Transcript Generated by AI 00:01 Hey, Mark Parkinson back for Park Place and 00:04 let's talk. 00:05 And we have a really special tree today. 00:07 We have what I believe is the leading expert in nursing home quality and the 00:13 regulatory system in Mary usually. 00:16 And she's been the leading expert not just for the last few years, 00:19 she's been the leading expert for over 40 years. 00:22 She was the sniff representative that had a front row seat in Congress and then at 00:28 CMS during the development of the modern regulatory scheme. 00:33 And in addition to that at various times in her remarkable 40 plus years in the 00:38 sector, she has saved us from critics who have 00:41 wanted to adopt regs that would have made it really impossible for us to operate. 00:47 And also in her southern charming way, she has pushed us to quality when we need, 00:53 have needed to be pushed. 00:55 And in doing so, she has made the life of every provider 00:58 better and she has improved the care of hundreds of thousands, 01:02 possibly of millions of residents over the years. 01:06 There are a gazillion things that we could talk to Mary about, 01:09 but today we're going to focus on the development of the modern regulatory 01:13 system. 01:14 Before we do that, I want to thank First Quality for its 01:17 continued support of Let's Talk. 01:19 First, Quality is a fantastic company and it's 01:21 completely appropriate that they would be connected to this podcast, 01:24 particularly as we talk about nursing home quality across the country. 01:29 Before I bring Mary into this, let me just give you some snippets of her 01:33 background and it truly is remarkable. 01:36 Mary is a registered nurse who has committed her entire life to the sector. 01:41 She's been an owner and operator of Sniffs for almost 40 years, 01:45 going clear back into the 1980s. 01:47 She was running buildings back in the 80s. 01:50 She was a champion of quality before that was really a thing. 01:53 As I indicated before, she was the sniff Rep both in front of 01:57 Congress and at CMS as we developed our modern regulatory system. 02:02 She was also the sniff Rep on the National Commission on Aging. 02:05 She was one of the first female chairs of the American Healthcare Association. 02:09 She's worked for multiple major companies in helping them figure out quality in the 02:14 regulatory system. 02:15 She the National Quality Award, the most prestigious quality award, 02:19 is named the Mary Usley Champion of Quality Award. 02:22 And most recently, she has been named as a lifetime 02:25 achievement winner by Mcknight's and their most prestigious award. 02:29 Mary, welcome to the broadcast. 02:32 Thank you, Mark, and thank you for that very, 02:35 very kind introduction. 02:37 I'm, I look forward to our conversation today 02:39 and it's always a treat to talk with you. 02:42 Well, I could have gone, I could have added a lot more. 02:45 So those are, those are just the highlights. 02:47 And it is remarkable you, you've been there not just to save the 02:50 sector, you've also moved the sector forward when 02:52 we've needed to be moved forward. 02:54 We're going to talk a little bit about that, but before we do that, 02:57 I want you to go back to the beginning of your time with Sniffs, back into the 80s. 03:02 You know, there's so many people have just gotten 03:05 into the sector in the last 10 years. 03:07 It's hard to think about owning and operating in the 80s and what it was like. 03:10 Can you tell us what it was like to own and operate in the 80s, Mark? 03:15 I guess if you think about one word, it would be that it was a little simpler 03:20 then that it than it is now. 03:22 Probably the biggest difference was the acuity level of our of our patients at 03:27 that time, residents and patients at that time. 03:30 There were two categories of care, our skill care and then intermediate care. 03:36 And overall again we saw a lot of stroke patients, 03:40 we saw a lot of the dementia diagnosis and that kind of thing. 03:45 But the issues that we face were still to some degree and ones we face today. 03:51 How do we take care of this very special geriatric patient? 03:55 We lower know a lot more now than we did then, 03:57 but that would still and the adequacy of reimbursement. 04:02 When I started I was being reimbursed $27. 00 a day. 04:06 That is about the equivalent of 110 or 115 today. 04:11 Workforce was not the issue it is now, but it was it was it was an issue so 04:17 simpler, easier, a little more time, but still with this challenges. 04:24 And what was the regulatory system like? 04:27 What was the survey process like back then? 04:29 Well, the regulatory process, you know, nursing homes came into being in 1965 04:35 with the passage of Medicare and Medicaid. 