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Update on 2009 Legislative Agenda of theLong-Term Care Imperative

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Elderly Waiver Customized LivingRate Setting Toolkit and Process

Phil ManzDirector of Assisted Living, Housing and Home Care

Pmanz@careproviders.org952 851 2484

Care Providers of Minnesota January 2009 Regional Meetings

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2009 Long-Term Care ImperativeLegislative Agenda

• Developed in 2008 with member input• $426 Million Deficit Thru June 30, 2009• November 08 Forecast of $4.8 Billion Deficit for

July 1, 2009 thru June 30, 2011• February 09 Forecast Deficit Will Be Growing • Governor Unalloted to Cover Thru 6/30/09• Governor releases plan for July 1, 2009 thru

June 30, 2011 on January 27, 2009

Care Providers of Minnesota January 2009 Regional Meetings

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Elderly Waiver Customized Living Rate Setting Toolkit and Process Agenda

• EWCL Rate Setting Process 2007 – 2008

• EWCL Rate Setting 2009 Timeline

• Goal – Understanding of the critical issues that current draft of tools presents

• Goal – Catalyze and capture feedback of stakeholders who have used the tools

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Rate-setting Process – 2007

• Providers met separately 5 times with DHS – Advocated for

– Joint meetings with lead agencies– User’s manual with definitions and

instructions– Test all parts of rate tools together– DHS Attendance at regional meetings

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Rate Setting Process - 2008

• January 8 – DHS Video Conference

• March Regional Meetings – DHS Discusses/Gets Feedback on EWCL Contract Planning Worksheet, Part 1

• June 19 – DHS Video Conference

• Fall Regional Meetings – Discuss county understanding of documents proposed at June 19 DHS video conference

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Rate Setting Process - 2008

• Fall – DHS negotiates renewal of Elderly Waiver Program with federal officials (CMS)

• November 13 – EWCL Stakeholder Group Meets – DHS Announces Agreement with federal officials (CMS) and New Timetable

• Dec 1 and 3 – Provider Stakeholders Meet for 5 to 6 hours to begin understanding the tools

• December 11 – DHS Video Conference

• December 16 – 1 Hour of EWCL Stakeholder Group Discussion

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Rate Setting 2009 Timeline• DHS to Issue Bulletin with Rate Setting Tool Kit by January 1,

2009

• Care Providers of Minnesota Regional Meetings: January 6 - 16

• EWCL Stakeholder Group Training – Jan 15, Jan 29, Feb 26, March 26

• DHS will use “SNAP” Surveys thru 3/31

• Care Providers of Minnesota Regional Meetings – March 3 - 13

• “Final” Bulletin to be Issued June 30, 2009

Care Providers of Minnesota January 2009 Regional Meetings

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Objectives: Critical Issue #1

Care Providers of Minnesota January 2009 Regional Meetings

Understand how most of your home care services operation for all clients, public and private pay, is allocated among five hourly service categories that are divided into scheduled and unscheduled (supervision) sections, for the purposes of negotiating your service rates.

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Objectives: Critical Issue #2

Understand the implications of having most of your home care services operation allocated in the manner proposed. For example, will “staffing ratios” for clients become available on the Internet?

Care Providers of Minnesota January 2009 Regional Meetings

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Objectives: Critical Issue #3

Care Providers of Minnesota January 2009 Regional Meetings

Understand if and how the separation of scheduled and unscheduled (supervision) hours is accounted for in the delivery of services to a client.

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Objectives: Critical Issue #4

Enhance your nursing practice by understanding how supervision as defined in the Nurse Practice Act is distinguished from the definition of supervision used in the service definitions in the EWCL rate setting tools.

Care Providers of Minnesota January 2009 Regional Meetings

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Objectives: Critical Issue # 5

Understand how a case manager will develop an individualized EW Customized Living Plan that takes into account the allocations of hourly service rates.

