1. Expanding Opportunities Caring for Older Adults Kenneth Brubaker MD, CMD Medical Director of Masonic Village

2. Learning Objectives 1.How will the Patient Protection and Affordable Care Act (PPACA) impact your mission? 2.How can you expand your nursing home without walls? 3.Will quality of care and cost of care be the trump cards that dictate your future caring for older adults? 4.What opportunities will you have to improve your bottom line in a competitive market place?

3. Where are Medicare/Medicaid dollars spent? $101 billion dollars are spent on long term care services and supports (about 1/3 of Medicaid spending) A decline in three or more ADLs cost 4.5 times more in Medicare spending 35% of LTC is privately financed

4. SCAN Foundation National Poll 8 out of 10 Americans support health care reform that includes improved coverage for home and community based long term care services 8 out of 10 Americans indicated that health care reform would benefit them 8 out of 10 Americans fear that they will not be able to pay for LTC services

5. Patient Protection and Affordable Care Act (PPACA) National insurance for LTC services Medicaid options and incentives to expand long term services and supports (LTSS) Chronic care coordination Nursing home reform

6. Community Living Assistance Services and Supports (CLASS) ACT New voluntary LTSS insurance program federally administered Financed by individual enrollees through payroll deductions Eliminates pre-existing conditions

7. Community Living Assistance Services and Supports (CLASS) ACT Participation by employers is voluntary Employees must participate at least 5 years to be eligible for benefit Premiums set by DHHS

8. Medicaid Options and Incentives to Expand Expand Medicaid 1915(c) Home and Community Based Services (HCBS) waivers Expand PACE programs (LIFE in PA) Other home health and personal assistance under the Medicaid state funding plan

9. Qualifying for Federal Matching Payments Describe state approach to make 3 structural changes in its delivery systems 1. Establish a Single Entry Point System 2. Adopt conflict-free case management 3. Adopt standard assessment tools to determine eligibility for non-institutional LTSS

10. Other Requirement for Federal Participation Collect data on service utilization Develop core quality measures Maintain data on consumer outcomes Restricted to eligibility determinations that were in effect in December 31, 2010

11. The Bottom Line to States States that spend less than 25% of their fiscal year 2009 Medicaid LTSS expenditures on non- institutional LTSS will: Receive a 5 percentage point increase in Federal Medicaid Assistance Payments (FMAP) between 2011-2015; and Are expected to achieve a target of 25% or more Medicaid spending in HCBS by 2015

12. Community First Choice Option Aims to provide financial assistance to Medicaid eligible persons with declines in ADLs/IADLs and require institutional LTSS Less restrictions in financial support (i.e. may cover one month’s rent, utility deposits, furniture, etc) Help individuals transition from institutional care to the community

13. Community First Choice Option More generous eligibility criteria of up to 300 percent of income threshold for Supplemental Security Income (SSI) Option becomes effective on October 1, 2011 for participating states States receive 6% increase in the Federal Medicaid Assistance Payments (FMAP) States cannot set ceilings on number of persons served.

14. The Money Follows the Person Established by the Deficit Reduction Act in 2005 and to end in 2011 Extended to 2016 Reduced institutional length of stay 90 days rather than 180 days

15. The Money Follows the Person July 2010 CMS released 2.25 billion dollars in grant money for Community-based Long-term Care service program in MFP

16. Other Provisions in the PPACA LTSS Workforce Aging and Disability Resource Centers Chronic Care Coordination (PCP/Transitions of Care)

17. Other Provisions in the PPACA Encourage the concept of Medical Homes Pilot Program on Payment Bundling (payment includes cost of care three days before admission and 30 days after the discharge) - begins in 2013

18. Accountable Care Organizations (ACO) Financial incentives to reduce the growth of Medicare expenditures and improve outcomes Participants of ACO must be accountable for quality, cost, and overall care of the Medicare fee-for- service beneficiaries assigned to them

