Value-Based Care in Senior Living: An Operator’s Perspective – Episode 3

Lisa McCracken: Thank you everyone for joining us today and listening to this episode of the NIC Chats podcast series. I'm going to introduce our guest here in a minute. Not that she needs any introduction, but I do want to thank our sponsor for this series of our podcast. 

So we're doing this series around value-based care. And Sage, who is an organization that you can find more about at hellosage.com is the sponsor of the series of podcasts. Sage empowers senior living communities with real time data, proactive insights, and intelligent care coordination, which transforms operations, enhances resident outcomes, and helps teams make faster, smarter decisions every day. 

We appreciate their support and encourage you to check them out further. So without further ado, I want to welcome our friend Lynne Katzman with Juniper Communities. And as part of this series, Lynne, you're giving us obviously the operator and provider perspective on value-based care. 

But before we jump into all of those conversations and the lessons learned and your perspective and so forth, for those people who do not know you and don't know Juniper, would you mind giving sort of the elevator speech so they have that as background? 

Lynne Katzmann: Happy to. So Juniper was founded 37 years ago when I was just a baby. 

I am the founder and the CEO. We are an owner operator in contrast to many companies that operate senior living today. We own the majority of our communities. Today we own 28 properties, or we are involved in 28 properties, 21 of which we own or control, and we operate across the continuum. We operate everything from independent living all the way through to subacute care in a skilled nursing environment. I think the thing that distinguishes Juniper is our long-term commitment to innovation, and I know we're gonna talk about some of that today. And also our values driven orientation. And we've been supported by the same group of investors for a very long time, who buy into our, “doing well by doing good” orientation. 

 So I think that's a simple overview of who we are. 

Lisa McCracken: Thank you. And there are a couple things I want to come back to because I think there are some key elements of what you just said that I think contribute to your ability to be successful in this environment with value-based care that might be a little different than some others. But just out of curiosity, what types of communities did you start with 30 some years ago? Was it on the nursing side, or…? 

Lynne Katzmann: It was all skilled. At the time there were very…assisted living came into being in the mid-nineties and we started in ‘88. So it was all skilled. We then actually got into assisted living by converting existing buildings, and we bought, we built several, we built one of the first small house model memory care communities and went from there. 

So yes, it was all skilled. 

Lisa McCracken: Yeah, it's so interesting to think back around just how the sector has shifted and emerged. And I think one of the key things for listeners that I wanna emphasize is this conversation around value-based care is we will get into is it’s not just a conversation in the skilled nursing environment. 

Correct. Okay. For background. Okay. Value-based care, that's a big umbrella. And the overarching statement and sometimes actually used broadly to even describe some relationships that may actually not be value-based care in terms of an at-risk arrangement and so forth. But could you just comment on the different buckets, for lack of a better term, or areas where Juniper engages in a type of value-based care relationship? I know you guys are all in some more sophisticated areas, but I know it spans the spectrum, so can you give that background as well?  

Lynne Katzmann: Sure. Let me start, Lisa, by saying that value-based care is defined by the term value. 

And it looks at outcomes. So the primary difference the government policy pushed toward was making sure that healthcare was driven, financially incented, by outcomes rather than the service provided. And so when you think about value-based care, you think about what we can do to make care better, the experience more satisfying, and the cost reasonable. That's what's known as the triple aim. So that's the framework in which we think about value-based care. So Juniper engages in value-based care at a number of levels, and I will talk about each in more detail if you want, but initially, value-based care has to drive outcomes and therefore it needs to look at something we call care transitions. And so initially the way value-based care came into being was to look at what happened between different sites of care provision. And what happens between the primary care doc and the specialist, between senior living and the SNF, between the SNF and the hospital, and all of those settings. 

And so the first way we engage in value-based care is to manage those care transitions through a care model we call Connect4Life. Which for, in simple terms, is designed to use data and communication, a technology platform. And a high touch vehicle known in Juniper as a medical concierge, so it’s high tech, high touch. 

And the goal is to manage care transitions successfully so people get the right care in the right place at the right time. And in so doing, we found that we're able to impact the outcomes. Outcomes typically in value-based care are measured by how often someone ends up in a hospital, whether that means for emergency care, for observation, or for an inpatient episode or a readmission. 