04:38 So as then the Healthcare Financing Administration, now CMS looked at, OK, 04:44 what do we do? 04:45 How do we, how do we really accredit, accreditate healthcare? 04:49 So hospitals were easy. 04:50 Matter of fact, deemed status was built into the Medicare 04:54 and Medicaid regulation at 65 for hospitals adopt the Joint Commission 04:59 standards. 05:00 We're good to go. 05:01 Nursing homes, no model existed. 05:04 So as they thought about what do we do when they thought, OK, we want them safe. 05:10 So for sure what they have to be safe. 05:11 So it was called the bricks and mortar regulations, you know, 05:15 build safe buildings, then everything will go. 05:18 But then there were the care provisions and in care provisions they you really 05:23 use the surrogate of policies and procedures. 05:27 If you have good policies and procedures, then good care will follow. 05:31 Unfortunately, it didn't work out exactly that way in 05:35 all of our nursing centers. 05:37 So that was the structure. 05:38 Surveys were again, simpler. 05:42 Surveyors would could spend an entire day just in a room going through policies and 05:47 procedures. 05:48 They got out on the unit some, but not that much. 05:52 You're surveyed. 05:53 If you had deficiencies, submit a plan of correction. 05:56 You were done. 05:57 I mean it, I assumed there were less surveyors and 05:59 the and the time was much quicker. 06:02 Well, there were fewer, fewer nursing homes. 06:05 And yes, I would say the average it was depending 06:09 on were you doing really great or not in your survey in two to three days. 06:14 But there were surveys that were completed in one day. 06:18 And I think you've described to me before that that the regulatory system was 06:23 really, and you've kind of mentioned it already 06:25 was really focused on this, the structures themselves, 06:28 fire safety and and those kind of issues as opposed to cure. 06:32 Yeah. 06:32 And very little. 06:33 I mean, today it's all about emergency 06:35 preparedness that were surveyed so intensely and should be against that, 06:39 but not emergency preparedness in those days just as your physical plant safe. 06:45 So in the 80s, there was then kind of a major thing that 06:48 occurred that led to the develop, you know, 06:51 Congress getting really focused on nursing homes. 06:54 Tell tell us about that. 06:57 CMS healthcare finance Administration. 07:00 They saw the need for a change and they tried to change the regulations in 80 and 07:07 82. 07:07 There was Joe, there were so many voices involved, 07:11 position, approval, just I mean, it was kind of insane. 07:16 And so they failed at at that opportunity in the early 80s. 07:21 So a little bit later there was a book written by Bruce Vladic and it was called 07:27 Unloving Care. 07:29 I remember reading the book at the time and thinking, 07:32 I've never encountered nursing homes like that's being described here. 07:37 It's surely this isn't true, but I guess I found out later that, yes, 07:42 some of that was true. 07:44 And as time passed a little bit, then the Institute of Medicine got 07:50 involved and said we need a study. 07:53 And who would chair that study? 07:55 Bruce Viladic. 07:57 Pretty, pretty telling there. 07:59 But again, he became a close friend of mine and I 08:02 really have admired him through the years. 08:05 It was a good panel they pulled together. 08:07 We had great representation on that panel. 08:11 So the panel studied what was happening in nursing homes and what would their 08:15 recommendations be. 08:17 The recommendations really centered on patient care, quality of life, 08:22 patient rights assessment, those types of things. 08:25 So in 1986, the study was published and was really 08:30 given a lot of attention nationwide. 08:34 There was a call everywhere for doing more and better work in nursing centers. 08:40 So CMS immediately started trying to promulgate regulations off of the IOM 08:46 study, and they actually got some regulations 08:49 written, but Congress stepped in in 1987 and 08:52 pretty much said to CMS that you've had your chance, 08:56 you haven't been able to do this, it's necessary. 09:00 And so we need to move forward and really take charge of this and pass legislation. 09:08 So go ahead. 09:10 So one, one of the things I really want to make 09:13 sure that we emphasize, just point out, and you've already said it, 09:17 but I just want to it, it is to me, it's incredibly significant. 09:21 The modern regulatory system occurred because of reports of poor care and, 09:25 and a, and a book that was written that I didn't 09:28 know about until we, I started interviewing you for this, Mary, 09:31 and I can't wait to go out and read this book. 09:34 But a book that was written that highlighted that care and that created 09:38 this momentum for the survey system that we have today. 