Building Trust Where It Matters Most

The Power of Showing Up: Advocating for the Long Term Care Profession

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 [https://associationbriefings.com/].   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.

Finding Solutions to Long Term Care Workforce Shortages

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 [https://associationbriefings.com/].   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 [https://www.geronurseprep.com/]. So the GeroNursePrep program [https://www.geronurseprep.com/] 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 [https://www.geronurseprep.com/] 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 [https://www.geronurseprep.com/], 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 [https://www.ahcancal.org/Pages/default.aspx] or careersincare.org [https://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.

What It Takes to Achieve Quality Excellence

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 [https://associationbriefings.com/].   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.

New CMS Models and What They Mean to Long Term Care Providers

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 [https://associationbriefings.com/].   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 [https://www.ahcancal.org/Reimbursement/Pages/Population-Health-Management.aspx] or providermagazine.com [https://www.providermagazine.com/Pages/default.aspx] 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.

Elevating the Customer Experience in Long Term 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 [https://associationbriefings.com/].   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.