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4/13/2015
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Long-Term Care/Chronic Care:What Will It Look Like?
Minnesota Gerontological Society Annual Conference
Friday, April 24, 2015
Session Sponsor:
Presenters
• Patti Cullen, President/CEO, Care Providers of Minnesota
• Bonnie LaPlante, RN, MHA, Capacity & Certification Supervisor, MDH
• Kari Thurlow, Vice President of Advocacy, LeadingAge of Minnesota
• Sarah Keenan, RN, President, Bluestone Physician Services
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Objectives
1. Understand the various challenges facing service providers and medical professionals
2. Understand the various initiatives/programs in place and/or under development to address these challenges and to lead us to patient centered care
3. Describe how health care homes can play a big role in integration and patient centered care
Challenges Today Facing Long-Term Services and Supports
-Demographics
-Prevalence of Alzheimer’s
-Workforce Shortages and Provider Responses
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Demographic Challenges
Aging of Minnesota’s Population
• By 2030 Minnesotans over 65 will double. • Aging of Minnesota’s population will dominate the demographic landscape for the
next 25 years as the baby boom population born between 1946 and 1964 turns 65. • We will not age only as individuals but as a society. This has profound implications
for the state. • Demand for health and long term care and its costs will increase exponentially.
– Illness and disease increase with age. – Chronic conditions such as cancer, heart disease, stroke, diabetes, obesity, arthritis, and pain
among the elderly are increasing. – 90% of all adults over 60 have at least one chronic condition. 25% of all adults have 2 or more
chronic conditions. – The majority of health care and related economic costs are for the cost of chronic disease and
associate risk factors.
Workforce Age Demographics
• The workforce is constantly changing as older people retire and younger people enter the workforce. Minnesota’s health care industry faces a double workforce challenge:
• As the baby boom generation leaves the workforce between now and about 2020, the health care industry will be competing with all other sectors of the economy for a smaller and more diverse new workforce generation.
• At the same time, the aging of the entire population is expected to increase demand for health care services, putting additional stress on this workforce.
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Impact of Alzheimer’s Disease in MinnesotaBaby Boomer Effect 2010-2050
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
2010 2020 2030 2040 2050
85+
75-84
65-74
By 2030, more than 1 in 5 Minnesotans will be an older adult, including all the Baby Boomers.
MN.GOV 2014
Impact on Alzheimer’s Disease in MinnesotaProjected Prevalence: 2010-2050
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2010 2020 2030 2040 2050
85+
75-84
65-74
101,500
140,600
180,200 184,000
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Staff Turnover in Minnesota Senior Housing Increased in 2014
9
15.8%13.2%
27.2%
48.0%
25.2%
18.2%
35.4% 36.8%
0%
10%
20%
30%
40%
50%
60%
RN LPN Home CareAides
DA
2013
2014
Source: Long Term Care Imperative 2015 Legislative Survey
Staff Vacancies in Minnesota Senior Housing Increased in 2014
10
2.4% 2.4%
4.9%
6.1%
9.3%
6.2%
7.3%
4.6%
0%
2%
4%
6%
8%
10%
RN LPN Home CareAides
DA
2013
2014
Source: Long Term Care Imperative 2015 Legislative Survey
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11
Decisions made in Response to Policy Decisions and Reductions in Payments to Customized Living Rates
Source: Long Term Care Imperative 2015 Legislative Survey
0.0%
28.6%
35.1%
7.8%
6.5%
0% 10% 20% 30% 40%
Withdraw from EW programaltogether
For new clients, accept only thosewho qualify for 24-hour Customized…
Lower the total number or percentageof EW clients you serve
No longer take Case Mix L clients
Other
Access for Elderly Waiver CL Clients being Reduced:
12
Vacant Positions in Nursing Homes Increased by 51% Now Total Nearly 2,800 Statewide
0
500
1,000
1,500
2,000
2,500
3,000
R.N. L.P.N. C.N.A. Dietary
Aide
Total
2007 2008 2009 2010 2011 2012 2013 2014
Source: Long Term Care Imperative 2015 Legislative Survey
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13
Typical Nursing Home has 7.5 Vacant FTE Positions2.5 More Vacant FTEs than Last Year
0.00.51.01.52.02.53.03.54.04.55.05.56.06.57.07.58.0
R.N. L.P.N. C.N.A. Dietary Aide Total
2007 2008 2009 2010 2011 2012 2013 2014
