Providers Get New Tool to Care for ‘Sense-Sensitive’ Residents

Patrick Connole

Some issues in health care seem so basic that they may be overlooked at times. One such area for long term care providers that could be missing from their checklist is how well residents can use each of their five senses: touch, taste, smell, hearing, and sight.

If these five are not accounted for then there could be follow-on ill effects for quality of life, according to a group of researchers at the University of Ottawa Life Research Institute and their partner Sodexo. The group has produced a new audit tool and real-world solutions to help long term care providers create “sense-sensitive” environments for seniors.

In addition, the researchers published what they call the first comprehensive study of how the five senses impact quality of life for those living in long term care communities: “How and Why the Five Senses Matter for Quality of Life: A Guide for Long-Term Care Communities.”

The point of this awareness of the senses, and how residents can tap into their abilities in these five realms, is to improve patient-centered care. Because as the study demonstrates through examples, seniors with low vision may have difficulty distinguishing between similar colors, so long term care communities might use high-contrast colors to help them see different items and areas.

Or, a diminished sense of smell can impact the ability to taste, which can be partially aided by creating an open kitchen area that helps residents better smell food and in turn stimulate appetite.

Another example is if a resident has a hearing impairment, which can of course make participating in conversations difficult. To counter, the center may work to minimize background noise from heating and cooling systems and create a quiet space for seniors to hear others. It is important to understand how the senses work in relation to life in a facility.

Thomas Jelly, vice president of the Sodexo Institute for Quality of Life, tells ProviderNation that it is no great mystery that, as we age, our senses can slip in ways large and small. But what needs to be explored further is how important this loss is to the overall quality of a person’s life, especially in the long term care setting.

“We know that our senses are a window that we have to the objective world around us. And, the senses are the vehicle in which we interpret the real world,” he says. “This is how we experience feelings of well-being, of quality of life, of purpose and meaning. The senses are fundamental to understanding the world around us.”

The task is to respond to the needs of the resident and make these impairments less of an impediment to enjoying life.

In order to advance their work on the senses, Sodexo and the Ottawa researchers focused on the basics of what providers can do to help. Even though health care is overwhelmed these days with data and complexities of care management, oftentimes the most fundamental assessment of new arrivals’ sensory capacity is not being undertaken on admission.

Jelly says while there is no standard screening process for sense-sensitivity, the new audit that his group created provides a guide on how the five senses affect the quality of life. “If there is a gap, we can help fill it and at same time help a facility’s performance. Everyone should be on same page,” he says.

The goal is to have an action plan in place on a resident’s sensory conditions for all stakeholders and families to recognize and track.

An example Jelly gives is that if a resident has an issue with sight, the way a window directs the light may blind someone walking toward it, which could limit that person from using a hallway or walking altogether.

“Another example is an eating area in a residential facility. Very often older people have a decreased sense of taste and smell, and quite often they find food not all that appetizing,” he says. “But what if there is not adequate lighting? That may not seem related, but food colors come out in proper light, and the texture comes and it goes some way to help mitigate that loss of a sense of smell and taste.”

The senses, he explains, all affect each other and often in ways we don’t think.

Senses are vital to the overall care plan, and the more research is done the more apparent taking steps to remedy the problems is not beyond the reach of the provider community.

Download the Sodexo study at http://www.sodexo.com/fivesenses.

MOELI May Point Way to Better End-of-Life Planning, Author Says

Patrick Connole

There is an interesting new development in the end-of-life planning space, with some experts in the field saying they back changes to the existing system to ensure that the wishes of patients are adhered to in a more organized and efficient manner.

Called MOELI (Medical Orders for End-of-Life Intervention), this new model is an improvement on the existing Physician’s Orders for Life-Sustaining Treatment (POLST) because it allows for more flexibility and acts as a more effective way to document and communicate patient wishes in institutional and community settings, according to Richard Stuart from the Department of Psychology at the University of Washington in Seattle.

He helped write an editorial in the September issue of JAMDA (Journal of the American Medical Directors Association) explaining how MOELI is an upgrade to the POLST Paradigm because it fills in gaps to increase the range of patients who can use the model. Stuart and others hope to spur a national conversation among various POLST organizations and collaborate with them to create a standardized national form for end-of-life patient wishes.

One major change would be to relax when POLST is offered. Currently, it is offered to patients with those of a life expectancy not exceeding 12 months due to a terminal illness or extreme frailty. MOELI would extend the offering to those who are 80 years or older, regardless of the life expectancy issue.

In the JAMDA piece, Stuart and company also recommend the development of a national evaluative database, creation of organizational policies and resources that support the paradigm’s use, and increased efforts to educate health care professionals and the general public about MOELI.

“Many patients get more invasive, expensive, and often harmful end-of-life treatment than they want, while others get fewer life-prolonging efforts than they want,” Stuart said. “The POLST program, and the MOELI that enhances it, are designed to help patients convey their treatment choices to providers who enter patients’ wishes in their medical records to increase the likelihood that care desired equates with care received.”