So care transitions is the first. We then went from a Care Transitions program to integrating providers, and I think what our audience will relate most to is the integration of primary care, rehab, pharmacy, and other ancillaries like home care. And when Juniper talks about integration in Connect for Life, we talk about a preferred provider relationship where each of these providers agrees to work from the same playbook. To enter into the high tech, high touch world that we've created for Connect4Life. That's very important. Now, most people, when they think about value-based care, think about accountable care organizations and think about Medicare Advantage. 

And of course, Juniper is involved in both. So accountable care organizations are a value-based care vehicle for people who choose not to be in Medicare Advantage. It is a fee-for-service option that the government has put in place to affect care transitions, and impact the triple aim for fee for service Medicare beneficiaries. You enter into an ACO through attribution in a primary care practice, so that means you don't have to enroll a member. But if someone does certain things with a primary care practice, they become part of that primary care practice's, ACO. And then if you want to see the value you create from that, you as an operator, need to enter into a contract with that ACO. 

And the right ACO will agree to pay quality incentives to the community as well as to the primary care practice, and that's what Juniper does. Juniper communities are enrolled in an ACO and we share 25% of any gain, the ACO makes on managing care appropriately under value-based care incentives that they accept to do with their agreement with CMS. And cashflow wise, ACOs are interesting because you get that money when CMS provides the ACO with an understanding of a year ago. What those quality and what, how they came and what their outcomes were like, how much money they saved Medicare.  

Lisa McCracken: Theres a year delay, I'm sorry. There's a year delay in that? 

Lynne Katzmann: There's over a year delay. And so cashflow wise, you can't budget easily until several years in, what kind of revenues you will receive from an ACO. But not every resident is going to be part of a Medicare Advantage plan, and so I highly recommend that those people who have preferred provider relationships, with primary care or onsite, make sure that their primary care practice is affiliated with an ACO and they can get a contract for their community, which rewards them for their participation. So again, Juniper has a care transitions program, which is effective, is part of an ACO and Juniper, many years ago as you know, got together with another group of owner operators and started a Medicare Advantage plan. 

And today I'm glad you asked me to talk because today I really want to discuss with people the benefits of being part of an operator owned Medicare Advantage plan. And so Juniper started this a long time ago where the only way to participate in Medicare Advantage was to take risk. Now there are many options in plans, that include ours, for people to join, but to become involved on a more slower pace and to do so with either electing risk or not electing risk. So in Juniper, we have elected risk and that has enabled us as an operator-owned plan to do two things that are really important. One is we shape the benefits that our residents get, which means that because we understand senior living, we can provide health related benefits that pay our communities for doing the services that manage chronic illness and that ultimately succeed in providing value-based care outcomes that work both financially and in terms of customer care and satisfaction. 

The second thing we can do is develop reimbursement, which is meaningful for us. And I'll give you two simple examples that are really important. As an operator-owned plan, we provide SNFS with reimbursement that equals 100% of PDPM. And most SNF providers are very upset with Medicare Advantage because their negotiated rate is far less. 

And while initially that made sense because they thought the alternative would be more scale, you'd get more business at a lower rate but that never materialized. And so the rates have stayed lower. In an operator-owned plan we can make a change. And that's really critical for those of us in senior living that own skilled communities or skilled beds or work with them. 

Another simple example of how rates make a sense control is we get to set reimbursement for things like care coordination, managing care transitions. So at Juniper, our operator-owned plan pays us for managing care transitions, pays us for care coordination, and it pays us $125 per member per month. 

And Lisa, that's budgetable. We get that every month. So the number of members that we have in the plan times 125 comes to us. And there are many other examples, but simply operator owned plans have different incentives then do the Humanas and the United Healthcare or Optimums of the world. 

They are beholden to shareholders and to other people for payment, whereas an operator owned plan, our goal is the best care for our residents and making sure that everyone who provides that value, who creates that good care and service is paid appropriately for that, including senior living providers. 

And that's the key difference. And what's changed in the world is that you don't have to take risk. You don't have to do what Juniper did together with our partners at Ohio Living and Christian Living Communities in Kirana to create an operator owned plan, you can join us now and enroll your members in that and still reap many of the same benefits. 

So long-winded answer, Lisa, but we have an ACO, a Care Transitions Program, and a Medicare Advantage program.  

Lisa McCracken: Yes. Yeah, and that was a very helpful overview and I'm sitting here jotting down questions and observations. So one of my observations, and I think this is just important to acknowledge, so when you-a couple-so first of all, value-based care is really an, it's an operating platform. 

