that's a great point. Enhancing is really a keyword there, Heather, is that what you're seeing?  Heather TerHark: Absolutely. And not only technology-enhancing, but I think that the technology, as Sam said, what are we doing as an organization next year in five years? AI is gonna play a big part in this too, as they scrub records, as they summarize things for us and [00:26:00] what we're so used to, okay, is it HIPAA compliant? Is making sure there's no security breaches? But the resident wants to know the highest wifi fastest speeds. How do we merge all of that together with the on demand, the great technology, not just fall detection, but also being able to know if they're restless at night, and what if they have had an accident from moisture being detected? What ways for them to have more freedom, even if they do wander from a memory care standpoint and not feel like they just have small places to wait. All those things that technology helps us do to better care and provide a better customer experience. But how do we blend it all together as an organization from a security standpoint, from a cost standpoint. Also, let's face it, [00:27:00] teaching staff how to use some of it only as good as what you use it or that you provide. The data comes from that technology. So it's a small shift that I think isn't going to stop right now.  Because how many have walked into different buildings and we're like, we have great wifi, but then there's pockets that we still have to find in the buildings. Buildings are big, so we haven't fully even got wifi where we want, in a lot of cases. What do our new policies and procedures look like when you start talking about fall detection or you start talking about families putting cameras in to monitor? What does this all mean to us? But we have to find a way to do it because that's what the customers expect. And there's a ton of things I think all of us are working on, but I think this is just the very, very beginning and I really [00:28:00] believe AI is going to play a big part in it too.  Debbie Stadtler: There's so much possibility. It's really amazing and a lot to try to integrate. Like you said, you really want everything integrated and working and all of that good data flowing and things like that. So that's a really great point of not only using the technology, but making sure we're really executing well with it. This has been a great conversation. I have learned so many things about ways to enhance my experience with other people and have a better customer experience, so I appreciate your information and wisdom with us today. Heather and Samantha, thank you so much for joining us.  Samantha Lawrence: Thank you for having us. We had a great time.  Heather TerHark: Yes, thank you. This, it's been great to speak to everyone at AHCA-NCAL and we always are looking for members for our customer experience committee in the next year.  So please know we would love to have you be part and help [00:29:00] us expand the customer experience journey and we're working to just try resources for members. As Sam mentioned earlier, with different scripts and playbooks and things of that nature.  Samantha Lawrence: Absolutely.  Debbie Stadtler: Thanks to everyone for listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long-term and post-acute care profession and be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.

In this episode, host Debbie Stadtler sits down with David Gifford, MD, MPH, chief medical officer of the American Health Care Association, for a thoughtful conversation on building trust in long-term care. Dr. Gifford shares his career journey and explores why trust is foundational to effective healthcare systems. Together, they discuss the role of empathy, authenticity, and clear communication in strengthening relationships among care teams, residents, and families. Dr. Gifford also addresses the challenges technology can introduce and offers practical strategies for cultivating trusted colleagues and leading with intention. The episode includes actionable guidance for fostering stronger trust and communication in long-term care settings. Perspectives in Long Term Care is produced by Association Briefings.