The enhanced end-of-life program would also assist long term care providers, considering that many patients are admitted to centers because of frailty, which can of course lead to declines in cognitive capacity.

“Facilitating the completion of a MOELI upon admission would allow patients to enter their treatment preferences in their electronic medical records. Doing so could save patients, their families, and the institutions that care for them a considerable amount of money due to the extraordinary unreimbursed cost of caring for patients with dementia,” the article said.

In a talk with Provider, Stuart days he does a lot of work in helping patients create living wills, but they are meaningless unless wishes are translated into medical orders. One of the problems is the lack of standardization across care settings. “A lot of patients are mobile so they go from place to place, and wishes validated in one setting may not be accepted in another,” he says.

Some of the other major changes MOELI would bring include what Stuart calls “middle” options in end-of-life planning. “POLST arbitrarily allows people to address certain options, but … the existing POLST system [doesn’t allow] people to choose or designate their preference for all of them. So, I try to make the menu complete so they indicate the kind of care that they would like,” he says.

There are also technical fixes Stuart would like to see made. One involves first responders. An example would be that as a first responder arrives to treat someone who is in shock, for example, that person may have a do-not-resuscitate order (DNR) in place. This means in a strict sense the first responder should not treat them and conceivably let them die.

“I want to put in a middle category if someone’s heart stops beating because of a treatable short-term event, then of course they want to be rescuitated. This is an example of why people in the past have been reluctant to make commitments because they realized they don’t want an absolute DNR order, which makes that middle category so important,” Stuart says.

Another example of a middle category in MOELI being an improvement from POLST is that many individuals who do plan for end-of-life voice their concerns about medical requests being taken out of context.

“It is often the case that patients are asked if they want active care or comfort care only,” Stuart says. With a middle category, people would be asked if they want to have active care as long as they can preserve their identity as the person they are now. “That middle category is extremely important. It gives people rational options,” he says.

Country Comes to the City: A ‘Cowpoke’s’ Day in a Dementia Care Center

Patrick Connole

Boundless energy. These two words come to mind when describing Chris Covell, the resident engagement manager in charge of the Life Enrichment Program at Forest Side in Washington, D.C. To witness her work, as I did during a recent all-day volunteer stint at Forest Side is to be challenged, in a good way.

Chris Covell

The challenge is to keep up with her as she progresses through a full schedule for her residents, all of whom have some form of dementia. On the day I was present, the theme was country life, as in country music, pioneer culture and the history of the American West.

Covell had created a roughly seven-hour program built to entertain, stimulate, and otherwise offer comfort and companionship for around 15 to 20 residents of the 33-resident facility.

When you walk into a volunteer situation like the one at Forest Side there is always a period of time you need to get accustomed to what are very foreign surroundings for most professionals. Usually, my day consists of working phones and the computer while anchored in front of a desk, CNN on in the background, news flowing all around. People come and go throughout the day, questions are asked and answered, and the pace of the day is pretty much self-dictated.

But when you enter the care center, the focus – all of it – is on the residents as guided. When you eat, when you break, when you assist, when you “play” and when you transport is all scheduled, based on a well-timed care plan and socialization platform meant to offer a fulfilling and interesting environment.

For this day, Covell starts with a drawing and coloring session, wherein each participating resident has a chance to create art from sheets of paper with a Western theme. As old-school country music plays on the large TV in a nearby lounge area, the residents occupy two large tables, which have been dotted by care givers with crayons, markers, glue and other arts and craft supplies.

Volunteers like myself assist one or two residents at a time in whatever they want to do within the 45 minutes or so allotted for the project.

My resident is one of the only males in the group, a former stalwart lawyer and investigator who prefers to take copious notes of the day’s activities versus actual drawing. But even as he goes his own way, there is a back and forth between and among the resident and staff, including Covell, and this volunteer. There is a quick rhythm and intensity to his actions, waking me up to the fact this is more than just regular work to care properly for residents, it seems to take supernatural patience and attention to detail.

As others create colorful art, the resident and I discuss who is doing what and where. It is during this time, around a half-hour in, that enlightenment starts to kick in. For all the writing I do on skilled nursing and assisted living facilities, the owners and operators, the nurses or the latest happenings in Congress that affect all of us, it is only at a time like this that I see what this industry is all about.

It is about sitting down and conversing with someone hampered by dementia, and doing so in a respectful, fun and patient manner. My own mind runs to the one thought I ruminate over again and again during the day: What dedication this must take to do this eight hours a day or more, everyday, because I am only in this position for less than an hour and I am exhausted.

We move on from the art to other activities and eventually lunch and an end of day ice cream social. All the time Covell is prodding residents to take part in whatever is being discussed, steering conversations to her themed subjects, prompting we volunteers to go outside of our comfort zones to assist and lead residents in for instance a pretend camp fire, complete with sing-a-longs to Gene Autry and Roy Rogers tunes from days long past.

