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Senior and Post-Acute Healthcare News and Topics

CMS Proposes New SNF Payment Model

Last Friday, CMS released the contents of its annual proposed rule updating the SNF PPS plus (as always), fine tuning certain related programmatic elements. Final Federal Register Publication is set for May 8.  (Anyone wishing the PDF version may download it from the Reports and Other Documents page on this site or access it here SNF Proposed Rule 4 2018 ).  The most watched information for providers is the proposed rate adjustment though lately, for the post-acute segments of health care, other elements pertaining to payment model changes have eclipsed rate “watching”.

Last year’s proposed rule for the SNF PPS contained the release of RCS-1.  After extensive commentary, CMS pulled back RCS-1, shelving it for some conceptual remake.  We now, as of Friday, know the remake – PDPM for short (Patient Driven Payment Model). As with all yearly releases similar, a comment period has begun, lasting until (if not otherwise extended) the last week of June (June 26).

PDPM as proposed, is designed to replace the current SNF payment methodology known as RUGs IV.  Unless date changes, etc. are made by CMS post commentary review, the effective date of the change (from RUGs to PDPM) is 10/1/19 (next October).   PDPM as an outgrowth of RCS-1 and received commentary, is a simplified payment model designed to be more holistic in patient assessment, capture more clinical complexity, eliminate or greatly reduce the therapy focus by eliminating the minute levels for categorization, and simplifying via reduction, the assessment process and schedule (reduced to three possible assessments/MDS tasks). Below is a summary of PDPM core attributes/features as proposed.  On this site in the Reports and Other Documents page is the PDPM Calculation Worksheet that provides additional details beyond the reference points below PDPM Calculation for SNFs.

  • PDPM uses five, case-mix adjusted components for classification and thus, payment: PT, OT, Speech, Non-Therapy Ancillary and Nursing.
  • For each of these components, there are separate groups which a resident may be assigned, based on MDS data.  For example, there are 16 PT groups, 16 OT groups, 12 Speech groups, 6 Non-Therapy Ancillary groups and 25 Nursing groups.
  • Each resident, by assessment, is classified into one of the group elements within the component categories. This means that every resident falls into a group within the five case-mix components of PT. OT, Speech, Non-Therapy Ancillary and Nursing.
  • Each separate case-mix component has its own case-mix adjusted indexes and corresponding per diem rates.
  • Three of the components, PT, OT and Non-Therapy Ancillary have variable per diem features that allow for changes in rates due to changing patient needs during the course of the stay.
  • The full per diem rate is calculated by adding the PT, OT, and Non-Therapy Ancillary rates (variable) to the non-adjusting or non-variable Nursing and Speech components.
  • Therapy utilization may include group and/or concurrent treatment sessions provided no more than 25% of the total therapy utilization (by minutes) is classified as group or concurrent.
  • PT, OT, and Speech classification by group within their respective components do not include any function of “time”.  The sole denominator of how much/little therapy a resident receives is the necessity determined by the assessment process and by the clinical judgment of the care team.  In this regard, the minimum and maximum levels are based on resident need not on a predetermined category (RUG level).
  • Diagnoses codes from the hospital on admission (via ICD-10) are important and accuracy on the initial MDS (admission) are imperative.
  • Functional measures for Therapy (PT, OT) are derived from Section GG vs. Section G as provided via RCS-1.
  • The Non-Therapy Ancillary component allows facilities to capture additional acuity elements and thus payment, for additional existing comorbidities (e.g., pressure ulcers, COPD, morbid obesity, etc. ) plus a modifier for Parenteral/IV feeding.
  • There are only three Medicare/payment assessments (MDS) required or predicated starting in October of 2019 – admission, change of condition/payment adjustment and discharge. NOTE: All other required MDS submissions for other purposes such as QRP, VBP, Quarterly, etc. remain unchanged.