Source: Long Term Care Imperative 2015 Legislative Survey
Nursing Facility Staff Turnover
37.9% 36.9%
49.0%44.7%47.20%
39.60%
50.90% 52.20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
RN LPN CNA Dietary Aide
2013 2014
Source: Long Term Care Imperative 2015 Legislative Survey
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The Wage Gap
$12.02
$18.44
$26.37
$17.61
$20.48
$41.78
$12.19
$18.30
$24.53
$- $5 $10 $15 $20 $25 $30 $35 $40 $45
NAR
LPN
RN
Care Center Hospital Home Care
Sources: 2012 LTC Imperative Salary Survey and 2012 MN Health Care Cost Information Service Hospital Salary Data
Gap=$2.18 per hour or $4,534 per year
Gap=$5.42 per hour or $11,274 per year
Gap=$17.25 per hour or $35,880 per year
Gap=$15.41 per hour or $32,053 per year
Gap=$2.04 per hour or $4,243 per year
Gap=$5.59 per hour or $11,627 per year
Senior Living Workers Underpaid in the Marketplace
Over 1,500 Admissions Denied During 2014 Due to Insufficient Staffing
55.13%
35.26%
9.6%
0%
10%
20%
30%
40%
50%
60%
Availability of Staffing has neverlimited our admissions
Availability of Staffing has caused usto occasionally deny an admission
Availability of Staffing has causedregular disruption in our ability to
accept admissions
Over the past 12 months, how would you characterize your facility’s ability to accept admissions due to availability of staff?
16Source: Long Term Care Imperative 2015 Legislative Survey
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Over 1,500 Admissions Denied During 2014 Due to Insufficient Staffing
17Source: Long Term Care Imperative 2015 Legislative Survey
• 12% of nursing facilities reported completely shutting off admissions for a period of time in the past 12-months.
• 37 days was the median reported period that admissions were shut-off
Transformation to Respond to Challenges
-Decrease in institutional care
-Shorter stays in institutional settings
-Expansion of new delivery models
-Telehealth
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Average Length of Stay
658
248
99
27.50
100
200
300
400
500
600
700
199019911992199319941995199619971998199920002001200220032004200520062007200820092010
Nu
mb
er
of
Day
s
Calendar Year
Average Length of Stay in MN NFs(Source: Minnesota Department of Health)
Mean
Median
Number of NF Beds in MN & U.S.
0
100
200
300
400
500
600
700
800
1987 1990 1993 1996 1999 2002 2005 2008 2011
Bed
s /
1000
Year
Beds/1000 85+: Minnesota, US
MN Beds/1000 US Beds/1000
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Examples of New Delivery Models
• Care Suites
• Campus-based community care
• Cooperatives
• Greater variety of service choices
• Integrated care pilots
• Post-acute/transitional care evolution
Bonnie LaPlante, RN, MHAHealth Care Homes Capacity and Certification Supervisor
Health Care Home
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Health Reform in Minnesota
Minnesota’s Three Reform Goals
• Healthier communities
• Better health care
• Lower costs
Institute of Medicine’s Triple Aim
MN Health Reform
TransparencyStatewide Quality Improvement Program, Provider Peer Groups,
Health Insurance Exchange
Statewide quality measures, developing provider cost and quality comparisons to be
incorporated into the Health Insurance Exchange
Care Redesign
Payment Reform
Health Care Homes / Community Care Teams
Quality Incentive Payments Medicaid Health Care
Delivery System
Demonstration(HCDS)
HCHs serving 3.5 million, Implemented pay for performance for state
programs and public employees / Medicaid HCDS Demo has contracts
with 6 health systems
Prevention/
Public Health
Statewide Health Improvement Program,
Diabetes Prevention Program (DPP)
Fighting obesity and tobacco –Schools, workplaces, communities, clinics
Health Reform Goals Action 2012 Results
Health IT, Administrative Simplification
Office of Health Information Technology
Implemented common billing/coding and e-prescribing, developing statewide EHR
exchange
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Health Care Home is not:Health Care Home is:
• Population clinical care redesign
• Transformed services to meet a new set of patient-and family-centered standards to achieve triple aim
• Foundation to new payment models such as ACOs
• Community partnerships that build healthy communities
• A nursing home or home health care
• A restrictive network• A service that only
benefits people living with chronic or complex conditions
Health Care Home
HCH Certification Updates
# Certified Clinics: 374Total
52% of Primary Care Clinics in
Minnesota (6 in border states)
• Applicants are from all over the state.
• Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations.
• All types of primary care providers are certified, family medicine, pediatrics, internal medicine, med/peds and geriatrics.
Approximately 3.5 million patients receiving care in a certified HCH.
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Certification as HCH is Voluntary
• Certification requirements are met at certification. Recertification occurs annually on a rolling 15 months rolling schedule thereafter.
• Overtime clinics are recertified based on quality benchmarks.
Health Care Home Standards
• Facilitates consistent communication between the HCH and patients and families, and provides the patient with continuous access to the HCH
Access
• Uses an electronic, searchable registry that enables the HCH to identify gaps in patient care and manage health care servicesRegistry
• Coordination of services that focuses on patient- and family-centered care
Care Coordination
• For selected patients with a chronic or complex condition, that involves the patient and the patient’s family in care planningCare plan
• In the quality of the patient’s experience, health outcomes, cost-effectiveness of services
Continuous improvement
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HCH Evaluation
45
• Enrollees attributed to HCH clinics had higher quality of care measures that those attributed to non-HCH clinics in most categories. (Data from the Statewide Quality Reporting & Measurement System)
Information from University of Minnesota Evaluation Report
HCH Evaluation: Findings
45
• HCH Medicaid enrollees were more expensive during start-up year but became less expensive that non-HCH enrollees by 2012
• Estimated Costs and Savings:
– Overall, HCH enrollees had 9.2% less Medicaid expenditures than non-HCH enrollees
Information from University of Minnesota Evaluation Report
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HCH Evaluation: Limitations of the Evaluation
45
• HCH initiative is in the beginning phase– While clinic and enrollee participation is increasing over time,
the participation rates in initial phases made initial evaluation difficult
– HCH effect may take a while to emerge because transformation to the HCH model may take some time for refinement
• Measurement of costs and resource use– Resource use analysis depends on attributing enrollees to clinics– Attribution is improving over time because improved data
associating providers with clinics and patients with providersInformation from University of Minnesota Evaluation Report
What We Know About Care in a Patient & Family-Centered (Health Care) Home:
• Patient and family-centered care is increased
• Family worry and burden are reduced
• Care coordination and chronic condition management lead to:
• Reduction in emergency room use • Reduction in hospitalizations • Reduction in redundancy• Efficiency and effectiveness are increased
Center for Medical Home Improvement
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SIM Grant - Minnesota’s Accountable Health Model Vision
• Every patient receives coordinated, patient-centered primary care.
• Providers are held accountable for the care provided to Medicaid enrollees and other populations, based on quality, patient experience and cost performance measures.
• Financial incentives are fully aligned across payers and the interests of patients, through payment arrangements that reward providers for keeping patients healthy and improving quality of care; and
• Provider organizations effectively and sustainably partner with community organizations, engage consumers, and take responsibility for a population’s health through accountable Communities for Health that integrate Medicare care, mental/chemical health, community health, public health, social services, schools and long term supports and services.