We even build a fire with real sticks, paper cut outs for the flames. The session is led by the spirit and will of Covell and her boom box, which fills the air with the aforementioned music. It all makes sense.

I take a turn reading a historical account of what the Old West was all about. Sure, there are some residents nodding off, others offer only blank stares, but there are many engaged in their own unique way. And, despite the lack of give and take in what we call a normal way, there is a warmth that emerges, fittingly at a camp fire, as residents follow Covell’s lead and if they want, get into character by wearing fun Old West hats or playing with stuffed animals posing as our animals for the cattle drive.

For it only takes one set of eyes on you, and your eyes back, to tie yourself to the humanity of this place, this home for people afflicted with one of the most trying and devastating illnesses known to man: the loss of one’s memory and ability to live out an independent life.

It is when pretending to be a cowpoke that I understand what enormous strength it takes on the part of staff and resident alike to move through each day. And, to do so in the best way possible, to make a go of it, to be a pioneer of sorts in waging the fight for a life that is dwindling in many ways, but is lifted up to a higher plane than otherwise could be achieved through the love of families and friends, nurses, and the entire staff of caregivers.

At least for one day, one short day for this volunteer, we are cowpokes in the city.

Employers Seek New Designs to Control Cost of Health Benefits

Patrick Connole

When it comes to finding efficient and more cost-effective ways to provide health benefits to employees, it is likely that medium- to large-sized skilled nursing and assisted living operators are part of a national trend among larger employers to try new models for managing such costs.

The subject of what these new models may look like is part of the National Business Group on Health’s (NBGH’s) annual “Large Employers’ 2018 Health Care Strategy and Plan Design Survey,” which captures the latest trends for the remainder of 2017 and into next year.

According to NBGH, employers estimate the total cost of providing medical and pharmacy benefits to their workers will rise 5 percent for the fifth consecutive year in 2018. When taking into account premiums and out-of-pocket costs for employees and dependents, the total hit is pegged to be $13,482 per employee this year, and projected to rise to an average of $14,156 in 2018.

NBGH said employers will cover almost 70 percent of those costs with employees picking up the rest, or 30 percent, which is some $4,400 in real dollars for 2018.

These employers ranked specialty pharmacy as the top driver of cost increases, with nearly 80 percent of those surveyed putting drugs among the top three cost drivers. NBGH said specialty pharmacy costs will likely remain a paramount concern as new high-priced drugs come on the market.

With another 5 percent ride in health care benefit costs staring them in the face, NBGH said employers it spoke to are examining how health care is delivered and paid for while still pursuing traditional methods for controlling costs, like cost sharing and plan design.

Some forms of this new focus on delivery include allowing more employees access to broader health care services, including telemedicine, Centers of Excellence (where the most efficient health systems provide care) and onsite health centers.

In a breakdown of the numbers, NBGH listed the following trends to watch:

• Telehealth utilization surging. Nearly 100 percent of employers surveyed will make telehealth services available in states where it is allowed next year. And, more than half (56 percent) will offer telehealth for behavioral health services, more than double the percentage in 2017. Overall, telehealth utilization is climbing rapidly, with nearly 20 percent of employers experiencing employee utilization rates of 8 percent or higher.
• Accountable Care Organizations (ACOs) could double in use by 2020. This prediction comes from the survey question that showed 21 percent of employers plan to promote ACOs in 2018, but that number could double by 2020 as another 26 percent are considering offering them.
• Employers opening health centers. More than half of employers (54 percent) plan to offer onsite or nearby health centers in 2018, and that number could increase to nearly two-thirds by 2020.
• Centers of Excellence (COEs) embracing bundled payment arrangements. Almost nine in 10 employers (88 percent) expect to use COEs in 2018 for certain medical procedures such as transplants or orthopedic surgery. Of these, employers said bundled payments or other types of alternative payment arrangements will be used by 21 percent to 48 percent of COEs contracts, depending on the medical procedure or condition.
• Controlling surging specialty pharmacy costs. Some 44 percent of employers will have site of care management tactics in place in 2018, a 47 percent increase over this year.In addition, 70 percent of employers will use more aggressive utilization management protocols.

Westcare’s Decker Leaves a Legacy of Business Smarts, Gentle Touch

Bob Decker

Patrick Connole

Through thick and thin, Westcare Healthcare Management founder Robert (Bob) Decker has held steadfast in his belief that hard work will be rewarded. And now with his own working days dwindling toward a July 1 retirement, those closest to Decker say a new generation will keep the tradition of perseverance and compassion going even when the founder is not at the helm.

Decker started Salem, Ore.-based Westcare in 1987, and along with a tightknit cadre has built the company into a mainstay in the management services space for the long term care industry.