For SNFs, the takeaways are pretty straight-forward. First, clinical complexity appears to be the focus of increased payment opportunity.  Second, therapies are going to change and fairly dramatic as utilization does not involved minutes and more is better, when clinically appropriate but less is always relevant (if that makes sense).  The paperwork via MDS submissions is definitely less but assessment performance in terms of accuracy and clinical judgment is increased.   MDS Coordinators, those that are exceptional clinicians and can educate and drive a team of clinicians, will be prized as never before.  RUG style categorization is over so the focus is not on maximizing certain types of care and thus payment but on being clinically savvy, delivering high quality and being efficient.  The latter is what I have been preaching now for years.  Those SNFs that have been trending in this direction, caring for clinically complex patients, not shunning the use and embrace of nursing RUGs, and being on the ball in terms of their assessments and QMs are likely to see some real benefits via the PDPM system.

More on this new payment model and strategies to move forward will be in upcoming posts.

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May 1, 2018 Posted by | Policy and Politics - Federal, Skilled Nursing, Uncategorized | , , , , , , , , , , , , , | Leave a comment

Upcoming Webinar: Reduce Citation Risk

SNFs are just a little past one year since the new Conditions of Participation were implemented along with a new survey process.  Today, we are in the first-full quarter of Phase 2 implementation and facilities are just now getting surveyed on these requirements. As a result, we have some data on how the new survey process is going, what facilities are experiencing in terms of citations, how survey teams are looking at Phase 2 requirements, etc.

On Wednesday, March 7th I will be joined by Diane R. Hislop, RN, H2 Healthcare’s compliance expert and Senior Partner, presenting a webinar on the Phase 2 aspects of the SNF Conditions of Participation, the new survey process and how facilities can reduce citation risk.  The webinar will last an hour and there are some great handouts and tools that Diane has agreed to share with all participants.  I hope you can join me and Diane for what will be, an exceptionally informative update on SNF surveys and compliance trends.

The registration link is here:

http://hcmarketplace.com/reduce-citation-risk

February 14, 2018 Posted by | Uncategorized | , , , , , , , | Leave a comment

Happy New Year!

Welcoming in 2018 with a bunch of new content and enough cold weather and limited travel over the next month to get some new posts up.  I apologize to the loyal readers and subscribers that have patiently waited for new content.  A horrendously busy (non-typical) end of the year limited my writing/composing time.  Thanks for waiting and stay-tuned; plenty of new stuff forthcoming.  Happy New Year!

January 15, 2018 Posted by | Uncategorized | , | Leave a comment

Leading Age Annual Meeting

For those readers that have been dropping me notes – YES, I will be in New Orleans next week at the Leading Age conference. I will be there Monday and Tuesday, presenting Tuesday morning with a team. Our session is from 10:00 to 11:30: Care Coordination Model for Improved Outcomes and Satisfaction. Diane Hislop RN, H2’s Senior Partner and clinical compliance expert is part of the team of presenters. Those in attendance will receive a great bonus! We are providing zip drives to the first 300, loaded with forms, clinical pathways (respiratory, ortho, and more), care coordination materials, etc. from the presentation.

Catch me and Diane at the session or drop me a note on this site or via my mobile mail at hislop3@msn.com and we will try to connect.

October 26, 2017 Posted by | Uncategorized | , , , | Leave a comment

Happy Memorial Day

As we pause for what most Americans consider the beginning of summer and an extended weekend break from work, etc., please never forget those who serve, have served and gave the ultimate sacrifice.  Freedom isn’t free!  To all my brothers and sisters in arms past, present and future my deepest thanks and respect to you for your service

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May 27, 2016 Posted by | Uncategorized | Leave a comment

Boards of Directors: Outside Looking In

Over the course of many engagements plus my years as an executive, I’ve addressed and been asked to address, the theme of effective governance, particularly at the Board level.  To bring this topic into full context, one of my many “hats” that I wear (periodically), is as an advisor to graduate and post-graduate students working in the arena of health policy and healthcare management. One of my students currently, is researching this topic of governance especially as the same (effective v. not effective) correlates with organizational prosperity.  Her area of concentration in this research is non-profit health care organizations, though for-profit organizations are included as a contrast subject.