Care Providers of Minnesota January 2009 Regional Meetings

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The EWCL Tool Kit1) EW Customized Living Contract Planning Worksheet, Part I

2) Purchasing Customized Living Services in the EW Program

3) EW Customized Living Excel Workbook Contract Negotiation and Management as of 11 21 08

A) EW Customized Living Component Input Worksheet, (AKA: Component Rates Input Form)

B) EW Customized Living Negotiated Component Rates

(AKA: Negotiated CL Rates)

C) Individualized EW Customized Living Plan

- One page 11 x 17 inches

- Seven pages 8.5 x 11 inches

Care Providers of Minnesota January 2009 Regional Meetings

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The EWCL Tool Kit3) (Continued) Reference Worksheets

D) CL Component Rate Limits

E) Customized Living Rate Limit

F) County Geographical Groups

G) Information from Individual’s Screening Document

H) EW Community Support Plan

4) Instructions for Workgroup Review and Testing of EW CustomizedLiving Tools (17 legal pages)

Care Providers of Minnesota January 2009 Regional Meetings

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The EWCL Tool Kit5) Instructions for Completing the Elderly Waiver Customized

Living/24 Hour Customized Living Component Input Worksheet(8 pages)

6) Corrected 07-25-01C Comprehensive Policy on Elderly Waiver (EW) Customized (Formerly Assisted) Living Appendix A, B, C not included in handouts

7) Deconstructing Definitions of Supervision for January 2009 Region Meetings

8) Class A and Class F Definitions of Home Management, Care Aide, and Health Aide Tasks for January 2009 Regional Meeting

We anticipate that some or all of the first 5 sets of handouts will be in the bulletin scheduled to be delivered by January 1, 2009.

Care Providers of Minnesota January 2009 Regional Meetings

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The EWCL Tool Kit TrainingUtilizes “Excel” Spreadsheets

Benefits from 5 and 6 hour meetings of multiple members from multiple organizations in early December 2008

Will defer to Bulletin that was scheduled to be sent January 1, 2009

Has led to extended discussions of terms used

Will benefit from extended discussions between providers and lead agencies

Care Providers of Minnesota January 2009 Regional Meetings

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The EWCL Tool Kit TrainingRepresents a significant amount of work that doesn’t

necessarily answer the question about what could change a provider’s reimbursement

Information not listed on the tools can be as critical as information listed on the tools

Focus on numbers/math because they are objective measurements and could be used to establish ratios that will be used for years to come

Daunting task to develop these EWCL tools and then provide training and instructions

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Tool Kit - 1) EW Customized Living Contract Planning Worksheet

• Vetted at State wide Regional Meetings in 2008• Colors of Services Have Meaning

Green – Home Mgt/Making/Support Service

Red – Home Care Aide Service

Orange – Home Health Aide Service

Purple – Licensed Nurse Service• Confusion of Class A and Class F language on

page 12 – “Like Tasks”Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 5) Instructions for Completing the

EWCL/24HrCL Component Input Worksheet Lines 15 – 19) “Setting” – Does this mean HwS registration?

Lines 21 – 24) “Level of service” – How is this determined? Memory Care, Case Mix A - K

Lines 26 – 29) Lead agency may request verification of staffing and average number of residents served

Line 53-54) HwS Provider Location – Physical site registered with MDH, How will campus names be included in “establishment name/provider location”

Lines 109 – 126) Hourly Rate Limits – “Legislature grants increases or

requires decreases in comparative rates”

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 5) Instructions for Completing the

EWCL/24HrCL Component Input Worksheet Lines 140 – 141) Staff time spent on congregate meal preparation

should be included in the total home management staff hours reported.

Lines 154 – 155) Level of service defined by different staff schedules and staff competencies

Lines 155 – 157) Worksheet for each staffing model (Schedule)

Lines 196 – 198) Medication set-ups must be purchased based on time

Line 263) Service Delivery Planning Tool(AKA: Individualized EW Customized Living Plan)

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) EWCL Customized Living Component Input Worksheet

Services Offered – Customized Living/24 Hour Customized Living

Program Offered – How to summarize 12 page document into one line?

Programs (Worksheet) vs. Setting, Level of Service (Directions)

Minimum Direct Care = Unlicensed staff hours available on average per day (24 hour period) in HwS setting, regardless of payor

Hourly Service Rate – Is for a service not an employee, although they can frequently be confused

Scheduled Hours with Assigned Tasks vs. “Supervision Only”

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) Component Worksheet

Minimum Direct Care = Unlicensed staff hours available on average per day (24 hour period) in HwS setting, regardless of payor

1, 1, 1, 1, 1.3, 1.64, 1.95, 2.27, 2.29, 2.56, 3.07

Average = 1.73Mode = 1.0Median = 1.64

Regardless of payor = All your clients

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) Component Worksheet

Hourly Service Rate – Is for a service not an employee, although they can frequently be confused.

