The financial environment has become significantly more complex. Skilled nursing facilities must navigate reimbursement across Medicare, Medicaid, managed care organizations, private insurance, and private-pay residents, each with distinct billing requirements, reimbursement methodologies, and compliance considerations. Continuing care retirement communities (CCRCs) face their own set of complexities, including entrance fee accounting, obligation-to-provide-future-services calculations, and actuarial assumptions that require highly specialized expertise.
At the same time, access to experienced finance talent has become more challenging. The pipeline of accounting professionals continues to narrow, and individuals with expertise in senior living or long-term care often command premium compensation. For many organizations, particularly smaller operators and regional providers, maintaining a fully staffed finance department with industry-specific knowledge has become difficult and costly.
Rather than assuming every function must remain in-house, alternative models, including outsourced accounting services, fractional CFO leadership, and hybrid approaches that combine internal oversight with external expertise, are gaining traction. The shift is less about replacing internal teams and more about ensuring organizations have access to the specialized capabilities today’s environment demands.
There’s more than one way to build a finance function
Organizations are exploring a range of operating models designed to balance expertise, cost, and flexibility. For some, that means outsourcing specific activities such as accounts payable, month-end close, or cost report preparation. Others engage external accounting teams to support day-to-day financial operations while retaining strategic oversight internally. The growing adoption of fractional CFO services reflects a similar trend. Many organizations need access to executive-level financial guidance related to strategic planning, debt covenant management, capital projects, acquisition analysis, reimbursement strategy, or board reporting but may not require a full-time CFO.
These approaches aren’t mutually exclusive. Adopting a hybrid model for organizations — which looks like combining internal personnel with external resources to address specialized needs, increase capacity, or supplement areas where recruiting and retaining talent — has proven difficult. The question isn’t whether finance support should be delivered internally or externally. Rather, it’s determining which combination of resources best aligns with the organization’s goals, complexity, and available expertise.
What organizations stand to gain
Alternative models offer more than cost reduction. They can also provide:
- Access to specialized expertise. Professionals who work across multiple senior living and skilled nursing organizations bring experience navigating a wide range of financial and operational challenges, including Medicaid cost reporting, Medicare reimbursement optimization, managed care contract analysis, entrance fee accounting, actuarial liability modeling, revenue cycle management, and operational metrics that help drive financial success.
- For skilled nursing organizations, expertise in areas such as triple-check processes, payor mix analysis, expected-versus-actual reimbursement reconciliation, and denial management can help identify issues that might otherwise go unnoticed. For CCRCs, specialized knowledge related to long-range financial planning and entrance fee obligations can provide valuable insight into future financial sustainability. Additionally, external advisors bring perspective gained from observing how different organizations address similar challenges, helping leaders identify opportunities and emerging best practices.
- Greater flexibility. Financial needs rarely remain static. Census fluctuations, acquisitions, divestitures, strategic repositioning and capital projects, refinancing activities, and regulatory changes can all create sudden demands on finance teams. Alternative staffing models allow organizations to scale resources up or down as circumstances change without the disruption and expense of repeatedly hiring and restructuring internal teams. This flexibility can be especially valuable during periods of growth or transformation.
- Reduced key-person dependency. Organizations rely heavily on one or two individuals who hold significant institutional knowledge, including relationships with auditors, familiarity with historical balance sheet activity, cost report methodologies, and internal financial processes. When those individuals leave, the resulting disruption can affect financial reporting, compliance, and decision-making. Broader team-based models help reduce this risk by documenting processes and distributing knowledge across multiple professionals, creating greater continuity during employee transitions and leadership changes.
- Stronger financial processes and oversight. Well-designed finance models introduce more formalized processes, clearer segregation of duties, and standardized workflows. In highly regulated environments where financial reporting intersects closely with compliance requirements, including Medicaid cost reports, quality incentive programs, reimbursement tracking, and state-specific reporting obligations, strong controls and consistent processes can help improve accuracy and reduce risk. For multisite operators, standardized financial management can also improve consistency across communities, enabling more meaningful benchmarking, cleaner consolidations, and earlier identification of performance issues.
- Enhanced technology and reporting capabilities. As finance becomes increasingly data-driven, many organizations are looking for stronger reporting and analytics capabilities. Providers serving multiple senior living and skilled nursing organizations invest heavily in automation, dashboarding, benchmarking, and financial analytics tools. Organizations may gain access to these capabilities without incurring the full cost of building and maintaining them internally. For example, operators using platforms such as PointClickCare may use integrated reporting that combines clinical and financial information, providing insights into metrics such as payor mix, average daily rates, days in accounts receivable, collections performance, and reimbursement trends. Advanced planning tools can also support long-range forecasting, capital planning, and scenario modeling.
The question facing many senior living and skilled nursing operators is no longer whether finance expertise is important. It’s how that expertise is accessed and scaled in a complex environment.
While alternative models can address a variety of staffing and expertise challenges, no single approach is right for every organization. Leaders should evaluate potential solutions through the lens of organizational size, operational complexity, strategic objectives, growth plans, and existing internal capabilities.
Just as important is selecting the right provider. Technical and industry expertise matters, but so do responsiveness, communication, and an understanding of operational realities. A model that works well on paper may fall short if it can’t integrate effectively with leadership teams, boards, and day-to-day operations.
Finding the right fit
Organizations should also remember that these decisions need not be all-or-nothing. Many begin by outsourcing a specific function or supplementing existing staff before expanding the relationship over time. A phased approach can help leaders evaluate culture fit, build confidence, and determine which model best supports their long-term objectives.
As talent shortages persist and financial demands continue to evolve, more organizations are reconsidering longstanding assumptions about how finance functions should be structured. Whether that leads to outsourced accounting support, fractional leadership, a hybrid model, or a traditional in-house team, the goal remains the same: ensuring the organization has the expertise and resources needed to support sound financial decision-making, maintain operational resilience, and adapt as circumstances change.