As the company website says, “like a great caddy to a golfer, [Westcare] serves clients by seeing the dangers ahead.” With operational experience in ICF/ID Care, community-based waiver programs, skilled nursing care, assisted living, and residential care, Decker’s creation offers consultations on facility evaluations, analysis of internal systems, development of new programs, and leadership on financial services. Amid all of these specialties, however, is the overriding priority to put the care of residents first and foremost in every business plan.

To picture how Westcare became the company it is today from when it started 30 years ago, is really an examination of how Decker has skillfully guided the company, says Van Moore, senior vice president for Westcare. He speaks with authority on the subject, given the fact Moore has been with Decker for the long haul.

“He is a nice, warm guy, very outgoing. I’ve been with him for 30 years,” he says. “Bob and his former partner had sold something like 40 nursing homes to National Heritage and part of the deal was Bob had to stay on for a period of time as a divisional vice president,” Moore says. “That was in 1987 and the time of the stock market crash. National Heritage lost over 50 percent of its value overnight in that debacle and we could see the handwriting on the wall. So, Bob actually incorporated Westcare Management in November of 1987.”

The powers that be who ran National Heritage visited the first week of December 1987 and told Decker that his division was the only one turning a profit, “but they said we can’t afford you anymore, and that is how we started Westcare, on a lick and a promise. It was a lot of hard work.”

A Meaningful Motivation

In the midst of creating a new company, Decker showed his true colors, Moore says. “When we first sat down there were four of us and Bob who had come over from National Heritage. We sat in the rented office and he said ‘I don’t need to work, but I want to work.’ And he was only 50-years-old. And he said, ‘I am not ready to retire,’” Moore says.

Decker went on to say while his goal was to do well, “my real goal in life, he said, ‘is to be able to make you guys able to make the decision I made in my 50s as to whether I want to work or not.’ And it was far beneath us to stand in the way of his happiness,’” Moore recalls.

Of the four people, Moore was the only who stayed with Decker.

“The rest of them couldn’t handle lean times, could not cinch up their belts enough and got very, very dissatisfied. To me, it’s been a great ride, a tough ride, there have been a lot of 70- and 80-hour weeks. But Bob was putting in the same 70- and 80-hour weeks that I was. He’s just a man that I admire,” he adds.

Keeping Two Buildings

When Decker made his business move in 1987 by starting Westcare, he kept two buildings, a little 64-bed nursing home in Indio, Calif., and a 30-bed facility for the developmentally disabled in Idaho Falls, Idaho. “This is what we supported ourselves on, the meager management fees from those,” Moore says.

To scare up other business, Moore and Decker searched for long term care properties in need of management help, which often meant doing major fixes and working nearly every day of the week to get things right.

“You hustled, you took the work you got and you sucked it up and did what needed to be done. Over the years, I remember one job in about 1991 or 1992 in Pocatello, Idaho. We went in and I spent five months there, going home every other weekend. I helped straighten out their problems, recruit a new administrator and what not. Bob worked those same hours.”

It was, Moore says, what you did to put bread on the table but more importantly about making life better for the residents in the facilities Westcare consults for and/or manages.

Do the Right Thing

With Decker, he says, it is resident first and always do the right thing. “He’s always had philosophy that we do what is right for our clients, for our residents and because that is the only way we can be successful and the money will follow,” Moore says.

“We talked many times that neither one of us would ever be as wealthy as a lot of the people that we would see building companies very rapidly. But our focus was on doing it right and having a good reputation.”

An example, he says, was that in on of Decker’s previous ventures, another partner had self-insured for workman’s comp and after that company had folded Decker had found the partner had taken all the money out of the workman comp reserve for himself, a sum of more than $200,000. But when it came time to settle-up on a Medicaid audit for the property with this other partner, Decker still wrote the man a check for his share. “I said he took over $200,000 of your money….and he said ‘Van, what is right is right. He took my money but half of this money is his. And he’s going to get it.’ That is the kind of person he is,” Moore says.

And Here Comes the Next Decker

Even as Moore looks at the history he and Decker have built, July 1 ticks ever closer and the time for a new president arrives. Fittingly, that person is Bryan Decker, currently the controller of Westcare, who looks forward to continuing the family legacy that his father has built.

Bryan Decker

“I wasn’t sure that was in my plans when I started with him, but I have been at Westcare for about 22 years and it has been a good experience,” Bryan Decker says. “It has been great to have him as a father and as a boss because he kind of exhibits the same characteristics at home and at the workplace. And, that is what makes him successful.”

Beyond his father’s ability to manage the dollars and cents of Westcare, it is the true caring for clients and staff that he wants to emulate. “Everyone from the administrator down to kitchen staff to those elderly and disabled residents, he [Bob Decker] has a soft place down in his heart for caring for people.”

And with that care, comes the Decker mantra of hard work.

