February 2015 Ohio State Budget and Federal Long Term Care Update Kenneth Daily, LNHA

District News CEUs for today’s program is 2 hours Next meeting March – COMs Rehospitalizations April LGBT in Long Term Care May – Future LTC Architecture

OHCA Education What Administrators Don't Know about the MDS Can Hurt Them... Practice good habits. Operate Efficiently. Deliver great service. March 5, 2015 Disaster Management Series (5 part webinar) Wednesday’s 2/18-3/18

State Budget …Right Sizing Since 2009 number of long term care consumers has ‘flip-flopped’ with today… 57,362 Nursing Home 83,377 Home and community based clients Changed to price based system Held rates flat to as much as 6% reductions

House Bill 64 Ohio State Budget Blueprint (OHT) for a New Ohio (invests $61 million over two years) Increases NF reimbursement $84 million in 2017 by rebasing the formula (+$154 million) and updating the “grouper” (-$70 million) Links 100%of the increase to quality performance Reduces reimbursement for low acuity individuals (-$23 million) Removes the NF rate formula from statute

HB 64 Replace current Quality Measure program and roll in $16.44 from quality to direct care. Problem is that any facility whose CMI is less than state average will lose reimbursement. Re-purposed monies equal ~ $7.00 per case mix unit

PA 1 /PA 2 Reduce PA1/PA2 from $130 to $91.70/day Incentive for discharge – numbers have not changed in past 4 years Reduces NF funding by $23.5 million

HB - Quality Current system scrapped 5 Quality Measures would replace system 1. Staffing measure 2. Consistent assignment 3. Antipsychotic use 4. Pressure ulcer 5. Avoidable hospitalizations

Staffing Staffing measure would be based on Consumer Voices 2001 study of optimal staffing in a facility 4.1 hours per resident/per day 1.3 hours of nursing (70% of NFs) 2.8 hours of nursing assistant (<10% NF)

Consistent Assignment At least 85% of residents experience consistent staffing that is that no more than 12 nursing assistants care for a single resident per month. Advancing Excellence data collection tool Maybe 10% of facilities

Clinical Measure Pressure ulcers (combination measure) A target percentage of the facility's short-stay residents had new or worsened ulcers and A target percentage of long- stay residents at high risk for pressure ulcers had pressure ulcers.

Clinical Measure Use of antipsychotics (combination measure) A target percentage of the nursing facility's short-stay residents newly received an antipsychotic medication and A target percentage of the nursing facility's long-stay residents received an antipsychotic medication.

Hospitalizations Achieve a number equal to or less than target of avoidable inpatient hospital admissions Source? Payers? Diagnosis? Report?

Increase? RebasingOHCA = $190 million Medicaid = $153 million But… use licensed beds - $37 million Different RUGs grouper (RUG IV 66 vs RUG IV 48* - $69 million Reduce PA1/PA -$23 million Quality hold back = 2.95% -$84 million New Quality MeasuresRedistribute $84 million State saysIncrease $61 million ($84-$23=$61) OHCAA wash at best but like at this point a reduction

ODH Rules Three rules filed Expedited Nursing Facility Survey Quality Assurance Dining and Activity space

Medicare.gov 5-Star Quality Rating Changes to system which became effective this week Added two measures Revised QM scoring Revised Staffing

5 Star Program Began in 2008 No industry input Fails to recognize complexities of long term care Failed to difference between long and short stays Horrible curve 20%(1)23%(2-4)10%(5) Today More input 45% of facilities are 4-5 Stars Used by many for various reasons including MCOs, ACOs and state

Changes Overall 5 Star Rating No change to methodology but altered staffing and QM components Survey no changes Staffing changed 3-4 stars determined QMs Added two measures Reset cut points to achieve each star rating

Calculate 5 Star Initial star rating is based on survey score achieved over past three survey cycles Add or subtract a star based on staffing Subtract 1 star for 1 star level staffing Add 1 star for 4 or 5 star level staffing Add of subtract a star based on QMs Subtract 1 star for 1 star QM rating Add 1 star for 5 star QM rating

Survey Distribution 5 star = 10% 2,3,4 star = 70% (23.33% each) 1 star = 20% Star rating cut points (2/2015) Only 7 states distribution is lower Greater than 48 = 1 star Between 48 and 28 = 2 stars Between 28 and = 3 stars Between and = 2 stars Less than = 5 Stars

Quality Measures Long Stay Antipsychotic use Resident >100 days who receive an antipsychotic (excluding those with schizophrenia, Tourette’s or Huntington’s) Short Stay antipsychotic us Residents admitted and with in 100 days antipsychotic is started.

Quality Measures OldNEW # QMs911 Points per QM10020 – 100 Total Points Possible Cut Points 1 Star11%15% 2 Star18%20% 3 Star24%20% 4 Star31%20% 5 Star16%25%

Broken in to 5 point groups

Changes to Program in 2015 More later this year? Use payroll data, as the ACA Mandates, to determine the Staffing Data Validate the Staffing information Phase in use of electronic data to begin January 1, 2015 Rehospitalizations Discharge back to community