Continuum Spring 2015

The Caregiver ShortageA publication for Wisconsin’s Long-Term Care Profession by

Spring 2015

Including: ICD-10: Ready, Set, Code Co-Chairs of the Joint Finance Committee Comment on the Budget Process Medical Record Requests: Who Gets What and When?

2015 MEMBER DIRECTORY ENCLOSED

Low Reimbursement, Competition,Regulatory Climate Limit Workforce

Attend the WHCA/WiCAL Spring Conference at Kalahari Resort April 15-17. See you there!

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WelcomeMake Your Voice Heard!The Spring 2015 issue of Continuum is being released as a part of the 2015 WHCA/WiCAL Legislative Day. On Legislative Day, WHCA/WiCAL members fan out into legislative offices of the Wisconsin State Capitol to share the stories of Wisconsin’s hard working skilled nursing and assisted living facility employees.

However, Wisconsin’s long-term care providers can’t limit their advocacy to one day out of the year. Throughout the year we need to show Legislators in our facilities how Wisconsin’s long-term caregivers provide exceptional care to the Badger State’s frail elderly and disabled on a 24/7/365 basis, despite the limited resources the state provides in Medicaid reimbursement. We need to explain in letters, calls and emails that times are changing… Between 2011 and 2029 – about 8,000 members of the Baby Boomer generation will turn 65-years-old every day. Now is the time to ensure that Legislators get our message that in order to maintain the quality of care Wisconsin’s consumers have come to expect, state leaders need to invest in our LTC workforce.

In this issue of Continuum, WHCA/WiCAL provides Wisconsin’s LTC provider community three articles that offer background on the stakes in the 2015-17 Biennial Budget. In Capitol Connection, we breakdown the budget process and the legislative climate in the State Capitol. The Cover Story for this issue highlights the importance of reimbursement for the training, recruitment and retention of certified nursing assistants (CNAs). Finally, in Stakeholder Spotlight, the Co-

Chairs of the Legislature’s powerful budget-writing committee, the Joint Finance Committee share their thoughts regarding the budget process.

In the other sections of the magazine: the LTC Legal Letter explains the who, what, and when of long-term medical record compliance; Media Matters offers an explanation of social media marketing; and finally in Clinical Corner, WHCA/WiCAL’s on-line education partner, CE Solutions explains some of the background on the upcoming change to ICD-10.

With the Spring 2015 Issue of Continuum, we are also pleased to provide a copy of our 2015 WHCA/WiCAL Membership Directory. WHCA/WiCAL offers this Directory to membership, other long-term care providers, policymakers and the public as a useful resource and roadmap for locating our member LTC facilities in Wisconsin.

As always, thank you for taking the time to read Continuum, and please be sure to contact your state Legislators in the coming weeks regarding the importance of funding for Wisconsin’s LTC provider community. We need your voice to make a difference.

Sincerely,

Tom MooreExecutive DirectorWHCA

Brian PurtellExecutive DirectorWiCAL

@ Kalahari Resortin the Wisconsin Dells

2015 SpringConference Date

April 15-17

Register: www.whcawical.org/spring

SPRING CONFERENCE AND EXPOSITION

53rdANNUAL

Learn How YOU can Help! www.whcawical.org/budget

Spring 2015 | CONTINUUM 4

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ContentsSpring 2015

6CAPITOL CONNECTION2015-16 Biennial Session of the Wisconsin State LegislatureCabinet Members Appointed, Legislative Committees Assigned, and Budget Debate BeginsThe initial 6 months of every new session of the Legislature is focused on the Governor’s proposed biennial budget bill. The Board of Directors has directed WHCA/WiCAL staff to prepare issue papers relating to the Governor’s proposed budget bill, which included Medicaid and Family Care funding, significant changes in Family Care, workforce shortages, transportation of residents, and a history of the bed tax to be shared with all Legislators.

