The following is an op-ed exclusive to Park Place Live.

In long-term care, some of the most clinically intuitive interventions are also the hardest to implement.

Take dehydration, an issue that is both common and consequential in skilled nursing populations. The clinical logic is straightforward: identify early signs of hypohydration, intervene proactively, and prevent avoidable decline. Yet, in practice, even well-supported interventions like IV hydration often stall before they begin.

Not because they lack merit, but because they challenge the structure of how care is delivered.

The Gap Between Clinical Logic and Operational Reality

On paper, proactive care models are easy to support. Early identification, earlier intervention, better outcomes.

But in practice, these models ask more of already strained systems. They require staff to recognize subtle changes, document differently, communicate more frequently, and act before a condition becomes acute. These are not small adjustments. They disrupt deeply ingrained workflows that define daily care delivery.

Nowhere is this more visible than hydration management.

Despite clear acknowledgment in frameworks like the CMS RAI Manual and INTERACT protocols, dehydration often remains a reactive diagnosis rather than a proactively managed condition. Residents decline, symptoms escalate, and only then does intervention occur. Often in higher-acuity, higher-cost settings.

The disconnect is not clinical, it’s structural.

Three Points of Friction

1. Clinical Ambiguity at the Point of Decision

Physicians are ultimately responsible for authorizing interventions like IV hydration, yet many lack standardized protocols for assessing dehydration risk in the nursing home setting.

Without clear pathways, decisions can feel subjective. In response, many default to caution waiting until dehydration is more acute or deferring to hospital-based care, where protocols are more defined and liability feels more contained.

This is not resistance to innovation. It is a rational response to uncertainty.

2. Operational Constraints on the Frontline

Nursing staff are often the first to detect early signs of dehydration subtle changes in intake, cognition, or function.

But recognition does not equal capacity.

Initiating and managing IV hydration requires time, training, supplies, and monitoring. In already constrained environments, even clinically appropriate interventions can become operationally impractical.

External partners can help bridge this gap, but their involvement introduces new layers of coordination and oversight, adding complexity to an already fragile system.

3. Regulatory and Financial Tension

Perhaps the most significant barrier is not clinical or operational, it is regulatory interpretation.

Under PDPM, interventions like IV fluids can impact reimbursement by increasing Case Mix Index (CMI). While often appropriate, this creates a perception risk: that clinically justified care could be viewed as financially motivated.

The result is a chilling effect.

Operators hesitate. Physicians defer. External providers operate under scrutiny. And interventions designed to prevent deterioration are often delayed until they are no longer preventive.

A System Misaligned with Its Own Goals

What emerges is not failure of intent, but failure of alignment.

Clinicians want to provide better care. Operators want to prevent unnecessary hospitalizations. Policymakers aim to control costs while improving outcomes.

Yet, the system continues to reward documentation of decline more clearly than the prevention of it.

In this environment, stabilization can be undervalued, even though, for complex long-term care populations, it represents meaningful clinical success.

Reframing the Question: From Utilization to Outcomes

The path forward does not require less oversight; it requires better alignment.

CMS is uniquely positioned to lead this shift. With visibility across the full continuum of care, it can evaluate not just what happens within a facility, but what follows: hospitalizations, emergency visits, and downstream cost.

This creates an opportunity to ask a different question:

Not just “Was this service justified?”
But “Did this intervention prevent something worse?”

In the case of IV hydration, the relevant outcomes are clear:

• Fewer avoidable hospitalizations

• Greater resident stability

• Lower total cost of care

• Improved quality of life

  
  

If these outcomes are achieved, the model should be recognized not scrutinized.

Recognizing the Role of Operators as Innovators

Long-term care operators are increasingly being asked to do more than manage facilities. They are being asked to innovate in real time.

They are testing new care models, investing ahead of reimbursement, and navigating the tension between clinical potential and operational feasibility.

In many ways, they are piloting the future of care delivery without a fully aligned system to support them.

Recognizing this role is critical.

Not to lower standards, but to evolve how value is defined and measured.

The Bottom Line

If long-term care is to move forward, policy must evolve alongside practice.

The question can no longer be limited to whether care was coded correctly. It must also consider whether that care kept a resident stable, prevented decline, and improved outcomes over time.

Because in long-term care, success is not just treating deterioration.

It is preventing it.

And the system should make that easier, not harder.

Avi Lev is the CEO for Vitaline Clinical Hydration Solutions. Vitaline’s mission is to solve the dehydration challenge in long-term care by delivering physician-led IV protocols that measurably improve patient outcomes and quality of life.