“He has a great logic in his thinking. That logic allows him to attack problems in a way that allows people to know he is thinking and considering their issues. At same time, it is a kind of great business sense. He says he may not be the smartest guy in the room, but he makes up for that through hard work. That is very true,” Bryan Decker says.

Preparing for the Next Wave of Payment Reform

Brian Garner, Medline Industries

Brian Garner, Medline Industries

The wait is over. The time is now.

While the rehab landscape prepares for more reforms, administrators should already have their facility and staff in line and operators need to be thinking about the future and how to deal with payment reform. Otherwise, they’ll be left behind and will ultimately lose out financially. The focus has to shift to functional rehab as employees are no longer working on a fee-for-service (FFS) model. Facilities are dealing with higher acuities and sicker patients, but being asked to provide better outcomes, and by the way, working for less money.

Due to the new quality measures from the Centers for Medicare & Medicaid Services (CMS), there’s now a greater burden on a staff as they’re being asked to do more with less to meet the Five Star quality rating. So how does a facility improve these quality outcomes with the same type of patient population while controlling their costs?

The Challenges
First off, it’s a consumer-driven market right now for Skilled Nursing Facilities (SNFs).

One challenge is we’re still in the midst of payment reform for nursing homes, especially when it comes to therapy services. With Section GG, introduced last year, nursing care centers are figuring out how to maneuver through the new functional assessments. There’s no real metric to get these patients to where they need to be and how to utilize limited resources to complete the expanding requirements. The plan for patient improvement starts with administrators and their interdisciplinary teams who must be smart and efficient when it comes to productivity and staff. That can all be achieved, especially with the proper equipment.

Also, part of the added stress is the processing of the new Activities of Daily Living (ADLs), looking at the functional mobility of patients. The federal government is tracking one of the stages of development, late-loss ADLs, and how that facility’s therapy team is impacting patient progress. More than a third of the Medicare population receives help with at least one important ADL.

Tie those challenges to the current mindset that there is still time to modify their approach. Some facilities don’t feel the immediate financial implications, which are causing some to hold off on their preparations for the pay-by-outcomes model. In this current health care climate, no one wins by waiting.

Keeping Rehab a Profit Center
With the state of nursing care centers today, administrators pay close attention to their therapy departments as it’s often considered the last profit center. With the new quality measures, there are concerns there will be less profit from the therapy department, moving away from a fee-for-service environment where the more you do, the more you get paid. The problem isn’t just the model, but it’s how the patient population fits into this new formula.

The numbers are staggering. The U.S. Department of Health and Human Services expects the number of people 65 and up to grow from 14 percent of the population to more than 21 percent by 2040. The patients aren’t just getting older. They’re sicker. The number of patients with diabetes continues to climb and the National Health Council is projecting 157 million Americans will have some form of chronic illness in just three years. Imagine this added and ballooning burden on therapists who must work one-on-one with a patient to achieve the same positive results, but in less time whereas before the facility was billing for that time, no rush and no consequences.

Therapists know the struggle, one in particular. About 20 years ago, Avi Nativ saw the challenge in helping his patients take a more active role to regain and maintain their mobility. He realized working with the patients one-on-one with the equipment he was utilizing wasn’t always safe for him or the patient. He struggled in achieving the outcomes he hoped for, and with his doctoral research in motor control and emphasis on brain plasticity, Nativ knew patients of all ages and conditions could regain strength and functional abilities. He created tools that enabled patients to practice functional strategies to regain mobility and prevent falls, by outlining three ideas essential to functional outcomes in the elderly: patient-enabled movement, functional activity and repetition.

Thoughtful Purchasing
Even with these new thoughts on tools, some skilled nursing care providers are panicking. Just last year, a customer received a negative survey that led to a serious downgrade and they became a Two Star facility. This operator, like many others in the same predicament, reached out to its vendor partner. In their quest to correct the deficiency-riddled survey results, they wanted to buy anything and everything for their therapy department.

This was not the solution. Their purchases appeared to have it all, costing $45,000 to almost $60,000 for each piece of new equipment, but the equipment was geared more toward high-performance athletes. The fancier products still required more than one therapist to get the patient into the equipment, a strain on staffing resources.

The expensive, fancy, futuristic products the facility thought it needed are now sitting in a corner, collecting dust.

Less Time to Treat Patients
Robert Tripicchio, PT, D.Sc., president of Community Physical Therapy, shared his facilities’ focus to meet the three tenants of healthcare reform: healthier populations, improved outcomes and decreased delivery costs.

“Regardless of what the product is called, we are transitioning from a FFS basis to one of cost containment and value,” said Trippichio. “Value can be expressed by the equation of outcomes over cost. The providers that will be successful are the ones who get better patient outcomes in a shorter period of time.”

Trippichio understands the transition is underway. Payment reform is no longer a discussion point in our nation’s capital. It’s a reality. Some of the changes have started, but do not go down this new path of payments alone. With the proper staff and equipment, facilities can still increase their reimbursement rates. Your therapy supplier should already be working with you to provide the wealth of knowledge they have to meet the demands in this new era.