19. Accountable Care Organizations (Cont) Should be ready by 2012 Considered the backbone of the new health care system Large health care systems are organizing Requires 5000 residents

20. Nursing Home Reforms Transparency by increasing availability of information about the operation of individual nursing homes Medicare requirements for cost reports: 1. Number of direct and indirect care staff employed in each position 2. Employee tenure and turnover

21. Nursing Home Reforms 3. Hours of care provided per resident per day 4. Resident census and case mix data 5. Administrative costs

22. PPACA - Opportunities & Challenges Improving quality of services for the dually eligible (Medicare/Medicaid) community residents Expanding services beyond our institutional walls Expanding needs for medical services with shrinking reimbursements for care

23. PPACA-Opportunities & Challenges Declining nursing home beds and occupancy of beds Hospitals will have a financial penalty for high readmission rates starting 2013 Hospitals experience longer lengths-of- stays due to nursing homes inability to accept dually eligible (Medicare/Medicaid) residents

24. STAR Ratings of Not-For-Profit Nursing Homes in Lancaster County

25. STAR Ratings of For-Profit Nursing Homes in Lancaster County

27. Percent of Medicaid Beds in Lancaster County in 2008 Not-for-Profits (19) averaged 40% (range was 28% to 82%) For-profits (12) averaged 73% (range was 59% to 91%)

28. Percent Medicaid Beds for Not- For-Profits and STAR Ratings

29. Percent Medicaid Beds for For- Profits and STAR Ratings

31. Low Costs and High Quality Will Determine Your Future Success “Innovator’s Prescription” (A Disruptive solution for Health Care) by Hwang, Christensen, and Grossman “The Cost Conundrum” published in The New Yorker June 2009 by Atul Gawande

32. As the Hospitals Go, So go the Nursing Homes Requiring regular surveys by outside organizations Reporting health facility acquired infections Reporting Preventable Serious Adverse Events (PSEA) Reporting quality indicators/measures Reporting cost of care in the future

33. Opportunities to Improve Your Margins Critical mass by local collaborative business models 1. Home care services 2. Hospice services 3. Limited medical staff 4. At risk contracts with dually eligible Medicare/Medicaid

34. Opportunities to Improve Your Margins (cont) 5. Pharmacy 6. Physical Therapy 7. Expanding your endowment

35. Masonic Village Home Care Services Projected vs Actual Billable Hours

36. Masonic Village Home Care Services Quality First year satisfaction surveys showed 88 respondents rated services excellent or above average, and 11 respondents rated service average. No question was rated poor or very poor, and all feedback was positive.

37. Masonic Village Home Care Services Financials Projected to show revenue over expenses in 12 th month, break even in 19 th month Showed revenue over expenses in 7 th month, broke even in 11 th month

38. Hospice Services Critical mass for hospice care in your facility/community Excellent family satisfaction Continuum of care for residents Recover your costs of quality end-of- life care

39. Hospice Services Opportunity to generate gifts of appreciation by families Expertise in end-of-life care

41. Masonic Village Hospice

42. Masonic Village Hospice Financials Projected to show revenue over expenses in 9th month, break even in 19th month Showed revenue over expenses in 6 th month, broke even in 10 th month

43. Masonic Village Hospice Gifts To date we have received 75 hospice gifts totaling $8,650 in donations Planning 2 gift giving programs around the holiday season Volunteer additions account for 13% total hospice staff

44. Limited Provider Staff Model Improve quality of care Reduce cost of care Require core competencies of care Better resident satisfaction Increase availability Reduction of readmissions to hospital

45. At risk Medicare/Medicaid Contracts Increased reimbursement for caring for residents in their home Decreased emergency room visits and hospitalization Improved quality of care Increase availability of provider staff

47. “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” - by Margaret Mead

48. The Parable of the Talents in Matthew 25 “The master replied to the servant who received 5 talents and brought back 5 more, ‘Well done, good and faithful servant! You have been faithful with a few things; I will put you in charge of many things’.”