Her research and our conversations, reviews, etc. are fascinating as the content leads me across my many experiences serving on boards (non-profit, for-profit and publicly traded) as well as my many client engagements working with and/or in conjunction with, senior executives and their boards.  Upon further thought it thus occurred to me that I haven’t written anything as of late on this whole issue of governance – what it is, what it should be, where effective and ineffective collide in terms of organizational prosperity, etc.  Of course as always, my episodic journey (fits and spurts over a few weeks where time permits) led me through tons of stuff from my notes on engagements to former lectures and presentations to other research I have gathered.  Being brief: Wow.  I have a collection; quite a bit deeper than I thought/remembered.  The net of my review is that this topic of “governance” lends itself to a series of posts.  This is the first and for simplistic sake, it covers the core duties and the counterbalance of liabilities, for any Board (non-profit or for-profit).

To start, the core duties of a board are completely separate and thus, different from the core duties of management.  A board has a bifurcated role and responsibility.  The first duty is the advise and consult responsibility with management concerning the strategic and operational direction of the company.  The second and equally important duty is to monitor company performance at the macro level (financial, compliance, risk, etc.).  Topically, the latter element includes but is not necessarily limited to (not in particular order);

  • Approval of strategic plans and strategies.
  • Testing of performance measurements and oversight of risk management.
  • Succession planning for the top executive(s) and the process of selection, when required, thereof.
  • Audit – assuring the completeness, compliance and integrity of financial statements
  • Compliance – assurance that the company/organization complies with all federal, state and other related laws and regulations.
  • Approval of major capital investments
  • Protection of company assets and reputation, including tangible and intangible assets (intellectual property, trademarks, name, etc.)
  • Assure adequacy of executive compensation packages and develop and implement, the same in order to assure the security of key executive(s).
  • Represent the interest of shareholders and/or stakeholders (non-profits).

The key issue for a board is the concept of independence; the independent director.  In this regard, the ideal is that a board is solely interested in the welfare of the organization and thus, each director is free of self-interest such that the same would compromise his/her judgment and/or render him/her unable to take positions opposite of management when required.

The board is headed by the Chair(man or woman) who is responsible for agenda, meeting schedules and structure, committee coordination and overall communication within and across the board.  Boards make decisions on a majority rule basis unless specifically required otherwise (certain actions may require a super-majority) and such decisions are based on the information and input from management.

Board committees may exist in large numbers or in smaller numbers.  In healthcare, the following committee functions/board committees require specific attention.

  • Quality/Compliance: This is a major risk area and it is perhaps, the most critical oversight function for a healthcare board today.
  • Governance: Boards need to address new member recruitment, director performance, board performance, board education, etc.  This element also includes CEO performance and may/may not encompass compensation for the CEO.  Some organizations split compensation into another committee.  I have found both split and shared equally as effective if properly managed.
  • Audit/Finance; Second only to compliance in terms of risk, boards need to engaged in the review of investments (capital, other), financial statements, the engagement of auditors, the review/approval of financial plans, budgets, forecasts, and where applicable, any organizational financing activities from feasibility through completion/non-completion.  This function also encompasses financial risk management and review of public release information.

Board terms are all across the map today but the two best practice models I favor are one-year, annual election of members or staggered two or three-year terms.  Each have merit and each have flaws.  The true test of effectiveness of any “term” condition is how effective the governance function is in terms of director review, board review, etc. Boards that have effective director performance review, clear criteria and effective board performance review self-police and thus, make term conditions work regardless of length.

Finally and key for all boards and members to understand is that boards have specific legal duties, typically identified under their respective state laws or as embodied in case-law.  These duties are typically identified as “fiduciary” in nature.

  • Duty of Care: The requirement that decisions are made via deliberation and investigation/data.
  • Duty of Loyalty: The requirement that directors act in the best interest of the corporation or enterprise.  This duty has also been, in some case-law decisions and state laws, expanded to include the best interest of shareholders.
  • Duty of Candor: This is more applicable to publicly traded companies but I have found it universally applicable.  It essentially means that the Board provides all relevant and transparent information to any party where the organization solicits business, solicits investment, or is inclined to be or involved in transactional business.  Effectively, this is the full and honest disclosure rule or as I like to call it, the tell the truth”  principle.

In my next post, I’ll explain how the implications of board duties, structures, etc. play out in real life and how public vs. private (non-profit vs. for-profit) situations compare and contrast.