Note: provider may receive higher “hourly rate” for private pay than public pay.

To determine the cost of your service, use all costs necessary to deliver that service that are not being allocated to another service, for example rent.

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) Component Worksheet

Outstanding issues: Distinguishing home management, home care aide and home health aide tasks for employees is challenging. (Handout #8)

Home care aides are not permitted to provide “assistance

with self-administration of medicine”

Home care aide rate is artificially created: Average of Home Management and Home Health Aide

Home health care aide rate is 90% of Fee for Service Equivalent

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) Component WorksheetOne example with 123 residents receiving services, 98 receiving supervision

Average daily payment for assigned hours: $6,239.96/123 = $50.76 for supervision hours: $2,229.38/98 = $22.85

Care Providers of Minnesota January 2009 Regional Meetings

Negotiated Hourly

RateAssigned

Hours

Cost of Assigned

HoursSupervision

Hours

Cost of Supervision

HoursTotal

Cost

Home Mgt Home Making

Support Services

$ 17.00 100.80 $1,713.60 NA $1,713.60

Home

Care

Aide Services

$ 22.00 16.67 $366.74 8.21 $180.62 $547.36

Home

Health

Aide Services

$ 27.00 154.06 $4,159.62 75.88 $2,048.76 $6,208.38

271.53 $6,239.96 84.09 $2,229.38 $8,469.34

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EWCL Kit – 3A) Component Worksheet

Average monthly supervision = $22.85 x 30.4 days/month = $694.64

Case Mix C 24 CL Monthly Limit $3,064.00 – Average monthly supervision $ 694.64

= Available for assigned tasks $2,369.36

If client’s total assigned tasks > $2,369.36, multi-tasking factor (Cell R94 on Individualized EW Customized Living plan) equation takes $ from supervision allocation.

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – C) Individualized EW Customized Living Plan and 4) Instructions for Workgroup Review and Testing of

EW Customized Living Tools

EW Customized Living Plan starts with smaller dollar items that, in general, increase in size, ending with supervision. How will this work practically with case workers and clients?

How will all stakeholders react if and when we can’t afford what we want to provide?

How will all these choices be shown to participants?One page 11 x 17 inches or

Seven pages 8.5 x 11 inches

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – 3A) Component Worksheet

1) Negotiated Rate vs. Service Rate Limit

2) Type of service rates – Slide 23 Example Home Health to Home Care Assigned Hours 154/16.67 ~ 10:1 Home Health to Home Care Supervision Hrs 76/8 ~ 9:1

3) Hours deployed Assigned vs. Supervision Home Care Assigned vs. Supervision Hours 16.67/8.21 ~ 2:1 Home Health Assigned vs. Supervision 154/76 ~ 2:1

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EWCL Kit - Discussion of “Supervision” Compare 6) Comprehensive Policy on EWCL page 11 compared to

Handout 3C) Individualized EW Customized Living Plan

Care Providers of Minnesota January 2009 Regional Meetings

Handout 6 Handout 3C

Frequency Yes Yes

Mode Yes Yes

Time of Day 24 or < 24 hours a day Yes

Specific Needs Yes Yes

Locations Yes NA

Staff Competencies No Yes

Identify Supervision not done by staff

Yes No

Other No Yes

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EWCL Kit – Discussion of Supervision

Do the supervision plan requirements and definitions change one’s understanding of how they deploy staff?

EWCL Kit implies all tasks are scheduled vs. unscheduled; what is your experience?

Does it make sense to deconstruct supervision? Handout 7) Deconstructing Definitions of Supervision for

January 2009 Region Meetings

Care Providers of Minnesota January 2009 Regional Meetings

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EWCL Kit – In Conclusion

Raised more questions than answers?

Evaluation Sheets Are Really Important

How to keep stakeholders invested in the validation of the tools?

Care Providers of Minnesota January 2009 Regional Meetings