09:42 Exactly. 09:42 And the regulatory framework. 09:44 And also along the same lines, the same time a group formed called the 09:49 National Coalition for Nursing Home Reform and they were great consumer 09:55 advocates and pushing really, really hard to get some type of reform 10:00 done in nursing homes to improve care and quality. 10:05 I mean, it really explains why I've heard you on 10:08 so many occasions tell us at the American Healthcare Association of providers in 10:12 general, hey, if you don't get your act together bad 10:15 things, it's it can occur. 10:16 It's not just the right thing to do to take care of patients in a great way. 10:19 If we don't do it there, there will be consequences, correct? 10:25 Absolutely. 10:26 And I mean, it's a great lesson for the future as 10:28 well. 10:28 But let's go back to the 80s. 10:30 So so you had Congress. 10:33 Let's go back. 10:34 Let's stay there. 10:34 OK, OK, go ahead. 10:39 Congress decided to jump in and tell us about your role with that effort and and 10:44 what Congress ended up doing. 10:47 Well, you know, things were very different in those days 10:50 with Congress. 10:51 It it there were two bills introduced and one in the House, 10:55 one in the Senate and the bill itself in the support of the bill was very much by 11:01 bipartisan and again I was young, but whether it was a Democrat or 11:06 Republican introducing the bill, I don't ever even remember being 11:10 discussed. 11:11 I'm sure it was by others beyond myself, but but during that time I studied that 11:19 the regulations or the legislation on a daily basis. 11:24 I was working very closely with the Kentucky Association at the time and I 11:30 would study the various iterations of of the legislation, 11:34 what changes it would mean. 11:36 Spent a lot of time calling Washington, DC and the American Healthcare 11:41 Association, just studying it, learning it, understanding it, 11:45 thinking through, you know, how would we implement this? 11:49 What would it be? 11:50 And really very much took on the role in Kentucky of keeping all of our membership 11:56 educated. 11:57 The state agency educated legislators in the state of Kentucky, 12:01 educated about this massive piece of legislation that was moving through 12:06 Congress. 12:08 And then eventually it passed. 12:11 But that's December 22nd, I think at 2:00 AM in the morning, 1987. 12:19 And at the time that it passed, I think that the sector felt OK about how, 12:24 how did the sector feel about the the actual legislation that passed? 12:29 Well, let's just say that there were a wide 12:32 variety of opinions to to say the least. 12:36 There were those that opposed it in its entirety, every single word. 12:41 We didn't need to change the way we were providing care. 12:44 And those were very loud voices within, within our profession. 12:49 There were those of those such as myself, the care provisions and that type of 12:54 thing, the quality of care, quality of life. 12:56 I was already doing it in in the nursing centers that were under my direction. 13:01 And of course, I would say to myself, who could oppose this? 13:05 Who wouldn't want to do this? 13:07 And I was always stunned when I received the feedback, no, 13:11 we don't want to do that. 13:13 No, we don't think it's necessary. 13:15 And always that overarching statement, it'll cost too much. 13:19 It'll cost too much. 13:21 And so, you know, from the perspective of the American 13:25 Healthcare Association, to say that the association was walking 13:30 on eggs is very, very mild. 13:33 The association supported most of the care provisions. 13:37 We all did not agree with the enforcement provisions because we did see them as 13:43 very punitive. 13:44 And I don't think you can punish your way to success. 13:48 I've changed my mind a little bit about that over the years. 13:51 And some of those enforcement provisions, but they looked very frightening, 13:56 I think to everyone at the time. 13:59 So we all know that once, once a law passes, 14:01 that's just the beginning. 14:02 The key is, are the rags and what has become CMS 14:06 developing those rags? 14:07 And I know that's when you really dove in deep. 14:10 I think that might have overlapped the time that you were the chair of the 14:12 American Healthcare Association. 14:14 It was around that time. 14:15 What tell us about your, the, the years that you then spent helping 14:19 develop the rags? 14:21 In January, CMS wasted no time. 14:25 In January of 88, they pulled together what we referred to 14:29 ourselves as the committee of 20. 