Transcript Creating the Future: Changing Aging Services

Creating the Future:
Changing Aging Services
AHCA Convention
October 8, 2007
Steve Chies, SVP, LTC Operations, Benedictine Health Services
Jeff Wilson, CEO, Liberty Healthcare LTC Group, North Carolina
Loren Coleman, Asst. Commissioner, Dept. of Human Services, MN
Nancy Rehkamp, Principal. LarsonAllen
John Richter, CPA, National Health Care Principal, LarsonAllen.
Today’s Discussion
• Overview of key changes that will impact the demand for
aging services
• Discussion of one state’s approach - Minnesota
• Strategic repositioning case examples
– Benedictine Health System, headquartered Minnesota
– Liberty Healthcare Long Term Care Group, headquartered North
Carolina
• Discussion of key strategic questions providers are
facing
Reasons for Future Changes in SNF Utilization
1.
Changing demographics
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•
•
•
2.
3.
4.
Hospital discharges to skilled
Swing bed utilization
Long term care alternatives
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•
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5.
Aging population
Growth in numbers living alone
Caregiver availability
Declining economic position of future elders
Home & Community Based Services
Other housing options – assisted living, housing with services
Age of admission to SNF
Length of stay decline
State and Federal policies and program initiatives
•
•
•
•
PACE
Managed care for dual eligible individuals
Medicare acute care changes
Medicare post-acute care changes
Factors Driving Changes
Projected Elderly Population Grow th
(2000 to 2030)
200%
183%
180%
65-84 Yrs
160%
147%
% Growth
140%
128%
120%
127%
85+ Years
104%
95%
100%
80%
147%
84%
65%
68%
60%
40%
20%
0%
Northeast
M idwest
South
West
Total U.S.
U.S. Region
The single biggest driver in aging services expansion will be the population
growth of those eligible for Medicare coverage, particularly the 85+ cohort. 85+
adults use health resources approximately 40% more than other Medicare
beneficiaries. The growing understanding of the changing family structure and
dynamics also leads CMS to believe future elders will rely on formal care more
frequently.
The Change in Age Distribution Will Challenge Us
United States
.Nevada
.Alaska
.Arizona
.Florida
.New Mexico
.Texas
.Idaho
.Georgia
.Utah
.Wyoming
.New Hampshire
.Washington
.Delaware
.South Carolina
.Virginia
.California
.Colorado
.Vermont
.North Carolina
.Montana
Chg in Tot
% Chg Tot
Pop
Pop
82,162,529
29.2
2,283,845
114.3
240,742
38.4
5,581,765
108.8
12,703,391
79.5
280,662
15.4
12,465,924
59.8
675,671
52.2
3,831,385
46.8
1,252,198
56.1
29,197
5.9
410,685
33.2
2,730,680
46.3
229,058
29.2
1,136,557
28.3
2,746,504
38.8
12,573,213
37.1
1,491,096
34.7
103,040
16.9
4,178,426
51.9
142,703
15.8
Chg In 65+
Pop
36,461,718
578,250
91,503
1,703,515
4,961,855
342,959
3,113,653
215,117
1,122,562
270,331
80,893
204,816
901,753
136,097
649,126
1,051,655
4,692,583
540,205
96,430
1,204,125
148,609
% Chg 65+
Pop
104.2
264.1
256.3
255.1
176.7
161.6
150.2
147.4
143.0
142.1
140.2
138.4
136.2
133.8
133.7
132.7
130.5
129.8
124.4
124.3
122.9
The rapid growth in
older adults with
significantly lower
growth in younger
populations will
create challenges
to informal
caregiving,
workforce
availability and
other issues.
Source: US Census Bureau
Statistics accessed 1/07
Key Learning – Living Arrangements Are a Predictor
SNFs today and in
the future primarily
serve Mom.
Women are more
likely to be poor
and alone in their
advancing year.
Men are expected
to live longer and
be single more
often than today. It
is expected that
single older men
will also have
fewer financial
resources than
today.
Source: CMS Chart Book; 1/31/07
Decreasing Role of Family Pushes up Demand for all Services
Percentage of Family Caregiving:
1988
1995
2001
2010
2030
97%
95%
91%
National Ratios:
Caregiver Ratio
Elderly Dependency Ratio
7.51
4.75
6.78
4.61
4.34
2.76
The Caregiver Ratio is a comparison of the number of elders 85 + to women aged 45 to 64.