Brian Garner is the Director of Sales, Rehab Division, for Medline Industries. He can be reached at bgarner@medline.com.

Changes to ACA Likely Mean More Pressure on Providers

Patrick Connole

With the Senate in the process of making heads or tails out of the American Health Care Act (AHCA), the bill passed by House Republicans on May 4 to rewrite major parts of the Affordable Care Act (ACA) and to revamp Medicaid funding, the financial analysts are out in force to assess what the proposal would mean for health insurers and providers.

In that vein, a new report by Standard & Poor’s (S&P) examines how two main health care market segments—Medicaid and individual—will be affected, and in turn what this means for payers and providers.

On Medicaid, the AHCA offers a titanic shift for the Senate to consider by putting a per-capita cap on federal funding pegged to beneficiary spending in the base year of 2016. States would have some flexibility to eschew the cap and go with a block grant formula instead, but for the most part the cap model would be in place for the long term care sector’s primary clients among elders and people with disabilities.

The Congressional Budget Office, which has not scored the version of the AHCA that rests with the Senate now, did so in March for a previous iteration of the legislation and said changes to Medicaid funding would result in federal spending reductions of $880 billion over 10 years.

There are also hotly disputed changes in the Republican bill to gradually end the Medicaid eligibility expansion under the ACA.

Analysts Weigh In

S&P said in its analysis that the proposed change in Medicaid funding for the expansion population would trim the number of enrollees in the program over time and “be a real test” for Medicaid stakeholders, from insurers to providers, to states and to beneficiaries.

“The bill shifts Medicaid from an entitlement program to either block grants or per-capita funding, with growth in spending likely to lag health care cost inflation. This will likely force some states either to reduce Medicaid eligibility levels or cut reimbursement to providers to offset the growing burden on state budgets,” S&P said.

In general, S&P said the ACA repeal and replace effort, which certainly will undergo a rewrite of some sort in the Senate, is a challenge for providers.

“We believe that passage of this legislation as proposed would add to credit stress in the not-for-profit and for-profit hospital sectors, which could lead to negative ratings actions over time and ultimately a negative outlook,” the analysts said. This negativity is most noted for safety-net providers that are vulnerable to Medicaid reductions.

“However, the funding reductions the bill currently proposes are spread out enough that an immediate negative outlook for 2017 is not currently warranted, in our opinion,” S&P said.

Joseph Marinucci, senior director, S&P, says it is important to remember that changing Medicaid from an open-ended payment system as it has always been to a capped system leaves the door open for trouble if there is a recession.

“The ACA was designed for recession, with buffers for a bad economy. If there are caps, there is then a stress scenario for states who won’t have the flexibility or federal budget to pay for their Medicaid budget,” he says.

S&P also said that providers are already under operating pressures “from a wide array of factors, including already weaker reimbursement growth, movement to value-based reimbursement, and rising labor costs.” This makes the possibility of a new law to follow—and the changes to Medicaid—an especially tough road for providers to navigate right now, the analysts said.

 

The Future of Tech-Enabled Partnerships between Post-acute and Acute Providers

Steven Scott

Steven Scott, PointRight

Whatever may happen to the Affordable Care Act, one thing is certain: The evolution that it created toward accountable and more integrated health care will continue onward, and the collaboration between different types of health care providers will only intensify in the coming years.

Information technology (IT) continues to be central to this effort, but what kind of technology?  Certainly systems that store, manage, and easily retrieve patient data have become state-of-the-art, but a new challenge emerges: turning data volume into value. Business intelligence solutions that affect both quality of care and costs will soon become the bridge across care settings.

It is because data aggregation, data exchange, and analytics are so central to value-based care and to collaboration across care settings that I was surprised this past February when I scanned the audience at the HIMSS conference, considered by many to be the world’s leading gathering of health IT professionals, and saw so few representatives from the long term/post-acute care (LTPAC) profession.  Of the 40,000-plus attendees that gathered over the several days of the program, not very many represented LTPAC providers.

While technology has been a latecomer to a field traditionally focused on the human touch, I certainly don’t believe the numbers are reflective of the LTPAC community’s commitment to leveraging IT solutions to advance quality and deliver superior outcomes. Those of us in attendance were highly motivated and eager to demonstrate to the broader health care universe the vast number of improvements skilled nursing has made thanks to technology adoption.

Post-acute care providers understand that IT has never been more important to the profession—influencing decision making at not only the bedside, but also in the boardroom. To anyone tempted to think technology innovation is exclusive by care setting, look no further than hospital readmissions.