14:33 And so we, we came in to to meet with CMS and to get 14:38 an overview of this regulation and the plans that the CMS again hit foot the 14:46 time we're actually making in, in order to implement this. 14:53 And as we came together with this group of 20, the federal staff, 14:59 I'll never forget it was Tom Morford that conducted that meeting. 15:05 And he emphasized to us the daunting task that we had in front of us. 15:10 Not only was this a massive piece of legislation, 15:14 it contained time frames where of that mandated when things would be implemented 15:21 that to a very large degree we're almost, well, 15:25 we're unrealistic and very few of those time frames were actually met. 15:31 I remember being so intimidated sitting in that first meeting being in and we 15:36 didn't have the beautiful building that we have now for CMS. 15:40 It was an old, old building and just going through 15:43 narrow hallways and then sitting down at these table, 15:47 the table with all of these people that I was just in awe. 15:52 And I'll never forget following that meeting, 15:54 I made a call to then the president and CEO of ACA and I said, Oh my goodness, 15:59 this is so big. 16:00 I have got to learn to walk before I can run. 16:05 And he replied to me, We don't have time. 16:08 You're it, you're selected. 16:10 And, and, and we are, we are on our way. 16:13 So you know, the way it worked with this committee of 16:18 20, I mean, all of it was very, very different. 16:22 It didn't work like the technical panels that we deal with today. 16:26 We were called advisors to ACMS. 16:30 We were subdivided, we received, had the opportunity to sit around the 16:36 room. 16:36 I will never forget this and talk about what does this legislation mean? 16:42 What do they want, What are they looking for? 16:45 If you're if you're thinking about this provision, what does it actually say? 16:50 What impact will that have to this day? 16:53 Mark, I think back to those moments and know 16:56 how very, very fortunate I was. 16:59 So then as opposed to those, as CMS would draft or the regulatory text, 17:05 they would send us the actual text. 17:09 We would have the opportunity to study it, make comment, then we would come back. 17:14 There were weeks that I spent four days in Baltimore, 17:17 multiple trips every single month. 17:20 I was very fortunate that I was working with our own organization, 17:24 that I had the time to be able to do that. 17:27 But they let us, you know, read that, read all the texts, give comments, 17:32 come together again to debate it. 17:34 And in the room again would be the associations, the consumer advocates, 17:39 the state agency directors. 17:41 So you can imagine the debates were hefty as we move forward. 17:47 Then when they were actually came out as proposed regulations, 17:51 they followed the same format. 17:53 We still had more opportunity to comment. 17:55 In AHCA. 17:56 We put together a subgroup of our then called facility Standards Committee that 18:04 I worked with on a daily basis. 18:07 We all worked almost full time on this piece of legislation on sharing with them 18:12 our discussion, getting their feedback and one of the 18:15 things that I think today gives real value to the regulatory framework that 18:20 was developed. 18:21 It was very much member driven. 18:23 It was it, it was thoughtful, good individuals that wanted to do the 18:30 right thing. 18:31 Also wanted, again, as Tom Morford had said, 18:35 make sure that these regulations were something that we could actually 18:41 implement and just give us an idea of a length of time that this, all this, 18:47 the group of 20 worked on all of this for the regulatory text, 18:52 a little over 2 years for enforcement and actually getting everything out there 18:59 until 1995. 19:01 And again, I made, I made all those trips back and forth 19:04 during that period of time. 19:06 I knew Baltimore more better than I knew my hometown in those days. 19:12 Now, Mary, over the years, you've often made the point about how the 19:16 sniff regs are different because of the treatment of standards elements and 19:20 conditions and how that's not true with other providers. 19:24 Can you explain that? 19:25 And then kind of how does that that all started? 19:29 Well, it started because it was driven by the 19:34 legislation itself. 19:37 And this is one of the areas, Mark, again, as you say, 19:41 that is so not understood at all even today by many people in the federal 19:46 government and, and at at at CMS. 19:49 So when you think about kitchen conditions, standards and elements, 19:54 think about condition as a really broad, really broad regulatory framework like 20:00 patient rights and then standards. 