There, there's the reimbursement and the revenue side of things and so forth, but it's a way of doing business to improve outcomes, optimize the resident experience, satisfaction, so forth. So you can do that potentially without going like full at risk. I think that's, those are the things that I think intimidate organizations. 

Lynne Katzmann: You can do all three types of programs without being at risk now. When we started, that wasn't an option, but now it is.  

Lisa McCracken: So the other observation is that this is a long-term play. The fact that you say just even with the ACO with those benefits you can wait over a year to see some of those benefits that obviously you put forth, 12, 15, 18 months prior. And I think that's important to know that this is a long game. So this is not a quick switch. Would you agree with that? There's different elements of that. Owning your own plan is a much longer game than potentially getting in an ACO network with a primary care physician group. But I think this is a calculation. 

Lynne Katzmann: Don't think so. 

Lisa McCracken: That people need to be patient with.  

Lynne Katzmann: I'm not sure that's true anymore, Lisa. Someone, so our plan is called Perennial Advantage, right? We have operators, people who operate senior living communities who have joined and are not at risk, right? 

Okay. They receive the same reimbursement for care coordination. They receive the same rent subsidies of $75 per member per month. They receive other reimbursements, all of which is budgetable. What is different is how much of the difference between the gain share, which I can explain if you'd like, they receive. 

They receive quality incentives rather than gain share. And so total reimbursement amount, will not be as much as if someone is successful at going at risk, but it will be budgetable and typically more than they receive in total from an ACO a year later. Yeah, so it does not have to be a long play for people now to enter Medicare Advantage with an owner operated plan. 

Lisa McCracken: Understood.  

Lynne Katzmann: They simply are not owners. They are enrolled their members as an operator, enrolled or an operator, contracted member.  

Lisa McCracken: Other questions that I have. So you mentioned primary care physician…so strategic partnerships, pharmacy, home care, primary care, physician groups. Are they all external partners or do you have any skin in the game with any ownership with any of them? 

Because there is that debate sometimes, do we bring it in out and do it ourselves versus do we contract out? Is there a little bit of both?  

Lynne Katzmann: Yeah. Yeah. Remember Juniper started our value-based care efforts about a decade ago with our Care Transitions program, it was 2014. So I will tell you that when we went from pure Care Transitions to preferred onsite providers, we could not find primary care providers to do what we wanted. So we did start our own primary care practice. We still run that. It's small. You can do it by starting your own, which is a different business, or you can do it with a partnership. And I think partnerships are pretty effective ways of doing it. 

The remainder of our providers, our preferred providers, are all partners. And if I were to suggest people getting into it, I would look at partnership options first, before I would look at forming your own. Although there are joint venture structures which provide for some amount of ownership, which I would say is another very meaningful option that people could consider. 

What you need, when setting up arrangements, Lisa, is understand what you need to make that arrangement successful under value-based care. And there were several non-negotiables that Juniper put into place early on that have enabled those partnerships, we believe, to be highly successful. 

Lisa McCracken: Are there any you're willing to share?  

Lynne Katzmann: Sure. Sure.  

Lisa McCracken: And then I wanna get into just where do people start your perspective on that, but I'm just curious to know some quick non-negotiables.  

Lynne Katzmann: Yeah. So non-negotiables are, you have to have the same providers visiting all the time. 

That doesn't always happen. You wanna have steady, reliable providers. You wanna have times, set times and hours every week where those providers are on site. Now, when your membership is high, that's never a problem, but when you're starting, membership has to bill. In order to be successful you need to define the hours and make sure that your providers are willing to provide those hours. That means that they will be providing some uncompensated time to you to help build their practice. But that's key. There's several other things, two other things that I'm gonna mention that I think are key. 

One of the things that we did is we required our providers to utilize the same playbook, and that means to enter certain data into our EHR. And that was very critical. Those things include certain types of data that they collect during their visits, but most importantly, entering progress notes into our system so that there's a running progress note. 

So anyone providing care or support to an individual reads from the same script. They know what's happened. And the other non-negotiable that they have to do in our system is they must have regular communication. We send, we have a scorecard, a set of alerts that go out every day. It looks like a 24 hour report in your EHR. 

We ask everyone to open that up every morning because in that is communication, special communication about things that have happened in the last 24 hours, and people who need rapid attention for a change in condition. And it's that change in condition, managing that, that makes you successful in value-based care. 

So those four things I would say are non-negotiables on the primary care side.  