In June 2016, just one year after the American Health Care Association (AHCA) introduced the AHCA Quality Initiative aimed at reducing the number of hospital readmissions within 30 days during a skilled nursing stay, one-fifth of AHCA member centers had achieved a 30 percent reduction in hospital readmissions or lowered their rehospitalization rate to below 10 percent.  These numbers are reported based on our PointRight® Pro30™ measure, a National Quality Forum-endorsed risk-adjusted rehospitalization measure that includes all SNF admissions regardless of payer, rather than Medicare-only data tracked by CMS.

The federal Hospital Readmission Reduction Program (HRRP), created under the ACA, makes lowering readmission a priority, as it penalizes hospitals with readmission rates that exceed the national average.  HRRP shines the light on the interdependence between acute and post-acute providers, a relationship that goes far beyond avoiding readmissions.

As hospitals and health care systems work on improving population health while strengthening their connection to patients and families, having a strong post-acute network in place is pivotal.  This means hospital administrators must have a very strong sense of the quality of the post-acute providers upon which they rely.

Data help tell the story about provider quality.  Hospitals can use analytics to better understand the post-acute facilities in their area that may be most adept at serving certain types of patients.  A patient being discharged with a respiratory diagnosis has vastly different needs than a patient recovering from a knee or hip replacement.

Understanding which facility is right for a particular patient will greatly decrease the likelihood of readmission.

Hospitals and post-acute providers, in many respects, have the same IT challenge, and that is leveraging the data in their EMRs to meet the new challenges of our value-driven health care system.  What is even more interesting is that each provider segment can learn a lot from the other’s data.

Establishing an integrated care continuum will depend on technology-enabled partnerships where data are shared and analytics are used to better serve patients as they move across diverse environments of care.

Steven Scott is President and CEO of Cambridge, Mass.-based PointRight,  which provides predictive analytics solutions to thousands of post-acute providers, hospitals, ACOs, and payers.

 

Fault Lines And Frontiers In Person-Centered, Long Term Care Part 3

V. Tellis-Nayak

Robert Murray sat at the desk with three octogenarian fellow residents; they had an air of authority. Across the desk, the young, shy, but confident Angelica Riviera took her seat.
At the Bethel Health and Rehabilitation Center, a meeting of the ages was about to begin: knowledge developed over 300 cumulative years, arrayed against the untested idealism of the 19-year-old Angelica. This was the final meeting where this team of seniors would declare whether Angelica measured up to the certified nurse assistant (CNA) job she was seeking.

Elders in skilled nursing centers recruiting their own caregivers is something you would expect Diane Judson, director of nursing, to initiate. She has a cultivated way of relating to residents. She connects with the person concealed within an aging body; she recognizes the human spirit yearning to be whole, to reach its potential, and to rise above selfishness and to serve others.

The four residents who interviewed Angelica are the Recruiting Council Judson installed over a year ago. As recruiters, they take over after the routine preliminaries and paperwork. They have the final say in CNA hiring. Robert Murray, a victim of Lou Gehrig’s disease, is an active member. He led the interview with Angelica. His amplifier headset muffled his labored words, but Angelica sensed the pathos in the question Murray directed toward her.

Compassion Over Competence

Murray asked her, “Angelica, you see, I am only 42, but I am not a whole person anymore. ALS has crippled me. I can barely move around. I cannot talk with you without this amplifier headset. I was a full person once. I am not anymore. Angelica, as my caregiver, what can you do to make me feel whole again?”

Angelica could not stop the gush of tears. “That is not what I had expected,” Angelica says. “I thought they would ask me about my training, my skills, and my experience. Bob’s question cut through all that I anticipated, it went deep inside me. It told me that what they were looking for was not a CNA. They wanted a caregiver that made them feel like a whole person. I cried.”

Angelica is now a caregiver at Bethel—a happy one. She has a special bond with Murray.
The recruiting elders are uncanny in detecting the kindness an applicant brings to the job. Not all applicants pass the test. Of the 40 or so prospective students or CNAs thus screened by the residents and recruited in the past year, only two have left Bethel: One was hired by Judson against the team’s recommendation—she soon discovered they were right—and the other, although big in heart, fell short on competence.

The “Residents Recruit CNAs” story is as much a tribute to Judson as it is a warning about the gaping lacuna in the person-centered approach in long term care. Not all well-regarded programs that preach or practice humanistic principles capture all the essential elements that make the human person.

Service Is Joy

A history written in blood, sweat, and tears finally brought the world to agree on a lofty vision of the human person; it is now shared by nations, religions, and cultures. That model posits that five innate yearnings define our goals, endow us our inalienable rights, and confer on us our humanity. We have distilled these primal needs and birthright as: to be, to become, to belong, to be your best, to reach beyond.

To reach beyond selfishness and to lift those in need are tendencies to be compassionate etched in our DNA. Adam Smith, the widely misquoted godfather of economists, refers to compassion as a “principle of human nature, the most exquisite sensibility to feel for others.”

Compassion is the most divine of human virtues. It brings blessings not only to the receiver and the giver, but also to the bystanding observer. The science of compassion has documented the beneficial changes in brain, body, mind, and soul.

