Policy Does Matter Testimony to Aging and Long-Term Care Committee Ohio House of Representatives Bob Applebaum October 2017

An Aging Ohio-- 2000 to 2040 Year 2000 2020 2040 Total Pop 11.4 11.7 11.7 (millions) 60 plus 1.9 (17%) 3.0 (25%) 3.4 (29%) 65 plus 1.5 (13%) 2.1 (18%) 2.8 (24%) 85 plus .177 (1.6%) .270 (2.3%) .553 (4.6%)

2010

Aging in Ohio: Health Conditions and Behaviors, 65 plus Health conditions % Ohio U.S. Ranking Diabetes 24 22 38 Arthritis 57 52 44 Hip fractures per 1000 6.2 5.9 33 Mult chronic conditions 40 37 39 Skill NF Admits per 1000 93 63 Health behaviors % Smoking 10.2 8.8 38 Obesity 33 28 50 No leisure physical act. 36 31 42

Are Individuals Prepared for Long-Term Disability? What is disability? Moderate shopping, getting to the doctor without help– Severe help with dressing or bathing Will it effect me? 65 and older with some long-term disability 28.4% 65-74 20.2% 75-84 26.9% 85 plus 42.4% Women higher rates than men U.S. low Savings rate Almost half of retirees rely on Social Security for majority of income (Avg. $1400 per month, maximum $2700) Less than 4% of Ohioans over age 45 with LTC insurance

Proportion of Ohio's Population Age 60 and Older with Severe Disability by Care Setting, 2015 (N=164,250)

Ohio’s Nursing Facility Characteristics, 2015   All Nursing Facilities County Homes Hospital Based Long-Term Care Unit Number of Facilities (as of 12/31/2015) 958 15 20 Licensed/certified nursing facility beds 12/31/15 Average number of beds available daily Average number of licensed beds 92,157 91,503 95 1628 1756 103 998 1017 50 Location (percent) Urban Rural 76.2 23.8 46.7 53.3 80 Ownership (percent) Proprietary Not for profit Government 79.7 18.1 2.3 — 100.0 36.4 54.6 9.0 Separate Memory Care Unit (percent) 51-100 100 or more 34 41 55

Ohio Nursing Facility Admissions, Discharges, and Occupancy Rates, 1992 – 2015   1992 1999 2001 2005 2009 2011 2013 2015 NF Beds in Service (000) 92 96 94 91 93 95 Number of Admissions (000) Total 71 150 190 197 207 219 211 Medicaid resident 18 28 24 34 27 31 37 35 Medicare resident 30 79 117 109 148 145 147 Occupancy Rate (%) 91.9 83.5 83.2 86.4 84.7 83.9

Time Period (Percentage Remaining) Newly Admitted Nursing Home Residents and Changes in Their Stay Patterns Over a Three Year Period (1994-2014) Time Period (Percentage Remaining)   Admissions 0-3 months At 6 months At 9 Months At 12 months At 24 months At 36 1994-1996 5803 56.7 41.1 35.2 32.2 24.0 NA 2001-2004 15,250 43.1 32.5 20.7 16.1 9.0 5.7 2011-2014 23,475 16.3 12.5 11.1 10.4 8.8 8.2 Medicaid* 2011-2014 4844 26.5 20.4 17.8 16.2 13.4 12.0

Demographic Characteristics of Ohio’s Certified Nursing Facility Residents Over Time, 1996, 2006 – 2016 1996 (Percent) 2006 2012 2014 2016 Age   45 under 2.6 2.7 2.3 2.1 46–59 3.8 9.1 10.4 9.9 60–64 4.5 6.4 6.5 7.1 65–69 4.4 5.9 7.9 8.3 9.6 70–74 8.1 9.5 9.7 75–79 13.1 13.2 12.0 12.1 12.3 80–84 18.7 19.2 16.4 15.3 14.5 85–89 21.2 19.4 18.2 17.6 16.7 90+ 25.5 17.9 16.9 18.0 Avg Age 80.7 78.4 77.3 77.5 77.2 Female 73.5 68.5 65.5 65.1 63.8 Race Wht 88.3 86.3 86.0 85.5 85.3 Marital Never 13.8 15.1 16.1 Wid/div 70.7 63.7 58.7 59.9 57.9 Married 15.5 25.2 23.4 24.2

Private Pay Nursing Home Residents Who "Spent-Down" to Medicaid, Over a Three Year Period

Ohio’s Residential Care Facility Characteristics, 2015   All RCFs RCF Only Assisted Living* Number of Facilities 655 73 582 Total licensed RCF beds 50,431 4229 46,202 Total number of units 35,979 3312 32,667 Average number of beds 77 58 79 Average number of units 55 45 56 Average Monthly Rate (Private Non Memory) Location (Percent) $4044 $3921 $4056 Urban 78.8 79.5 Rural 21.2 20.6 Ownership (percent) Proprietary 71.6 80.0 70.5 Not for profit 28.4 20.0 29.5

Occupancy and Length of Stay in Ohio’s Residential Care Facilities, 2013 – 2015   Overall (Percentages) RCF Only Assisted Living 2013 2015 Unit Occupancy 87.8 88.9 84.2 85.3 88.5 89.3 Bed Occupancy 67.3 70.6 70.8 72.1 66.5 70.4 Average Length of Stay (Days) 867 823 877 872 865 821

31.1 31.8 32.0 35.6 34.1 35.0 35.5 33.4 33.0 31.4

Policy and the Future Even with changes the current system is simply not sustainable. Short-term window where “boomer growth” remains small, before the major increase. The current system was never designed-- it just happened– Meaningful change is very slow. We often have policy changes with unplanned consequences. Hospital reform meant a new nursing home. Very low Medicaid rates for AL have resulted in high rate of terminations to NF (PASSPORT 28% AL 52%).

Recommendations for Ohio Heavy pressure driven by Medicaid budget concerns– but most older people not on Medicaid (90%), Nationally and in Ohio-- Medicaid about 25% of state budget– Ohio -- 36% allocated to LTSS Today 164,000 older people with severe disability– Almost half, about 81,000 on Medicaid. In 2040, 310,000 older people with severe disability– if 50%-- 155,000 on Medicaid– not easily sustainable Strategy needs to be to lower Medicaid use through prevention, individual planning, technology development, environmental adaptation.

Recommendations for Ohio Lowering Medicaid spend-downs by leveraging the Senior Service Levies and use of support services. Enhancing family support through programs and policies. Workforce will always be critical. Ohio NF’s have a 66% retention rate– varies– how can we improve? Dramatic increase in short stay residents. Pre-Admission Review process designed 25 years ago needs to be changed. (16% continue after 3 months) Short-term stays-- implications for LTC Consumer Guide and Quality & Inspection Process

Recommendations for Ohio One in four NF residents under age 65– 45% stay less than 3 months and are being used for rehab. But a large group have a behavioral health diagnosis– 28% 0,1 ADL impairments. MFP has made progress, but– problem continues. Ohio has reduced supply and use of NF beds– in 2011, 29% of severely impaired elders in NF in 2015 dropped to 25%. (Oregon’s rate about 10%). LTC system must be innovative and efficient-- It will need to use technology, public-private partnerships, and new ideas such as aging friendly communities to meet our future challenges.

Contact info Bob Applebaum Applebra@Miamioh.edu Scrippsaging.org (Scripps web site)