20:03 Get into a little bit more of the details. 20:06 Exactly what does this mean? 20:07 What are we trying to accomplish? 20:09 And then you get into the elements and what elements are they're really the 20:14 detail, What practices should be in place, what procedures, 20:18 what will you be doing in order to comply with this condition? 20:23 For hospitals, home health, Hospice, almost well everyone except for nursing 20:29 homes, conditions, standards and elements. 20:33 And you're not out of compliance where you could get an enforcement action until 20:38 you're out of compliance with the entire condition. 20:42 So you could have elements out, standards out, 20:45 but you're still in compliance with the condition overall. 20:48 So no enforcement and submit a plan of correction. 20:53 The statute itself said that we shall remove the hierarchy of conditions, 21:00 standards and elements for nursing facilities and the how compliance will be 21:07 determined will be on the impact on people, on people, on patients, 21:13 on residents, and that on their face, all requirements of participation will be 21:21 equal. 21:22 And it it would be actual harm or potential harm that it would be 21:27 determined how compliant we are. 21:31 And one of the important things and the one of the federal surveyors and myself 21:37 trained on this at an ACA convention standing room only, 21:41 you can't imagine as we trained and the federal surveyor interpreted in this way 21:47 for the group. 21:50 The law says that the speed limit is 55. 21:55 When you're going 56, you are out of compliance. 22:00 There was a gasp in that room that I will never forget that day. 22:06 Now through the work that we did on enforcement and all of that and even 22:12 creating how we're deemed today isolated or a pattern or widespread, 22:18 we were able to get a little bit of protection in there. 22:25 So, but totally different. 22:28 So when the when the headlines in the New York Times said nursing homes are out of 22:33 compliance here and hospitals only this nursing homes are bad. 22:39 It's apples and oranges. 22:41 It is not the same, but so few people there are state agency 22:45 directors today that don't know that. 22:49 And we have it. 22:50 We have it on tape now. 22:51 So hopefully, you know, you and I were in a meeting once with 22:55 with with CMS Mark, when the individual sitting across the 22:58 room from us referred to condition standards and elements and he was a 23:03 federal employee. 23:04 Exactly. 23:06 Mary, I know you'll be humble on this, but think about a world where you and the 23:11 American Healthcare Association and the industry had not been at the table back 23:16 when Congress passed Oprah and for the two years that you worked on the regs, 23:21 what do you think would have happened? 23:25 I think the enforcement provisions would have been so onerous that many of us 23:30 would have been closed. 23:33 I'm not sure we would have seen the expansion of, 23:36 of nursing homes that that we have had today. 23:40 It's hard to even imagine how bad it would have been if we hadn't been 23:45 involved. 23:46 And one of the things where we could step up and say, we support patient rights, 23:54 we support quality of life, quality of care, 23:58 but let's keep that guiding principle in in place that that that knows that we 24:05 have to have regulations we can implement and surveyors can survey. 24:12 And you know, Mark, we put together what we called guiding 24:15 principles. 24:17 And it was the guiding principles that led my discussion. 24:20 And it was our AHCA, our team there that helped put them 24:24 together, that guided my discussions and my 24:28 representation every single day that that I sat there. 24:32 And I don't want to go on too long here, but one of the key things, 24:37 and this was a very important day for us. 24:41 We were sitting at the table, we were talking about survey, 24:43 we were talking about enforcement. 24:45 And the CMS individual says, OK, we're going to create a penalty index. 24:52 And this penalty index will be how we will be punitive to nursing homes that 24:56 are not in compliance. 24:57 The day ended, I went back to my hotel room and I knew 25:01 that life as we knew it were going to be over. 25:04 I studied the legislation again that night. 25:07 I studied the penalty index that they had given us. 25:10 And the next morning when we went back, I asked if I could open that meeting. 25:15 And when I opened the meeting, I talked about the fact that the statute 25:19 says penalty once only in the area of civil monetary penalty. 25:23 The language in the statute says remedy. 25:29 Remedy is to remediate. 25:31 It is not to punish. 