As a Nobel Prize laureate put it,
“I slept and dreamt that life was joy.
I awoke and saw that life was service.
I acted and behold, service was joy.”
—Rabindranath Tagore

Compassion Spreads its Blessings

The residents in nursing centers know much about the rewards of selfless sacrifice. They were parents, teachers, doctors, lawyers; they volunteered and were good neighbors; they gave. Why should we presume that in their ripe years they desire to disregard life’s lesson, to become self-absorbed and egocentric?

It is rare that the person-centered agenda specifically caters to the noblest human instinct that yearns to transcend, to serve, and to give. Ironically, this is a glaring deficiency in many well-funded programs. However, compassion thrives in innovative practices at many nursing centers.

At Bethel, Judson opened one route to attain fulfillment via compassion. Other people like Judson at other sites have opened different pathways to compassion:
Residents partner with hospice staff; they bring comfort and peace to their dying friends and co-residents.

Residents serve on advisory groups that plan menus and improve layout, décor, and furnishings.

They serve as ambassadors-at-large that facilitate communication, troubleshoot, and spread cheer and smiles.

One nursing center in New Jersey reinstated a resident’s past career role as a judge. She arbitrates disputes and grievances that residents and staff bring to her.

At another Eastern site, a resident with a distinguished career on the stage was helped to turn residents and staff into actors; they put on stage shows for their families, friends, and neighbors.

In a California nursing center, residents make fancy colored soap, market it at fairs and online, and spend the profit feeding the homeless.

Many nursing centers across the nation connect with churches and schools. They host children; encourage intergenerational play; do foster-grandparenting and baby-sitting; and help with homework, writing letters, and so on.

At other sites, residents pass on their skills and wisdom to the younger generation. They teach, mentor, and counsel.

Kindness and compassion are deeply felt urges that seek fulfilment even as our body ages. Compassion spreads its blessings all around. As Judson says, “Seeing residents hire their caregivers is rewarding enough. Sitting on the sidelines, I listen to residents, I understand what they really want. At each session, I learn something new. It has made me a better leader. It has blessed us all, made each of us a better person.”

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He and his wife, Mary Tellis-Nayak, have co-authored a book, “Return of Compassion to Healthcare,” which upholds humanity as the ultimate measure of success. He can be contacted at vtellisn@gmail.com.

Possible New Federal Medicaid Policies Put Pressure On States

Patrick Connole

With Congress weighing whether to alter how shared federal and state payments work in the Medicaid program under a Republican federal per-capita cap, the possibility of such a shift could leave long term and post-acute care (LT/PAC) providers much more focused on state policymaking moving forward.

That is the thinking of Robin Arnold-Williams, a partner and head of the Medicaid practice for Leavitt Partners in Salt Lake City, Utah, who tells Provider that if a per-capita cap comes to be then states will be faced with enormously tough decisions on “who they are going to cover and for how long.”

Of the many factors playing into how states decide, under a possible cap system, to allocate money to the various populations able to receive Medicaid funding (low-income elderly, disabled, pregnant women, etc.) is the Affordable Care Act’s (ACA) eligibility expansion. What the House Republican bill, the American Health Care Act, currently proposes is that enhanced federal funds, or matches under the ACA, will continue to be paid for enrollees on the books by Dec. 31, 2019.

So, states like Kansas, which is slowly moving forward in its legislature to possibly expand eligibility under the ACA for its Medicaid program, may want to act sooner rather than later in order “to get critical mass” and take advantage of the enhanced match of 90 percent, Arnold-Williams says.

How these state decisions on ACA eligibility directly affect LT/PAC funding is that if a state does or does not take on the more generous federal match and more enrollees, then they may or may not have more money for other buckets, or populations, in need of the capped federal funds.

All of this is very complex to understand, she explains, and will leave state Medicaid offices working overtime if the House Republican bill survives its trek through Congress.

“I imagine there are a lot of Medicaid directors looking at their data and trying to calculate that. That will take some sorting through,” Arnold-Williams says. “There are different per-capita rates for each group: children, adults, seniors and the disabled and the blind. It is one thing to say the money is going to flow to the state in those set per-capita rates by group, but it is quite another thing at the state level to say how that revenue will be allocated.”

An example of the tough math ahead is if you have different inflation costs for seniors and people with disabilities versus children, leaving states to allocate Medicaid budgets for these different groups and services within Medicaid without open-ended entitlement.

Some states, she says, will be more generous and may even weigh keeping their program open-ended with possible tax increases, decrease in health benefits, or other moves to pay for it, but more likely it sets up an intense period of competition between various Medicaid groups when the Republican proposal would go into effect in 2020.

“And one decision point in 2020 will be a state making a conscious decision to roll back ACA expansion in order to manage money better. It is hard to manage expansion and not have new people come on at lower match rate,” Arnold-Williams says.