MEDIA MATTERSUsing New Media to Attract New ClientsSocial Media Presents Marketing Opportunities for Long-Term CareFacebook. Twitter. Instagram. You may use these tools personally, but now you’re being challenged to use these tools as part of the marketing strategy for your facility. You’ll also understand why you can no longer afford to ignore social media.

CLINICAL CORNERICD-10: Ready, Set, CodeProviders Expected to be Ready October 1, 2015Beginning October 1, 2015, the ICD-10CM (diagnosis) codes will be used for all health care settings with the exception of inpatient hospitals which will use the ICD-10PCS (procedure) codes. This is of importance for those health care providers that work with workman’s compensation companies.

COVER STORYThe Caregiver ShortageLow Reimbursement, Competition, Regulatory Climate Limit WorkforceLong-term care professionals often say that the most difficult job in a skilled nursing or assisted living facility is the role of a certified nursing assistant (CNA) or other front-line caregiver. Caring for frail elderly and disabled residents is challenging work that requires patience, a positive attitude and frequently a strong back and heart. Many CNAs say working with their residents is very rewarding; yet with a median CNA wage of $12.39/hour, those rewards don’t translate into competitive take-home pay. However, with the State of Wisconsin ranked as the second-worst Medicaid reimbursement system in the country, long-term care providers are often unable to provide wage rates that retain qualified CNAs in positions critical to maintaining quality care for residents.

STAKEHOLDER SPOTLIGHTCo-Chairs of the Joint Finance Committee Cut Through State Budget ProcessCo-Chairs of Powerful Joint Finance Committee Address States Medical BudgetSenator Alberta Darling (R-River Hills) and Representative John Nygren (R-Marinette), Co-Chairs of the Joint Finance Committee, have introduced SB21/AB21, the proposed 2015-17 biennial budget bill at the request of Governor Walker. The bill(s) have been referred to the Joint Finance Committee which will conduct a series of public hearings, meet in executive session to vote on the Governor’s initiatives, then message the bill both Houses of the Legislature for final approval. The Co-Chairs review the issues and their responsibilities.

LTC LEGAL LETTERMedical Record Requests: Who Gets What and When?Clear Processing Procedures Needed to Limit Regulatory ExposureThe time to identify who is entitled to what portions of a resident’s record is not when a request is presented. SNF and AL providers should identify what constitutes a “record,” the rules about who, besides the resident, is entitled to all or part of a record, and the process to be followed by the requestor and facility personnel.

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Continuum is published for theWisconsin Health Care Association and the Wisconsin Center for Assisted Living131 W. Wilson Street, Suite #1001Madison, WI 53703Phone: 608.257.0125Fax: 608.257.0025www.whcawical.org

Managing EditorJohn J. Vander Meer

PublisherDean Gille

EditorMelissa Keller

Account ManagerAbbie McDowell

Creative DirectorSara Rice

Layout & DesignDavid Cox

Published by

1155 Wilburn RoadSun Prairie, WI 53590608.834.3400www.bgsinc.com

For more information in advertising in Continuum call 608.257.0125 or go to www.whcawical.org/continuum.

If you are planning on moving and would wish to continue receiving Continuum, call 608.257.0125 and inform WHCA/WiCAL of your new address.

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Spring 2015 | CONTINUUM 65 CONTINUUM | www.whcawical.org

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2015-16 Biennial Session of the Wisconsin State LegislatureCabinet Members Appointed, Legislative Committees Assigned, and Budget Debate Begins

By Jim McGinn

Capitol Connection

The November elections last year maintained the political power in

Wisconsin State government with the Republican Party as Governor Scott Walker was reelected and the State Senate and Assembly increased their majorities in both Houses.

A brief review, Governor Scott Walker defeated Democratic candidate Mary Burke with 52% of the vote, marking the third election of Governor Walker in the past 4 years.

In the 33-member Senate, Republicans continue in the majority and control the Senate, 19-14, an increase of one seat from last session. Senator Scott Fitzgerald (R-Juneau) again leads the Senate as Majority Leader and Senator Mary Lazich (R-New Berlin) serves as Senate President. The Senate Democrats are led by Minority Leader Jennifer Shilling (D-LaCrosse) and Assistant Minority Leader Dave Hansen (D-Green Bay).

