Filling beds is much more complex than just marketing to potential referral sources. Marketing to referral sources, for example, hospitals and physicians, is certainly a starting point. However, when that hospital calls and says "Will you take this patient", that is where the success or failure lies. If the nursing home is not prepared from both a resource and skill perspective, to be able to handle that patient, after a couple more tries the hospital will not refer that type of patient or any patients to the nursing home.

This requires looking at the entire admission process from a clinical competency perspective. The competency of the staff in being able to handle IVs, antibiotics through IVs, fractures, really skilled nursing, is something that requires a self assessment of the nursing home in terms of its honest capabilities. The last thing that anyone wants is for the nursing home to take a patient whom the nursing home is truly unable to care for. But if a nursing home does not staff up and skill up and resource up to handle complex skilled nursing patients, the nursing home is going to have difficulties filling its beds, and it is going to end up with case mix indexes that are low scores which translate into low reimbursement.

Rehab needs of residents, which might result in ultra high case mix index scores, are excellent. But many facilities at most can only hope for 25% of their population to qualify for this. Fifty percent of residents at an ultra high rehab case mix index can easily result in being an outlier and being investigated for potential fraud. If the case mix index for skilled nursing is very low, then the facility is going to end up with walkie talkies, i.e. people who are ambulatory and really do not need skilled nursing, the case mix index will be low, and they will have difficulties filling the beds and motivating hospitals to refer patients to them.

The admission process is very complex. It starts with a self assessment as to what the nursing home's skills and resources are and what capabilities the nursing home has. Based upon that, the nursing home is in a position to be able to promote itself to hospitals. This ties right into the accountable care organization strategies that are needed.