Early in December, Concerto Renal Services announced that it was expanding its partnership with the skilled nursing provider SavaSeniorCare, with the addition of on-site dialysis treatments to a facility in Georgia.

For Concerto, the partnership with Sava at the Dunwoody Health and Rehabilitation Center is the fourth such agreement between the two companies and marks the chance to bring the model to the south, Concerto CEO Shimmy Meystel noted in a press release announcing the transaction.

It also provides the chance to reduce chances of infection while providing the patients with services that they need, he told Skilled Nursing News in a December 15 interview.

“We have some other providers we work with who told us that they trace back something like 60% to 70% of their COVID outbreaks to patients who had who bought it back from dialysis,” he noted, pointing to a report by the Centers for Disease Control and Prevention (CDC) that found nursing home residents who receive dialysis have a significantly higher chance of contracting COVID-19.

Currently, the Lincolnwood, Ill.-based Concerto partners with Sava at three facilities in Maryland, and Sava plans to expand the partnership — though the timeline is uncertain due to the COVID-19 pandemic.

Concerto provides in-house dialysis services to SNFs in Illinois, Maryland, Kansas, Missouri, Wisconsin, Georgia, Michigan, and Ohio.

For Sava, the expansion is part of a wider plan to position itself for a SNF world being shaped and reshaped by the ravages of the pandemic. The three Maryland partnerships were part of a pre-existing arrangement with another vendor — programs that Concerto took over, SavaSeniorCare Consulting executive vice president and chief strategy officer Ray Thivierge told SNN in the same December 15 interview.

The partnership with Concerto, which began in June 2019, allowed Sava to align the program more with its own goals for an in-house renal program.

That is becoming especially critical given the events of 2020, which is forcing Sava and other SNFs to “rethink our business model,” as Thivierge said in a July webinar.

Developing an in-house renal program is one way to lay the groundwork for the future, he told SNN on December 15.

“Traditional models called for our frail elderly who require dialysis to be bundled up and packaged up and sent out through transportation to an off-site dialysis den where they were dialyzed for eight hours and then came back to the center three times a week,” Thivierge said. “That model is very difficult for anybody, but in particular difficult for a frail senior … so the idea of bringing dialysis to our residents in our setting has always been something that’s an opportunity for the sector.”

The opportunity of bringing dialysis to a patient has been facilitated by advances in technology, he noted, and the pandemic has heightened the ways bringing the treatment in-house can benefit patients by both improving quality of life and lowering their risk of infection.

That said, it is not a straightforward silver bullet against COVID-19 for dialysis patients. For one thing, the layout of the dialysis dens themselves had to be considered, taking into account scheduling patients who might have been exposed to COVID-19 and patients who were not. But it did eliminate transportation companies and outside staff at the dialysis center as possible sources of contagion, which brought the challenge “within our control,” Thivierge said.

The COVID logistics included creating additional shifts and segregating the dens to create a separate area for patients who were not exposed to COVID-19. Different state rules also created different challenges when it came to coordinating patient shifts, Meystel noted; at one point Maryland required all new SNF admissions be considered “patients under investigation” for COVID.

Setting up in-house dialysis programs also requires retrofitting for space allocation, plumbing and electrical overhauls, Thivierge noted, and because of the pandemic, patient cohorting also became a consideration. With COVID, this poses a particular hurdle to expansion.

“When you’re trying to plan for the expansion of these programs, while at the same time being on lockdown in your buildings and controlling access to the facilities from the community, that is definitely a challenge,” he told SNN. “It actually has been the number-one challenge for us right now in terms of expansion of these programs. I think but for that, we would probably be underway with several more already.”

In addition, the cost can vary considerably depending on the scope of the project, size of the unit and even the size of the building — Meystel noted estimates for an entire project can range from $50,000 to $250,000.

Because of the pandemic, the strategy for future expansion is fairly “theoretical,” Thivierge noted. While Sava believes every market or service area could benefit from a program such as its dialysis offerings with Concerto, planning for 2021 is made difficult because of the effects of COVID-19 on SNF census.

“We don’t really know what demand is going to look like going forward — not necessarily demand for renal care patients, but demand in general for skilled care,” Thivierge said.

Other factors include COVID-19 resurgences in communities, multiple lockdowns on construction and visitation in SNFs with no clear timeline, and questions about what reimbursement and the economics of SNF care will be going forward, he told SNN.

But even with the census uncertainty — Sava has seen “a significant decrease in our long-term care census as a result of COVID” — the need for dialysis care is allowing Sava to at least map out where the programs might be, and it is likely to be a critical part of the future for SNFs of any stripe, Thivierge argued: Census will likely take a while to recover in SNFs, except for patients who have no other choice, he pointed out.

“It’s clear there are certain populations of folks that are always going to require traditional nursing home care, and those populations are folks that cannot be met at home, or have got some level of comorbidity that makes for complex care,” he said. “What we know about dialysis and renal care patients is that’s exactly the situation that those patients find themselves in. We expect that no matter what the model is going forward, renal care will be a component to it.”