March 18, 2014 Posted by | Assisted Living, Home Health, Hospice, Senior Housing, Skilled Nursing, Uncategorized | , , , , , , , , | 2 Comments

Debt Ceilings, Government Shutdowns and Health Policy

Most of my readers know by now that I am an economist by training and formal education.  My clients know this as well.  The net result is that I’ve been queried, almost to death as of late, as to what this current round of Washington folly is really all about.  Is it about the ACA?  Is it about the budget?  Spending? Is there really a debt ceiling, etc.?  Suffice to say, this post is intended as a concise answer (and no, economists are not known to be concise or clear on anything so I’m going out on a limb here).

While most Americans express concern over the amount of debt at the Federal level, the truth is that the amount is really not the issue.  The ratio of debt to GDP is the bigger issue plus the cost of servicing the debt as percentage of the revenue received by the government.  Today, the debt load is approximately $16 trillion (beginning of 2013).  Of this total, around $10 trillion arrived since 2002.  The $10 trillion is the result of the wars in Iraq and Afghanistan, entitlement growth, stimulus spending, tax cuts, and the recession.  Income flows into the government coffers reduce substantially during recessionary periods and periods of stagnant GDP growth.  As revenue evaporates faster than spending, and during recessions spending on behalf of the government normally increases (income support programs, entitlement growth, etc.), the deficit gap widens.  Deficits require funding (the bills must be paid) and thus, the source for the government is borrowing.  As of late (last few years), the government has borrowed more than $1 trillion annually to cover its cash outflow shortfalls.

While the question of long-term sustainability begs and the debate wages on about fiscal balance, the truth is that while this process (escalating borrowing) is on its face unsustainable, it is likely more temporary in nature than permanent.  At the very least, the policy drivers and economic factors will shift, altering the present course of borrowing.  For example, across the last two fiscal years, borrowing has reduced as budget deficits recede naturally.  Spending priorities in Washington have shifted and taxes increased.  The 2013 deficit will not exceed the trillion-dollar mark, coming in at $700 billion or so. As wars conclude and the economy recovers, even if slightly more than present, the deficit shrinks and the need to borrow is lessened.

What is central to the issues referenced in the title is the budgetary math and how the dollars are received and spent.  Within a budget of $3.8 trillion, two-thirds is allocated toward “fixed” or “mandated” spending.  That leaves $1.2 trillion in the variable or discretionary bucket.  Interesting to note, the budget proportion as a percent of GDP hasn’t changed all that much – up only 2% compared to the most recent forty-year average.  What has changed is the allocation percentages with more dollars spent today on entitlement programs.  For example, Medicare spending is nearly three times greater as a percent of GDP compared the forty-year average. Health spending is more than double and Social Security is one and a third times more.  Because the percentage of GDP spent is roughly the same, the offsets are found in defense spending, science and technology, general government and interest (yes, even with a rising debt level, lower rates have kept the interest cost lower than the historical average).

The government via taxes, will take in approximately $3 trillion.  The gap thus is $800 billion, give or take a billion or so.  This gap is the driver of borrowing limits and debt ceilings.  In effect, the debt ceiling is a self-imposed number and one that is totally arbitrary.  Congress established the debt ceiling back in 1917 with the passage of the Liberty Bond Act.  In the 70s, via passage of the Budget Control and Impoundment Act, the debt ceiling became less relevant.  Effectively, the debt ceiling issue was tied to the budget and a parliamentarian procedure known as the Gephardt Rule (after Congressman Dick Gephardt) allow the ceiling to automatically adjust incident to budget passage.  The problem to a certain extent of late is that the government hasn’t operated with a budget for at least three years and spending bills (appropriations) have stalled in the Senate.  Essentially, a debt ceiling discussion thus becomes separate from other fiscal operation activities.