• www.health.state.mn.us/healthreform/sim
Health Care Homes Contact Information
http://www.health.state.mn.us/healthreform/homes/index.html
651-201-5421
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Long-Term Care/Chronic CareMedical Challenges and Opportunities
Sarah Keenan
Bluestone Physician Services
Chronic Care-Medical Challenges
• Acute care model-based on curing, not quality of life
• Changing norms of primary care
• Fragmented system-single problem approach
• Fee for service drives short appointments and unnecessary medical care
• Lack of data integration drives duplicative treatments, added patient/family stress
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Risk/Frailty and High Cost
87%
13%
Clinic Medical HomeChallengesHOSPITAL-Long Hospital Length of Stay (LOS)-Hospital Staff Intensity per Patient-Readmissions w/in 30 daysCLINIC-Long clinic visits under-reimbursed-Staff intensity per visit-Provider/staff burnoutASSISTED LIVING/GROUP HOME FACILITY-Lost bed days-Lost service charges-Staff turnover/burnout
Challenges
87%
13%
OpportunitiesHOSPITAL-Decreased LOS-Lower 30 day readmits-Improved staffing ratiosCLINIC-Enhanced access for patients-Higher staff/provider satisfactionASSISTED LIVING/GROUP HOME FACILITY-Higher resident retention-Higher fill rates-Higher service delivery-Higher staff/family satisfaction
Opportunities
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What is Optimal Chronic Care?
Chronic care requires a reorientation and reorganization of clinical practice AND how medical and non-medical services relate to each other
Bluestone Physician ServicesChronic Care Model
• Certified Health Care Home-2010• On-site primary care
– 4500 patient in assisted living communities• Average age of 86• 87% have diagnosis of dementia
– Growing presence in group home communities• Emerging care area as people with disabilities age in place
• Care Coordination Systems– MSHO Care System
• Integrated Care System Partnerships• Integrated Systems
– Integrated Health Partnership
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Impact of Health Care Home
• Intentional Development of Community Partnerships
– Residential Care, Ancillary Services, e-Health
• Strengthening of Care Coordination Models
– Define as functions, not a person
• Development of registry based care decisions
– Population based care
• Quality improvement programs
• Care Coordination Toolkit for Frail Seniors and People with Disabilities
Medicare-Changing Landscape
Shift to quality based payments -
where Medicare goes, so do we
“30% of Medicare payments by 2016 and 50% by 2018”
– Recognition of chronic care models
– Funding supports complex needs
• Chronic Care Management
• Transitional Care Management
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Medicare-Chronic Care Management (CCM) Program
• CMS new program-2015
• Monthly payment not tied to office visit
• Requirements
– At least two chronic diagnosis
– Consent on file
– Comprehensive, accessible care plan
– 20 minutes of non face-to-face time
Long-Term Care Role in Accountable Care
• Move from “post-acute” care to “pre-acute”
• Align payment incentives
• Development of partnerships across continuum
– Example-LTC Collaborative
• Aggregation of high risk patients
• Development of effective communication and e-Health data sharing
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Bluestone BridgeComBmunication Portal
RN Services Social Support
MD Services
NP/PA Services
Risk/Frailty and High Cost
Community –based, Care Coordination On-site Primary Care
Clinic Medical HomePartnershipsAssisted Living Group HomesHCBS
Appropriate provider resource
across the care continuum for
maximum value to the patient, health system and payer
Community-Based Chronic Care Model
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Objectives Revisited
1. Understand the various challenges facing service providers and medical professionals
2. Understand the various initiatives/programs in place and/or under development to address these challenges and to lead us to patient centered care
3. Describe how health care homes can play a big role in integration and patient centered care
Questions
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Contact Information
• Patti Cullen, President/CEO, Care Providers of Minnesota– [email protected] or 952-851-2487
• Bonnie LaPlante, RN, BS, Capacity & Certification Supervisor, MDH– [email protected] or 651-201-3744
• Kari Thurlow, Vice President of Advocacy, LeadingAge of Minnesota– [email protected]
• Sarah Keenan, RN, President, Bluestone Physician Services– [email protected] or 651-342-4273
