Concerto Renal Services, a growing in-house dialysis service provider for skilled nursing facilities (SNFs), is capitalizing on a renewed interest in its services and continues to expand coming out of COVID-19 as operators look for new ways to take on higher acuity patients.

The Lincolnwood, Ill.-based Concerto has grown from operating in one state just two years ago is now on track to be servicing 12 states and over 100 facilities by the end of the year.

As better kidney treatment becomes a greater need and emphasis for SNFs with an aging and sicker patient population, Concerto Executive Vice President Kyle Stone thinks nursing home dialysis service will only become more attractive for the operator and its hospital partners.

He spoke with Skilled Nursing News about why he thinks SNF operators are losing out on patients and hurting their quality by not investing in in-house dialysis in a conversation that has been edited for clarity.

Tell me a little bit about Concerto.

We are a six-year-old company that was created based on a dire need for on-site dialysis. Our founders are SNF operators and they identified this as an area of need due to frustration. Back then and still now for most SNF operators, there are two options: you can either send out your dialysis patient, or you can go with one of the very few dialysis in-house providers.

Concerto was created based out of that need. [It’s] three-day conventional hemodialysis that brings the delivery of that service to a patient’s doorsteps and brings the technology to their living room and allows these services to meet the patients where they are.

What pushed SNF’s need for in-house dialysis?

First, on the regulatory front, there was up until relatively recently, a lack of clarity from the Centers for Medicare and Medicaid Services (CMS) as to how this sort of delivery model would be governed.

That changed in 2018, when CMS put out some more definitive and clear guidance to the state survey agencies so that it was very clear what the rules of the road were. In that respect, what we had been doing as a company from a staffing administrative, logistical, and legal perspective and clinical perspective had been validated.

We had a more definitive roadmap, regulatory roadmap. So all of a sudden, any hesitation that operators and other end-stage renal disease ESRD providers had in getting into this space was washed away.

The other area is financial.

The patient-driven payment model (PDPM) provides incentives for operators to take certain kinds of higher acuity patients and dialysis patients are attractive for SNF operators.

As long as that’s the case, on-site dialysis is going to be an attractive feature.

Why do you believe on-site dialysis is a better plan for SNFs than sending patients to an off-site facility?

The single best thing that they can do for these patients, and we tell operators this all the time, is to invite ESRD providers like Concerto on-site to service patients, just a few steps away from their bedrooms.

It’s a powerful tool in enhancing the coordination of care and minimizing risk.

From a COVID perspective, the clinical nature has enhanced the incentive for operators, as insurance for infection control.

We also saw during the pandemic peer-reviewed studies that show that dialysis patients who were sent to outpatient clinics were bringing back COVID-19 to those facilities and infecting other residents and staff.

And so operators are more and more understanding and embracing on-site dialysis.

Another aspect for patients, which we probably don’t emphasize enough, is just the sheer inconvenience of going out to outpatient dialysis three times weekly. It’s exhausting, it’s demoralizing, it often takes the entire day, it can often cause confusion, it can disrupt the continuity of care, it results in patients and residents often waiting for transport both at the facility and at the outpatient center.

How important do you think it will be for SNF operators to open themselves up to take on higher acuity patients to survive post-COVID?

It’ll be everything. And dialysis is just one piece of the puzzle, there’s also respiratory care. There’s a heavy emphasis on that.

Trends show that you are going to have an ever-expanding pool of not only clinically complex patients that are going to be depending on the skilled nursing community but clinically complex patients who require enhanced kidney care and who have ESRD.

Kidney care is becoming more of a point of emphasis in the health care world, in part because it’s so costly, but also because there is unfortunately an expanding patient population requiring the services. SNF operators understand generally and appreciate that the number of ESRD SNF patients is expanding considerably.

If you live and operate in, particularly a metropolitan area, with a great many hospitals you know, because you see from the hospital case managers in town, they are looking to place patients with dialysis at facilities that can handle them in the best way. [They are looking for SNFs] to show and demonstrate an ability to adequately address the care needs for such patients and to show your on-site dialysis program is flourishing.

I think SNF operators are becoming more mature in working with a partner like Concerto which tells me and is a real indicator to me, that SNF operators understand and appreciate that on-site dialysis is a wave of the present and future.

Do you have any data showing that adding your service led to an uptick in referrals for the SNFs?

I can tell you anecdotally how this tends to work is if it’s a new market, where Concerto is just entering, we have gone out of our way to interact with and communicate with the major hospital systems in the area.

Part of the reason we’re getting these calls from operators who we don’t know and we’ve never had any contact or a relationship with is simply because they’re losing out dialysis patients to competitors. So they recognize that need, and oftentimes, they’ve already gotten feedback from the hospitals, whether direct or indirect, that they’re losing patients because of the lack of an on-site dialysis program.

How has Concerto dealt with staffing issues seen across the long-term care industry?

Staffing is a primary concern. There’s been a nurse shortage nationally, that’s even more acute in the dialysis space.

Particularly during COVID, we had to take another number of measures that really helped us deal with the staffing shortages.

Many had obligations to schoolchildren who were home and many had an understandable fear of the virus. We were confronted with this abnormally high degree of call loss. We never canceled a shift. We never worked short staff.

We were forced to take some unexpected measures. We had hazard and overtime pay for those willing and able to work. We pulled qualified members of our corporate team into the field to provide direct care. We availed ourselves of state nursing waivers, which allowed registered nurses qualified in one state to temporarily practice in another. We were moving people around, even during the height of the pandemic.

It was a constant need for creativity.

Have you been making more of play inside the home?

It’s something that’s constantly on our radar. We provide true home residential services in our Maryland market. In that respect, our Maryland market stands alone because we do not offer any residential home services currently in any other market. That’s not to say we are foreclosed on the idea, in truth, we’re fully capable from a regulatory standpoint of providing such home services. It’s just it’s not something that we’ve really tried to drive just yet.

The truth is the nursing home space for dialysis is still in the process of maturing. There is a great deal of progress and advancements to be made. There’s still only a small sliver of nursing homes that could have on-site dialysis that does. There’s still a lot of work for us to be done in this space.

That’s not to say we can’t do both. It is just to say that while it’s certainly on our radar, it’s not our focus at the moment.

For a clinically complex patient, one of the reasons why I remain bullish about the skilled nursing community’s future is that whether we like it or not, these clinically complex patients aren’t going anywhere. Their numbers are only increasing. And these are clinically the sorts of patients who it would be unusual and unique for them to be able to care at-home in a residential setting, if not impossible.