So where are we now and what does this mean?  In cold hard reality, the issue of the debt ceiling is less about default on credit but about the ripple effect economically that will occur.  The U.S. really can’t default on its debt and does operate with enough cash flow to keep interest payments current.  The President does have unique authority via executive privilege and orders to adjust the U.S. borrowing limit.  The Treasury also has other temporary powers.  Using these powers is a last resort as doing so will certainly cause economic havoc world-wide via the real signal that the U.S. government is in chaos.  Remember, the stability of much of our economy is based on the stability of our systems of banking, credit and government – the full faith and credit stuff – nothing more.  If this system isn’t credible and stable, the erosion is tsunamic.

History and an updated view of the economic reality we live in, paints the true picture.  Today, our debt driver and our economic structural flaws within the government budget (such as it is) are entitlements as presently configured.  There simply is not enough room on the discretionary side or the variable side to right size the budget, offsetting the entitlement growth.  The demographic shift that is occurring in the U.S. and all first world countries (aging) is the catalyst. By 2033, 20% of our population will be 65 and older, eligible as presently configured, for Social Security and Medicare.  Moreover, the expenditure to income ratio per each under Medicare produces a significant outflow deficit.  For example, a 65-year-old couple in 2020, assuming average wages earned during their work years will contribute $110 thousand (with employer share) into Medicare.  Across their remaining life, Medicare will spend in present dollars, almost 4 times more ($430,000).  By 2022, Medicare spending is projected (under current law) to consumer 4.5% of GDP (3% today) and rise of 6.7% by 2035.  This net change equates to a spend rate of more than $1 trillion in current dollars on Medicare alone.

To the point: Health policy is the shutdown, budget and debt ceiling debate.  The good news is that it is fixable but the bad news is that it must be fixed by government.  There is no other course of action that can and will adjust the debt trajectory.  Now, hope is also muddled within the mix.  The healthcare industry has gotten smarter and evidence suggests that recent reductions in healthcare spending increases are as much due to more efficiencies in healthcare delivery (generic drugs, better insurance bargaining, smarter consumption habits of patients) as due to a weak economy.  A public-private initiative could create a paradigm shift, favorably changing the entitlement spending outlook.  Congress and the President will need to get creative and utilize a different legislative approach to resolve the present dilemma.

Is the sky falling because of too much debt?  Not really.  Governments and especially ours, don’t really need to be too concerned about the debt load in the short-run.  The concern is about changing or adjusting the factors that drive debt.  As long as the increase in new debt is less proportionately, than the increase in GDP, debt load as percentage of economic activity reduces.  For example, between 1945 and 1980, the government only encountered 8 years with surplus revenue.  Fully all other years involved deficit spending. In 1945, at the end of World War II, debt as percent of GDP weighed in at 120%. By 1981, the level subsided to 30%.  The reason?  GDP growth accelerated during these years and the deficits were relatively small.  The economic truth is that government policy needs to focus-in on all things fundamentally favorable to GDP growth while constraining with simple austerity, the deficit levels.  The debt problem thus resolves itself.  There is no need to “pay it back” and fundamentally, no reason to do so.  The best approach is to minimize its impact on the economy by fixing the root cause.  In this case, adjusting entitlement spending by relatively modest means (currently structural changes to reduce about $500 billion) is all that is needed.

October 10, 2013 Posted by | Policy and Politics - Federal, Uncategorized | , , , , , , | Leave a comment

LeadingAge Annual Meeting and Conference in Dallas

In response to a number of e-mail and other inquiries, hoping to avoid more and the guilt that comes from not responding to each promptly, I will be in Dallas for the LeadingAge Annual Meeting and Conference.  I am speaking twice – two sessions.  The first is Tuesday, October 29th and the session reference is Data Driven Marketing and the second is on Wednesday, October 30th and the session reference is Bring Your Therapy In-House.  I’ll be generally around the conference location Monday through Wednesday.  Anyone wishing to connect, contact me as far in advance as possible.

September 27, 2013 Posted by | Uncategorized | Leave a comment

Obamacare/ACA: Where it is at, why and where next

A number of my regular readers and clients routinely ask for my thoughts/analysis on where the Reform Act/Affordable Care Act/Obamacare is at, particularly in-light of the recent one-year delay in the employer mandate.  Given the complexity of this subject and the scope of the overall law, a single post won’t cover the subject adequately.  In compiling my notes, research, etc., the logical approach is to address this subject in four posts;

  • The economic, social and political environment
  • The implications for providers
  • The implications for consumers/employers
  • The “best guess” of what happens next, post-the mandate delays, etc.