25:34 I had a page and 1/2 or so written out. 25:37 I went through it carefully. 25:39 At the end I said if we're going to set up a penalty index, 25:42 the American Healthcare Association gets up and walks away from this table. 25:47 And Mark, I'm not sure I asked anybody if I could 25:51 say that, but I did. 25:53 And CMS said let's take a break. 25:56 And they came back and they said, Mary is right, 26:00 we're throwing out the penalty index and we're going to start the discussion from 26:06 using remediation and making determinations that that again was one of 26:11 our guiding principles. 26:13 What is the lowest level remedy that we need to achieve and sustain compliance? 26:20 Fix the problem. 26:21 Yeah, fix the problem. 26:22 So unfortunately there's now so many times when the remedy is seems like it's 26:26 so much more than that. 26:28 Yes. 26:28 But that, that, that's that. 26:29 That's for another discussion. 26:32 It, it feels like there was more of a 26:34 collaboration with the sector, Congress, CMS, 26:37 even the advocacy groups that I tried to get along with when I came to DC and I 26:42 just couldn't, I couldn't break the ice. 26:46 It's what happened because we don't have that now. 26:50 Well, as as we move down the road with the 26:53 implementation of the requirements, I mean from 1988 until 1998, 26:58 it pretty much existed. 27:00 And for those that are still with us, and I miss those that are not that were 27:05 part of this group, I still consider them friends. 27:08 And it was a collaborative effort. 27:11 Some of best friends I think I've ever had were some of the federal staff. 27:15 But in 1998, unfortunately, we usually do it to ourselves, Mark, 27:20 we still had a subset of nursing homes just coming in and out of compliance, 27:25 serious non compliance. 27:28 And that remedy to sustain, correct and sustain really wasn't holding 27:32 as much as we would want to. 27:35 It was called the Saturday Night Massacre inside of CMS and outside there was, 27:40 it was during the Clinton administration, there was a massive reorganizations of 27:45 the Health Standards and Quality Bureau that included the survey cert inside of 27:51 CMS. 27:52 And it was the beginning of the special focus. 27:55 There were 100 facilities that were selected as the worst performing in the 28:00 nation and they would be surveyed more frequently. 28:03 And we began to lose such as opportunity to correct before imposition of civil 28:09 monetary penalty. 28:11 We started losing many of those provisions. 28:15 We are at least some of them that we had been able to. 28:19 And it our, our, our relationship just wasn't as close 28:24 anymore. 28:25 It was more kind of like the technical panels, a little bit more hands off. 28:30 Don't get too close to us. 28:33 Yeah. 28:34 So Mary, let's Fast forward 30 years to the here 28:36 and now. 28:37 Obviously there would be many people in the sector that would that would say that 28:41 the regs right now are too punitive and they they hinder patient care. 28:45 What's your thought about how the system is evolved and and what do we need to do 28:49 about it? 28:51 Well, number one, I do think that the regulations are 28:54 necessary. 28:55 I don't see regulations as punitive. 28:58 I see the survey system as necessary and an opportunity to celebrate who we are 29:05 when, when, when the survey team actually comes in to 29:10 our to our facilities. 29:12 But we have lost a lot of those protections that we had, and too many, 29:19 including individuals at CMS Central right now, 29:23 again thinks that the remedies are to punish facilities. 29:28 And they have taken actions in so many different ways that are demoralizing and 29:36 I think actually hold people back from wanting to make this a career. 29:43 I have encountered far too many individuals that have been through a 29:48 horrible survey, been so disrespected and say I don't want 29:52 to do this anymore. 29:53 I just don't. 29:55 But you know, what do we need to do about it? 29:59 We need to continue. 30:00 We need to build collaborative partnership like we have never had before. 30:04 Mark, right now the world of Healthcare is 30:08 moving and moving so fast and we need to be a part of it. 30:12 And how do we develop that partnership? 30:15 I think we start in our states as we did back in the olden days and and we 30:21 continue. 30:22 You know, states can push the federal government 30:25 and we have partners at the federal government right now. 30:28 I mean, Holly has a great relationship with some 30:31 of the individuals there. 30:33 We still meet with them. 30:35 So it it's it, it's that collaborative. 30:38 We've got to push it back, but we've got to demonstrate that we can 30:42 be trusted. 