2. Historical Information “Long Term Care & Medicaid” has been a priority of the South Dakota Health Care Commission Bill passed and signed by Governor Rounds in 2006 to authorize long-term care study Long Term Care Study conducted by Abt Associates; completed November 2007

3. Long Term Care Study- Challenges Key challenges identified in the study include: A rapidly aging population Number of elders will double by 2025 and increase by 92,000-105,000 Number of disabled elders will increase by 42,000-50,000

4. Long Term Care Study- Challenges Counties where the elderly population is expected to more than double by 2025

5. Long Term Care Study- Challenges Geographic mismatch between the places where services exist today and the places where the elderly population is expected to grow over the next 20 years Slow growing East River counties averaged 7.2 nursing home beds per 100 elders in 2005. Rapidly growing West River counties had 3.8 nursing home beds per 100 elders in 2005.

6. Long Term Care Study- Challenges Historically low rates of use of home and community- based services (HCBS) South Dakota ranks second lowest in the U.S in terms of utilization of skilled home health episodes Rural and Frontier areas face particularly low availability of HCBS: 34 counties have no adult day service facilities 28 counties have no, or one, senior center per 1,000 elders 18 counties have no, or one, nutrition program per 1,000 elders Every county in South Dakota is served by a homemaker agency, but 40 counties have no homemaker agencies located in their borders

7. Long Term Care Study- Challenges Aging skilled nursing facilities

8. Long Term Care Study- Challenges Shortages of front-line health care workers Sharply rising costs of care coupled with tightening of Federal dollars for program support and provider reimbursement Inadequate individual planning and financing of long- term care costs, and limited use of long-term care insurance

9. Long Term Care Study In summary, there are both short and long term issues Shorter-run: Right-sizing aging facilities, excess capacity, assuring access critical services Longer-run: Sharp growth in demand in parts of the state Elders increasingly want to remain at home as long as possible; and this must be at the forefront of any policy recommendations

10. Long Term Care Study Need to address rate of utilization of expensive nursing home care SD has10th highest rate of nursing home use in the U.S. National average is 4.8 beds per 100 elderly; SD use is 6 beds per 100 elderly Study provided 3 options: Scenario 1: Status Quo – NH utilization rates are fixed at recent levels 2003-2005 avg NH utilization in SD as % of elderly = 5.9% Scenario 2: NH Utilization declines over time, at national rates 0.17% annual decline, reach 5 bed per 100 utilization by 2025 Scenario 3: SD will move to national norms in NH utilization NH utilization is declining 0.04% annually in the US and will reach 4% by 2025

11. Long Term Care Study South Dakota is pursuing nursing home utilization rate in Scenario 3 Will require major expansion of Home and Community-Based Services Large financial ramifications for future system

12. Task Force Development Meeting the Continuum of Care Needs of the Elderly in South Dakota Task Force convened by Department of Social Services in March 2008 based on study results 100+ members, including legislators, providers, advocacy groups and state agencies Subcommittees Right-Sizing Long-Term Care Financing Expansion of Home and Community-Based Services

13. Task Force Recommendations 1. Develop a Single Point of Entry system for long-term care services Network to provide public with information and referrals to variety of services, including transportation, nutrition, assisted living, etc. Help individuals plan for long-term care needs Method to assess needs for services and provide connections to services Assist public in determining funding options from self- support to public assistance

14. Task Force Recommendations 1.Develop a Single Point of Entry system for long-term care services (cont.) DSS should develop regional centers within existing field office structure Develop hospital discharge planning process that includes DSS staff

15. Task Force Recommendations 2. Expand existing home and community-based services so people can stay in their own homes and communities as long as possible Identify and define critical core services that need to be available at least regionally Work with entities such as the Board of Nursing and Medical Association to increase use of home and community based services Use technology to increase service options

16. Task Force Recommendations 2. Expand existing home and community-based services so people can stay in their own homes and communities as long as possible (cont.) Provide information to the medical community and the public about the need for home and community based services Advocate for changes on the federal level to better support home and community-based services

17. Task Force Recommendations 3. Enhance existing home and community-based services to ensure services are comprehensive and meet the needs of the elderly Strengthen and create better access to services such as chore services, drop-in visitor services, and transportation services Work with community leaders and organizations

18. Task Force Recommendations 4. Implement an access critical nursing facility model to ensure people have access to care within a reasonable distance to their communities No other nursing home within 20 miles Facility located in largest town within 35 miles Must provide skilled facility services Must be integrated with other health care services Projected county demand for nursing homes is less than 60 beds in 2015 Must relinquish excess moratorium beds

19. Task Force Recommendations Locations where facilities meet access critical criteria: -Philip-Miller -Lemmon-Hot Springs -Chamberlain-Eureka -Martin-White River -Britton Recommendation to increase reimbursement for access critical facilities Increase overall rate growth cap from 8%-10%, also provide up to a 2% adjustment to rates

20. Task Force Recommendations 5. Right-size the nursing facility industry by realigning moratorium bed levels to reflect projected demand for nursing facility services Moratorium on new nursing home beds in state statute Facilities adjust the number of beds they license according to their occupancy rates for Medicaid reimbursement purposes Recommendation to change reimbursement methodology so moratorium beds, not licensed beds, are used Allow facilities to voluntarily close the gap between moratorium beds and occupancy

21. Task Force Recommendations 6.Expand nursing facilities through a Request for Proposals (RFP) process developed by state agencies for areas in the state that will need additional nursing facility services Not a Certificate of Need process Only certain parts of the state will need more nursing facility beds in the future State agencies would allow expansion in certain areas based on population-based projections for need, occupancy of existing facilities Would need to change moratorium statute and develop administrative rules

22. Task Force Recommendations RFP will request: business plan with payor source info and evidence of community contributions, plan to meet workforce needs Consideration of providers for expansion include factors such as: Facilities that give up existing moratorium beds if there is future service need in the area Providers who demonstrate integration with full continuum of care Providers must accept people eligible for Medicaid Special consideration for providers serving specialized populations

23. Task Force Recommendations 7. Maintain a sustainable financial infrastructure for the current and future system of care Help nursing facilities access funding to replace or renovate aging facilities Provide financial incentives to long term care providers that serve a higher percentage of people on Medicaid No consensus on how to get additional funding for services

24. Task Force Recommendations 8. Collect data and analyze the need for additional assisted living facilities DSS has started to collect data needed to project the need and costs for additional assisted living facilities in the state

25. For More Information Final Report Online: www.dss.sd.gov/ltctaskforce.asp Abt Study Online: http://www.dss.sd.gov/news/2007/LTCStudy.asp