The Elderly Dependency Ratio is the number of elders 65+ compared to workers aged 20 to
64. The lower the ratio the fewer the number of caregivers or workers. The expected
decline in available caregivers and available workers will be over 40%
As an example we find in Minnesota each 1% drop in family care giving requires
approximately $30M in additional public funds for Minnesota.
Source: National Caregivers Association & US Census Population Projections by Age & Sex
Hospital Utilization is Not Uniform
Medicare
Beneficiaries
DCs/1000
Medicare
251,305
461
6.06
300,870
448
5.42
194,155
446
6.24
139,040
434
5.55
202,935
421
5.50
644,310
415
5.58
256,160
411
5.51
647,805
405
5.95
177,570
403
5.77
328,155
403
5.79
Minnesota
204,135
349
4.80
Wisconsin
249,475
327
5.22
California
848,985
327
6.06
State
Louisiana
Alabama
Mississippi
West Virginia
Oklahoma
Illinois
Kentucky
Pennsylvania
Arkansas
Tennessee
ALOS
Hospital utilization by
Medicare beneficiaries is
not uniform across the
country.
This variance can also be
seen in the discharge rate
to SNFs. Nationally about
16% of acute Medicare
patients use SNFs post
acute.
The range in percent
discharged to SNFs,
however, is estimated to be
8% to 35%. If the use of
swing beds by small rural
hospitals is included the
numbers could be higher.
Source: Kaiser Family Foundation, State Health
Facts based on 2003 data accessed via the
internet June 2007.
Growth in 85+ Will Increase Acute Care and Post Acute Care
Medicare Discharges per 1000
625.0
600.0
575.0
550.0
525.0
500.0
475.0
450.0
425.0
400.0
375.0
350.0
325.0
300.0
275.0
250.0
225.0
2000
2001
2002
2003
2004
65-76
75 - 84
85+
65+
Medicare discharges per 1000 grow significantly with age. The rapid growth in the
population 85 and older may result in higher numbers of Medicare admissions and
more individuals requiring post-acute services. Nationally, 16.5% of 65+ use Part A
SNF services following an acute stay, but this goes up to almost 35% for those 85+.
Source: The Chart Book 2007, CDC published 1/07
Changing Business Model – the Minnesota Example
Residents’ needs are changing significantly. Many more residents will be shorter stays
and will have higher clinical care needs. This will result in facility changes, different
equipment needs, and specialization. It may result in new competitors and changes in
market thinking.
Actual 2005
2030 Imperative
Recommendations
% Change
2005 to 2030
Short Stay
0 to 90 days
3,148
16%
10,918
39%
247%
Moderate Stay
91 to 365 days
2,990
8%
7,120
25.5%
138%
Long Stay
> 1 year
29,400
76%
9,842
35%
-67%
Total Beds
35,538
27,880
-22%
The residents that stay one year or less will probably represent about 85% to 90% of all
resident admissions by 2030. These will be residents transitioning from acute care to home.
Key SNF Customer Groups in the Future
• Short stay, post-acute residents who require complex
medical care, rehabilitation or time to heal & recover
• End of life residents whose care needs have become
greater than could be accommodated in their prior residence
• Frail residents who have limited mobility, complex
medical issues or who have no informal support systems &
do not have the resources to pay for the support privately
• Residents with cognitive impairments which make them
unsafe, an elopement risk, or the disruption they create in
other living settings is so significant that they need greater
supervision or control in their environment, i.e., individuals
with end stage Alzheimer’s Disease or Dementia
Benedictine Health System
Strategically Using the
Imperative Demand
Model
Mapping the Future: Key Conclusions
1.
2.
3.
4.
5.
6.
Demographics are the key
Product lines and services
Financial considerations
Workforce challenges
Bricks and mortar vs. programs
Resident and patient outcomes
Operations – Key Objectives
• Understand the impact of demographic changes
• Develop insight into the changing customer expectations
and the implications to facilities and providers
• Support facilities in preparing for the future
• Monitor public policy changes
• Secure resources to address the issues facing skilled
nursing facilities
• Track competitors
The Benedictine Living Community is…
A vision for elder care which:
• Is centered on the individual
• Is offered in modern, safe and comforting
surroundings in a compassionate environment
that enhances human worth
• Has a high quality spectrum of services
• Focuses on excellence, not just compliance
BHS Quality Elements:
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MN Baldrige Quality Process
AHCA Quality Award Recognition
Demonstrated use of quality improvement
Key data elements - metrics
Exceeding expectations
Superior outcomes
Is 50 the New 20?