30:44 And I, and when I say we, I mean the collective, we all of us that, 30:49 that we have a consistency in performance and that we have a platform that we 30:54 operate from and that platform is quality assurance, performance improvement. 31:01 Back in the olden days again, back when I was running my first nursing 31:06 home, AHCA had developed a book called Quest 31:09 for Quality. 31:11 It was continuous quality improvement, but I picked that book up and said, hey, 31:16 this is a great platform to operate from and we can do the same today. 31:21 We lost so much in COVID. 31:23 So many of our systems are processes and we're still in the process of getting 31:27 that back and building it back. 31:29 But how, how do we, how are we looked upon as being 31:33 absolutely trusted to provide and collaborate and, 31:37 and build a healthcare system that we are an integral part of? 31:43 So Mary, you've been at this for a long time. 31:45 And by the way, you, you do not, you do not look like somebody who could 31:49 have done anything for 40 years. 31:51 You've been, you look great. 31:53 What lots of ups and downs for the sector over the years. 31:58 I'm God, there's been times when we've been, 32:00 you know, it's really felt like it was over, 32:02 but and then times when it's been really good. 32:05 Where do you, what do you see the future of the sector 32:07 as being? 32:09 I see it twofold. 32:10 Mark and I just alluded to part of it. 32:13 We did lose so much in COVID. 32:17 We never thought any of us would go through what any of us. 32:20 And it's not just long term care post acute, all of healthcare lost so much, 32:25 lost so much time, lost so many people. 32:29 So the immediate of getting back, making sure that we're a solid operating 32:34 platform, that our systems and processes are 32:37 routinized in our everyday care and everybody understands them. 32:42 And then the biggie workforce of getting workforce and Mark every single week when 32:48 you were Chair or President of ACA, when we had our weekly calls, 32:53 you talked about, well, we're picking up in workforce, 32:58 but we're lagging behind. 32:59 We're not picking up or we're not recovering as fast as hospitals or as 33:04 fast as. 33:05 And I always had a huge question in my mind every time you said that, 33:10 why don't we ask why we are not getting? 33:13 Is it our culture? 33:14 Is it our environment? 33:16 And we still haven't gotten inside that why, what do we need to do differently? 33:21 And I think the future must be driven by understanding that why and changing that. 33:27 Now on to the second part of that is that Healthcare is moving. 33:31 It is moving so fast. 33:35 7 new financing models were introduced and started on January 1st of 26. 33:41 Three of those impact nursing centers in such a significant way. 33:47 I'll just reference one. 33:48 It's called Teams transforming episodic accountable care. 33:54 And and are we ready? 33:57 How does a hospital, this is a bundle program that the 34:01 hospital holds the bundle. 34:02 How do they save money? 34:04 How do they hit their targeted price? 34:06 They skip post acute care, they skip post acute care. 34:10 That's how they do that. 34:12 My question is how do we become such a trusted partner in providing the care for 34:19 patients that need it, not all due in that first 30 days post 34:24 hospitalization that they don't want to skip us, we're not there. 34:29 How do we go about doing that? 34:31 I see us capable. 34:33 I see us absolutely capable of doing that. 34:36 But those are the things of being getting on this train with all of healthcare, 34:41 upping our level of sophistication in many areas, 34:45 including understanding the financing models, 34:48 understanding the care expectations and and creating those partnerships with 34:54 everyone around us. 34:56 I have believed since 1996 that nursing centers can be the hub of care in many 35:05 communities. 35:06 I still believe that and especially with what's happening with rural healthcare, 35:11 I believe it more today than I ever have. 35:13 We can do it. 35:14 We can help providers get through this unbelievable, 35:19 confusing maze of what's available post your hospitalization. 35:25 Well, Mary, thank you for a remarkable interview here. 35:28 Thank you for all that you've done over the last 40 plus years. 35:31 Thank you for sharing it with us today. 35:33 And I think we can hear from your passion and your thoughts about the future that 35:36 you're not done yet. 35:38 But thanks so much for all of that. 35:40 I want to thank First Quality again for making it possible for this to be a free 35:44 and open website. 35:45 And I want to thank all of you for your support of Park Place. 35:50 Thank you, Mark.