This first post, not to state the obvious, is focused on the economic, social and political environment that envelopes the legislation and is impacting its course.

Like the legislation or not or like or not its intent,  the ACA is a fascinating window into current social, economic and political realities.  It by its legislative intent, is a governmental attempt to address a number of social, political and economic factors within one large, overarching piece of law.

  • The rate of spending or expenditures relegated to healthcare in the U.S.
  • The cost of and access to, health insurance for a subset of individuals not covered or inadequately covered through traditional entitlement programs (current or former eligibility tests applicable) or traditional health plans (employer sponsored primarily).
  • The government’s role in assessing the adequacy and quality of provider programs.
  • Certain innovations deemed worthy of further exploration that in theory, will improve efficiency, care delivery and thus, quality as measured via outcomes.
  • The legislative mechanics to accomplish the above (authorizations, funding, delegation to various agencies, creation of other governmental entities for implementation and administration, etc.).

Structurally, the ACA is overlaid across existing governmental programs such as Medicare and Medicaid.  It does virtually nothing to change these programs, their benefits, their funding, etc. Arguably, the most the ACA does to these programs is fine-tune certain elements and add some subtle adjustments to payments and disclosure requirements for providers.  The most notable change within the ACA occurs within Medicaid as the ACA expands the definition (financial) of eligibility allowing people with greater financial means (up to 133% of the federal poverty limit effective in 2014) to participate in the program.

Politically, the need for the ACA was expressed (condensed) as an intervention to increase the number of people in the U.S. with health insurance coverage (reduce the number of uninsured) while simultaneously, “bending the cost curve” on Medicare and other entitlement programs (the rate of spending).  Both intents are laudable.  The latter may be somewhat attained but the cost curve bend, not and certainly, not as a result of the ACA.

The primary reason the ACA will have negligible impact or frankly, none at all in changing federal outlays for healthcare is that it doesn’t address, by legislative language or other, any specific funding and benefit elements of current entitlement programs, save to actually expand benefit eligibility (Medicaid).  It further ties the government to enhanced levels of funding in order to effectuate the expansion.  Additionally, the economic and social factors at play in the U.S. don’t coalesce around the legislation and in fact, are polar opposite to the legislation.

The driving elements of increasing expenditures, current and future, under Medicare and Medicaid are economic and social factors that can’t be adjusted by legislation.  Legislation or policy at its best can only respond to these factors via incentive and alignment but essentially, in the U.S., government fiat doesn’t work to adjust economic and social factors.  Our system of government and enterprise, even with greater regulation and oversight, can’t alter certain mercantile and social forces at play.  Principally;

  • An increasing percent of the population, even without changes to eligibility criteria, is eligible for federal entitlement benefits.  This is fundamentally the case for both programs – Medicare and Medicaid.  The aging population alone is the principal driver for increasing Medicare enrollment.  The economic shift in labor and payroll, an increasing driver for Medicaid eligibility.  These factors can’t be changed by policy unless the policy changes the eligibility in such a manner as to constrain growth.  The ACA did not do that.
  • The economy in the U.S. is in a period of adjustment and it has been now for the past twenty plus years.  This period is continuing and will for at least another twenty or thirty years.  The U.S. is no longer a production-based economy in the traditional sense; it is a consumptive, service based economy.  Economic activity is heavily influenced today by consumer behavior (consumptive) and as it has shifted toward an  employment locus in a service sector, the wage profile is different and lower than what was realized in the former production economy.  See the manufacturing industry as an example, particularly the assembly line style.  Today, the overall number of jobs are fewer, demand higher skills, and are slowly replaced by innovation and automation.  The fear is not overseas manufacturing usurping jobs but onshore technology advances eradicating jobs.  Manufacturing will remain a vital portion of the U.S. economy although not as relevant when viewed as a labor source in quantity.
  • Socially, we have come to expect government to be an arbiter in the distribution and production of health care and health benefits. We expect interventionist policy and the government to employ distributive justice for our care.  One only needs to look at the coverage breadth for government programs compared to private programs to see this evolution.  Gone are the days when private, employer sponsored plans can be considered “Cadillac” coverage compared to government entitlement programs.  Today, the inverse is true as employer plans have scaled options, imbedded greater increments of cost-share, and narrowed provider choices.  Oddly enough, the ACA is an evolved governmental effort to reach into the “private sector” and lay-over, a mandate for expanded coverage, benefits, and conditions – very similar to a government run, entitlement based infrastructure (e.g., no pre-existing condition limitations, no lifetime benefit caps, mandated coverage and benefit levels for group plans, etc.).  If government is, and I believe it is, a reflection or mirror if you will. of present-time, social expectations then one can readily conclude that the ACA exists because the dominant social trend current demands government intervention in health care.

