Diakonos, Good Samaritan COOs: Nursing Home Investments in 2025 Will Focus on ‘Flexibility’ 

As providers focus on building up the nursing home workforce, and in turn protecting access to care, many leaders in 2025 are prioritizing shift flexibility for staff while also launching new programs to better support hiring and retention.

At the same time, investments in integrated health services and behavioral health are top of mind for providers, even as operators figure out what to do about Medicare Advantage, which some leaders see as an unsustainable model. Increased Medicaid rates, meanwhile, will need to be protected as this year’s legislative sessions begin.

Team member retention in the first 90 days has been one of the largest impact goals for leaders at the Evangelical Lutheran Good Samaritan Society, COO Aimee Middleton told Skilled Nursing News.

About 4.1 million Americans turned 65 last year alone, and in North and South Dakota, where Good Sam has a large number of facilities, about 30% of the population will be older than 60 by 2030, she said.

“The silver tsunami is here…I do think it’s going to get progressively worse,” said Middleton. The Good Samaritan COO spoke with Skilled Nursing News about industry trends for 2025, along with Kimberly Green, COO for the Oklahoma-based Diakonos Group.

Income changes over the past generations has meant that many older adults won’t qualify to pay privately for much needed long-term care nor be eligible for Medicaid.

“They’re falling down in this hole. There’s a big demographic there that we have to look at … their resources are limited. They’re in this mid-level group,” said Green.

The baby boomer generation, for example, has more wealth than previous generations at this point in their retirement journey, said Green, but not so much that they can afford to live in newly built, expensive assisted living facilities. And yet, they’re making too much to qualify for Medicaid.

Flexible care models may be able to address this demographic’s income limits, Green said.

Care outside of silos

Diakonos is working toward providing a “place” instead of a “space” for aging community members, meaning nursing homes need to understand what services are needed to create an integrated care model.

“We have to have those flexible care models, and we have to be thinking out of the box,” said Green. “What if we added a home care model where the people that cannot afford extended, long-term care or extended assisted living [can go]?”

That way, funding is maximized so that these residents can go to long-term care or assisted living when there’s no other option.

And those operators who aren’t considering integrated care services with more adaptable models will be left in the dust in the next five years, she said. Siloed health care won’t serve future residents well, she said.

“The public is struggling. It’s emotional, it’s scary, and we have to align our programming and pricing with what today’s seniors and their children both want and can afford. We are going to miss a whole demographic if we don’t change the way that we think,” said Green.

Reimbursement trends and how to meet them

Medicare Advantage rules around length of stay need to be modified, Green said, as it is affecting quality of care and facility reputation. And, the pay gap in pay between MA and traditional Medicare is widening, impacting financial viability, and administrative burdens continue to take a toll on staff recruiting and retention.

Green, who is a therapist by background, gave an example of how length of stay affects care delivery. Under MA, a patient that experienced a stroke might be expected to have a nine-day length of stay, determined by the MA plan.

“I’m not God. I can’t fix it in nine days. I can’t even get them safe enough to go home in nine days. We have to figure out a way to address that,” said Green. “[MA] is just abusive to our aging adults and those that we care for.”

Especially for Diakonos’ “super SNFs” which serve mostly high acuity patients, MA plans are really hitting them hard. MA length of stay is detrimental when the average length of stay for traditional Medicare is 19 to 20 days. And prior to the patient-driven payment model (PDPM), that length of stay was closer to 35 days.

The nursing home industry needs to come together to advocate for modifications to length of stay, and to increase reimbursement to match the cost of care, Green said.

“It’s just not good care. We’re going to pay for it as a society as well. We have to take control of it,” said Green.

Meanwhile, Middleton said providers this year are gearing up to defend the Medicaid rate increases seen in many states, with legislative sessions already beginning.

A lot of different groups, especially in rural states, are coming together to explore creative ways to continue meeting community needs and make meaningful change for nursing home residents and staff, including reimbursement.

“In the state of South Dakota, before last year’s session, they actually had a special long-term care summer study. I’ve never heard of something like this before, but it was really, really encouraging,” said Middleton. “So they pulled in a bunch of different providers. We had lots of really good conversation and some subcommittees about innovation, about community-based services.”

Gen Z recruiting

The solution for problems facing baby boomers lies with another demographic: Gen Z. Many within this demographic have already launched their careers and are gearing up for major life transitions, they’re pivotal years and providers would do well to focus on what it is this generation wants and how they perceive the industry.

Good Samaritan has revamped its administrator in training (AIT) program with this generation in mind, Middleton said, and is empowering young leaders to make decisions with work-life balance in mind.

“We’re hardwiring support networks so that they know that they don’t have to do everything on their own,” Middleton said of her staff. “We are focused on prioritizing resources and investments toward these trends, to really strengthen the quality of care and services, to meet the comprehensive and evolving needs demands of our senior staff.”

Scheduling flexibility is a huge focus for 2025, Green added, with changes as simple as making sure a shift and bus schedule are in alignment. And then, reducing agency and overtime costs while increasing retention is also key.

Both Diakonos and Good Samaritan are looking at ways technology can be used as a supplement to human care, especially predictive analytics and smart scheduling tools.

“The work isn’t going to change. It’s how we do it that really has to change. I don’t think we have an option to not look at technology as being a part of that,” said Middleton.