Join us on Full Circle for a fascinating inside look at skilled nursing done differently — with Keeshan, Executive Director of a skilled nursing facility in Indiana and a 10-year veteran of healthcare operations. Indiana has quietly built one of the most innovative SNF ecosystems in the country, and Keeshan is living it from the inside. In this episode, he breaks down how Indiana's Medicaid incentive model ties reimbursement directly to quality outcomes, what an iSNP actually is and why competing SNF operators chose to build one together, and how wall-mounted telehealth and dual nurse practitioner oversight are keeping residents out of hospitals. He also unpacks the billing mechanics, the grassroots power of aligned Executive Directors, and where AI is already showing up on the admissions floor. If you work in post-acute care, value-based care, or health tech — this is the model worth paying attention to.

0:45 From volunteer to licensed Executive Director — Keeshan's 10-year healthcare journey

2:17 Running a skilled nursing facility — and how Indiana ties Medicaid to quality measures

4:09 The key metrics — rehospitalization, pressure ulcers, falls, and the shift to proactive coverage

5:39 Measurable results — lower readmission rates and why treating in place enables better care

6:38 Wall-mounted telehealth, virtual provider oversight, and the iSNP early alert system

7:33 Two nurse practitioners, one resident — how iSNP layers clinical oversight

8:25 What is an iSNP? The Institutional Special Needs Plan explained

9:17 Competing SNF operators building a shared iSNP — Indiana's unlikely collaboration

9:37 iSNP vs. regular Medicare — what actually changes for the resident

10:32 Shared risk as an incentive — why iSNP pushes facilities toward proactive care

11:24 Who qualifies for iSNP — long-term residents, meal cards, and personal care allowances

12:55 The iSNP visit schedule — NP two to three times weekly, RN once or twice on top

14:24 Is the redundancy worth it? Why more clinical eyes reduces hospitalization risk

15:30 Same standard of care for all — consistent chart reviews regardless of insurance status

17:47 Billing without overlap — how iSNP and medical director groups coordinate visit scheduling

19:00 Value-based billing codes in practice — CCM, behavioral health, and time-based billing

19:55 Replicating the model — what it takes to build an iSNP in another state

20:49 Competitors sharing clinical staff across buildings — the Indiana model in practice

21:33 How much can an ED actually change? Decision-making authority in skilled nursing

23:09 Grassroots change in action — when aligned EDs successfully pushed for a medical director switch

23:55 AI in SNFs today — admissions paperwork parsing and EMAR monitoring alerts

25:38 Indiana's model goes national — presenting at state and national SNF conferences

Guest: Keeshan | Executive Director, Skilled Nursing Facility, Indiana

Host: Prerna | Circle Health