Resident and Family Expectations:
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A sense of being in control.
A sense of belonging.
Trust in You!
OHANA
Physical Plant Elements:
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Compliance with codes and standards
Private rooms
Performance on inspections and surveys
Safe environment
Comfortable and home like
Interior design
Preventative maintenance program
Closing Thoughts
“The problems that exist in the
world today cannot be solved by
the level of thinking that created
them.”
Albert Einstein
LIBERTY HEALTHCARE:
Creating and Changing Aging
Services
Liberty Healthcare is……
• Small Regional Company based in Wilmington, NC
• Liberty offers a continuum of services to the communities we serve
through several different divisions.
• Long Term Care Management Services operates 17 SNF’s with
2013 beds all in NC
• Liberty Home Care and Hospice has 25 Home Care Offices and 27
Hospice Sites in NC, SC, and VA
• Liberty Assisted Living Division operates 4 Assisted Living Facilities,
and 2 Independent Living Apartment Sites.
• Liberty also operates several ancillary service companies: LTC
Pharmacy, DME Company, and a Therapy Company.
Preparing for Demographic Changes
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Offer services across the continuum of care
Physical Plant Changes
Staffing
Technology
Marketing
Offer Services Across Continuum of Care
Diversify the services offered to meet the changing
needs and demands by the communities served.
 Home Care
 Hospice
 Assisted Living
 DME
 Outpatient Therapy
 Dialysis
 Obesity treatment
 Secure Dementia Care Units
Physical Plant Changes
Renovate or replace older buildings.
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Increase percentage of private rooms.
Increase number private showers in each room.
Provide flat screen televisions and telephone service.
Implement neighborhood concept with smaller dining and activity
spaces.
– Less emphasis on nurses station.
– Create secure dementia care units
Barriers
– Capital for renovation or replacement
– Certificate of Need
– Reimbursement systems providing a return on investment
Staffing
Recruitment and Retention
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Recruitment and retention committee
Supervisor Training
On-going staff education
Creating a culture of Customer Service – Hospitality Model
Foreign Worker Recruitment
– Program in place for four years
– Recruited 18 RN’s, with 40 in process and have retained 100% to
date.
– Recruited 54 Physical Therapists and have retained 52.
Technology
Electronic Medical Records
– Each CNA documents direct care on a PDA at the bed side,
allowing more time for direct patient care.
– Nursing Documentation and Medication Administration is done
electronically, reducing errors, and making staff more efficient.
Management Tools
– Digital Dashboard with real time financial and clinical information
available to managers to respond quickly to changes.
Resident Tools
– Wireless Internet available
– Computer stations for resident use including games, websites,
customized to each resident’s areas of interest.
Marketing
Culture Change
– Traditional Medicaid facilities have approached marketing from
more of an order taker mentality.
– Nursing Centers need to transition to more of a sales driven model
to tell their story, make consumers aware of array of services that
are available, and capture a share of the growing short term stay
market.
– Create and foster relationships with key decision makers for
services in each community.
Creating the Future – The Driving Questions
• Why do states or regions vary so significantly in the use of SNF
services?
• What is our “rightsizing” goal for nursing-facility based care?
• Assuming reduced future demand, how can we ensure that skilled
nursing beds are in the right locations?
• How can we make the best use of replacement and renovation dollars to
address new technologies, new clinical practices, and consumer
preference in the care centers of tomorrow?
• How can we reposition our aging facilities to meet the customer demands
within the current economics of SNF reimbursement?
• How do I evaluate when to get out of or reduce SNF services?
• The reduction in skilled beds will require other facilities and services.
What services will substitute for skilled and how many units, visits or
other services will be required?
Creating the Future – The Driving Questions
• How do we transition our facilities to care for larger numbers of short stay
residents?
• What programs do the local hospitals offer that could be extended into
skilled care, i.e., orthopedic, congestive heart failure, low back pain
management and rehab, post-surgery de-conditioning?
• What will be the economic investments required by state and federal
funding sources to develop the aging continuum?
• What are some of the regulatory changes that will be required to retain
care delivery flexibility and allow resident choice?
• Why are skilled care providers better positioned to provide a greater
array of aging services?
• What are the strategic opportunities for new services, innovations, etc.
that might develop from the evolving continuum of aging services?
• What are the changing workforce needs to serve the growing and
changing older population?