Politics in the U.S. has evolved as well.  The political environment is about wins and losses in and across party divisions and sub-interest groups.  Broad consensus is rarely attainable on issues of substance.  The ACA evolved as a result of a point-in-time shift in central governance – a movement toward an ideological trend that government can and should be more involved in social imbalance.  The truth however is that the present wave of social imbalance, the slow decline of a “middle-class” isn’t fixable by government policy and redistribution.  This shift has occurred as a result of a changing world economy and in the opposite, government policy which hasn’t evolved.  In short, the change in social structure has arisen gradually, across multiple administrations and the trends have been present since the mid-70s.  Government can’t fix or legislate a re-balance.

In order to frame the life or death or evolution of the ACA going forward, the environmental factors of politics, economy and social expectations need dissection. For example, the political environment remains fractured so the likely remedy legislative is as we see today; subtle shifts around the edges, delays, and partial recalibration mostly coming via administrative rule-making and executive order rather than legislation.  While party balances in power may shift moderately, a ground-swell shift is unlikely – the electorate too disjointed and divided for this to occur.

Socially, the structures of society continue to shift.  People are more mobile.  Traditional jobs more scarce especially those with benefits.  Education is required but not necessarily in the form of traditional four-year degrees for many new and evolving jobs. The ability to earn a family supporting or for that matter self-supporting wage without special training or skills is eroding quickly, save for farming to a certain degree.  Wages will not inflate to any large degree for quite some time again, except in certain industries where scarce labor-skill is operative.  Child bearing occurs later and today, in rising numbers within single parent, non-intact couples. Saving rates remain low although personal debt levels have declined but this is likely temporary.  And finally, most individuals don’t view their income allocation toward health care as favorable and would prefer, a greater amount of their income be available for discretionary spending.  As long as this view, not supported economically, remains prevalent, the pressure on government to subsidize or create cheaper health care will remain high.

Economic trends and economies are changing and will continue to evolve for another decade plus.  This essentially means that labor-levels and employment levels are different and will remain different and thus, higher levels (historic) of unemployment, under-employment, income and non-participation will remain.  These factors cause governments to fund entitlements and support programs.  This will change over time as new sub-economies evolve and social structures adjust.  Expectations move and production shifts to balance a mixed demand for different services, goods, and commodities world-wide.  Today, the imbalance however is palpable as fossil fuel production has moved geographically, food production and distribution as well, and manufacturing re-structuring to a heavy industry third-world production and high-tech production and design residing in first-world countries  The U.S. economy will be different and thus so will be standards of living, valuations on real property, consumer behavior,, and credit and investing.  How this shapes the ACA going forward, I’ll delve into in the next series of posts.

August 17, 2013 Posted by | Policy and Politics - Federal, Uncategorized | , , , , , , , , | 2 Comments

Assisted Living, PBS and the Lessons Learned

Since last week, I’ve fielded a number of questions/inquiries stemming from the PBS segment on Assisted Living.  Interesting, a number of the queries have come from sources tangential to the industry (policy folks, trade associations, advocacy groups, etc.).  Thematically, these sources are looking for answers as to “why” and “what can be done”.  Aside from ill-advised regulations, my perspective is the best fix is an industry driven effort.