Lisa McCracken: And I think similar on they seem like fair to me, non-negotiables because at the end of the day again, that's gonna set you up for success, which I wanna spend a moment on. This is not something where an operator says we should, let's get into this value-based care thing. 

There's some foundational work that needs to be done. You've already referenced obviously, investment in some the technology, the data, your Connect4Life. Clearly you spent some time designing that and what that means. So what are some of the foundational elements, the ducks in a row, for lack of a better term, that groups need to have in place, whether it's resource allocation, other things. 

Before they dive in? What, do you have any core elements that you would recommend?  

Lynne Katzmann: Yes, I do. I do. Data. Data and technology is key. There are many ways to collect data today. Many more people are, have utilized any HR than did when we first started. We implemented an eHR at senior living communities, as well as our SNFs, in 2011. 

We started that process. It was fully operational in 2012, so we go way back. But you need to have a way to collect the data and understand the outcomes that are needed for success in value-based care. You'll also need a means to access real time information and do that among providers if you want to be very successful. 

And the latter, the inter provider communication or intra provider communication has enabled us to intervene quickly at a change in condition, which is what ultimately achieves the outcomes of keeping people out of hospitals. Which is where the money is, right? So you need data and you need a platform, a real time data and communication platform, which can be your EHR. 

So that's one of the things that you have to have if you don't have that you can perhaps work with others to pull some of the data you need out. What are the data pieces that you absolutely have to understand before you enter into certainly an at risk value-based care program and frankly, any value-based care program because the plan that takes your risk is not going to want you if your hospitalization or your readmission rate is too high. And they're gonna wanna know what that is. And there are different ways of looking for those data. But the best way to get into it is to be able to produce that data on your own. And any of our EHRs, any of them now, will enable you if you use the right modules to understand those data, they will make those data available to you. So that's number one.  

The second thing you need to do, frankly, is you need to understand the basis of value-based care. What it is, you need to understand that the way to win is to manage changes in condition. Essentially, it's to manage chronic illness through managing times when people's condition changes, when it gets worse, and then to have the right systems to intervene. So to do that, you need to understand that our core competencies in senior living are care assessment, planning, and 24x7 monitoring. We have always done that. In most states, we are mandated to do it, whether you've considered yourself a hospitality oriented senior living operator or not. 

Most of us have always had to do assessments, have had to do care plans, and by virtue of the fact that people live with us, we provide 24x7 monitoring. And when you accept and recognize that's what you do, and that those things together with the data and communications platform are the foundations for value-based care, you've got what it takes. 

So it's a mindset shift to understand that we have always, at least in the last decade, managed chronic illness. We've gone unfortunately in post COVID, I think we all accept that the people we support who live with us need support services, ADL support. They need chronic care management. It is what we do. It's our core competency. We can think about how we do that differently. 

And that means accepting it and changing some workflows and some job descriptions, but it is not a major shift, Lisa. The point I wanna make is that the foundations are in place almost everywhere. It's how we choose to work with them and the importance we attribute to that work, right?  

Lisa McCracken: We thank you for the inspiration and really the leadership of you, for you and also the Juniper organization. 

Because you really are pioneers, I think, and it helps the industry if you have successful examples to look at and really to learn from in your transparency is just so appreciated. Anything of what's next for Juniper on this front?  

Lynne Katzmann: Yes. So you know, chronic illness, chronic care management, chronic disease management, as it's known, has all has been a part of what we've done for a long time. 

We're into wellness and we define wellness differently than healthcare and wellness in Juniperland is lifestyle management. Again, it's something we do as a basic in senior living. So what is that? It's food and nutrition. It's mobility assistance and it's socialization. At Juniper we call those things food, fitness, and fun. 

And so we extended our continuum, Lisa, to think about what we do from wellness and lifestyle management all the way to integration of medical services and that type of intervention. And I think that continuum will enable us to not only improve our outcomes under value-based care, which is a good thing, but also provide a variety of different programs that we hope will attract younger people and enable us to provide the kind of experience that people like me, a Boomer, want.  

Lisa McCracken: We've often talked about not just living longer, but living life longer, better. Thanks for your time, Lynne. 

I know we just touched the surface on all of this stuff, but I think this gives listeners the ability to learn. To think differently, to maybe take that leap and some of those initial first steps. So thank you again, Lynne Katzman with Juniper Communities, and we appreciate all of you listening to this NIC Chats podcast. 

Thank you again to Sage, our sponsor, and we look forward to bringing you additional information and insights soon.