One could over-simplify by saying, “don’t take anyone as a resident that needs more care than can be or should be provided in Assisted Living” but that’s not practical.  Residents change throughout their stay, sometimes rather abruptly.  The most complex changes, and those that represented the focus of the PBS piece, are cognitive and behavioral.  While medications exist to ameliorate or control certain behaviors, the medications have side-effects and are ideally, the final, last course of behavior management.  In all instances, behavior medication should only be given in a setting where a Registered Nurse is present and assessments and monitoring can occur (remember, only Registered Nurses can assess by license authority).

The lessons learned or should have been learned and the counsel I have provided to clients and inquisitors alike is as follows;

  1. Be clear with residents and families on admission, what kind of staff are on-site and immediately available.  This communication should frame then, the services that can and will be provided.
  2. Be clear with resident physicians on the same information.  Don’t encourage or allow physicians to become comfortable with providing orders for PRN (as needed) medications if the same medications require a professional assessment prior to administration, unless the facility has RN coverage on each shift.  Effectively, this means that PRN orders for anxiolytics, hypnotics, anti-psychotics, narcotics, etc. are inappropriate without access to an RN for an assessment.
  3. Beef-up pre-admission screening and assessments with qualified, licensed personnel to fully understand, prior to admission and re-admission, the care needs of the resident.  In many cases, I advise going to the resident’s current place of residency prior to admission.
  4. Make certain that any public (written in particular) or oral representations of Assisted Living as an alternative to nursing home care are gone and certainly, not made or implied. Assisted Living is not a substitute for institutional care if the institutional care is truly required.
  5. Create specific assessment and re-assessment periods to address care changes more frequently.  I like quarterly reviews for Memory Care residents and no less than semi-annual for Assisted Living (non-Memory Care).  I also like mandatory 30-45 days post admission, again at 90 days and then semi-annual.  I also like this schedule to repeat whenever a resident is hospitalized and returns or returns after an SNF stay.
  6. Utilize evidence-based, best practice protocols for AL and Memory Care.  AMDA is a good resource.  Provide physicians with the information as well.
  7. Develop and utilize, a solid orientation and training program for staff.  For Memory Care, there are some good resources available today from Leading Age, AHCA and ALFA.  For facilities and organizations that are heavily invested in Memory Care, I also recommend exploring and using, TCI or CPI to augment training (specialized training in dealing with aggressive and combative behaviors).
  8. Be focused on staff levels based on care needs of residents.  If increasing or integrating more professional staff is not an option, be vigilant on discharge planning or transition planning.  Bottom-line: If you can’t effectively meet resident needs 24/7, say so and start discharge planning.  Have sufficient numbers of staff trained and available, even PRN if required, to address resident care challenges.

For facilities/organizations capable of going to the “next” level, either by size or by financial status, I recommend the following as true “game-changers” for Assisted Living.

  1. Contract with a “house doctor” or Medical Director.  Build a system that integrates elements of medical oversight and engagement with your resident population and staff.
  2. Expand the care team to include social workers, in Memory Care a psychologist or psychiatrist (or RN extender), a dietician, qualified activities professionals, and rehabilitation therapists.
  3. Employ a building or program administrator with appropriate degrees and training plus a demonstrable history of working in a post-acute/long-term care environment.  Paying a bit more is worth it for someone with appropriate training and education.
  4. Become active participants in state and national trade associations.  Encourage staff to participate as well.  I also encourage networking with other professional organizations such as the Alzheimer’s Association.
  5. Hold regular family meetings or focus groups to both inform and solicit feedback.  I like at least semi-annual.
  6. Connect with a local home health provider for staff augmentation when residents need more care, temporarily or until discharge.  I also recommend connecting with a hospice agency.
  7. Contract for pharmacy consultations on all residents and if possible, have a pharmacist as a resource to Memory Care staff.

Final Word: Communicate and be clear with residents and families regarding the services that are “truly” available and where the “appropriateness” line resides for the organization/facility.  Don’t ever extend beyond what staff can provide and what the organization is capable of delivering on a consistent almost constant basis.  Recognize that resident care needs change and that limitations exist as to what ALFs can and should provide.  Be clear, be compassionate, and be honest – within the community and the organization.

August 6, 2013 Posted by | Assisted Living, Uncategorized | , , , , | 1 Comment