In the 99-member State Assembly, Republicans also increased their majority by three seats margin to 63-36. Assembly Speaker Representative Robin Vos (R-Rochester) is the presiding officer of the Assembly and supervises all other officers of the chamber and appoints committee chairs. Representative Jim Steineke (R-Kaukauna) serves as the Majority Leader. The Assembly Democrats are led by Minority Leader Peter Barca (D-Kenosha) and Assistant Minority Leader Katrina Shankland (D-Stevens Point).

Shortly after his election, Gov. Walker announced his Cabinet for the 2015-16 Legislative session. Pleased with the leadership of his Secretaries, the Governor reappointed both Department of Administration Secretary Mike Huebsch and Department of Health Services Secretary Kitty Rhoades. DOA Secretary Huebsch is currently assisting the Governor with the proposed 2015-17 biennial budget bill, with DHS Secretary Kitty Rhoades focusing on Medicaid funding and massive changes to the Family Care program in the budget bill.

Effective March 1, Gov. Walker announced that DOA Secretary Huebsch was appointed to serve on the Public Service Commission and Scott Neitzel, an executive at Madison Gas and Electric, will serve as his Department of Administration Secretary.

Following inauguration ceremonies, Gov. Walker delivered his State of the State address to a joint session of the Wisconsin Legislature on January 13. The Wisconsin Constitution requires the Governor to “communicate to the legislature, at every session, the condition of the state, and recommend such matters to them for their consideration as he may deem expedient.”

Focusing on a Wisconsin Comeback, the Governor reported that “more people are working today while fewer are unemployed and there are now 7,600 more private sector jobs in Wisconsin than there were before the recession.” The Governor also noted that over the past 4 years, the Legislature and his Administration have reduced the tax burden by $2 billion and property taxes on a typical home are $141 lower in December 2014 than they were four years ago.

With respect to specific proposals, the Governor asked the Legislature to pass legislation to: 1) ensure objective information is available for every school receiving public funds; 2) stipulate that no school district is required to use Common Core standards; and 3) combine four state agencies to two.

As with most State of the State messages, few details were provided on budget issues which the Governor addressed on February 3, in his budget address to a joint session of the Legislature.

Identifying his 2015-17 biennial budget proposal as his “Freedom and Prosperity” budget, Gov. Walker stated that his plan “is based on growth and opportunity, which leads to freedom and prosperity for all.” The Governor further commented that his budget plan includes “common sense reforms to create a government that is limited in

Continued on Pg. 8

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previous year and at $32.347 billion (all funds) in state fiscal year 2016-17, a -10% decrease.

Wisconsin’s GPR (general purpose revenue-or state tax dollars) contribution for the operating budget is $15.875 billion in 2015-16 and $16.943 billion in 2016-17. State GPR contributes 52% to the operating budget, with the federal government contributing 28%, segregated funding (gas tax) contributing 12% and program revenue (license fees) contributing 8%.

The largest increase in GPR funding in the Governor’s biennial budget is $663 million to the Department of Health Services (Medicaid), followed by a $200 million increase to shared revenues and tax relief, $44 million to the Department of Public Instruction and $53 million for other programs. The Department of Administration notes that “compared to the base budget, this increase (Medicaid and Badger Care) totals $657 million

scope and – ultimately – more efficient, and more accountable to the public.”

Gov. Walker’s proposed budget continues “the tuition freeze for undergraduates from Wisconsin at each of the UW-System campuses and adds a tuition freeze in our technical colleges for high demand jobs.”

Other initiatives Gov. Walker highlighted included expanding the requirement for able-bodied adults to be enrolled in employment and training programs and require those adults without children to pass a drug test in order to get a welfare check.

While not providing details, the Governor stated that “in this budget, we put more than $600 million into Medicaid to provide health care for needy families, children and seniors. Through our bold reforms, among the states that did not take the Obamacare expansion, we are the only state in

the nation without a gap in coverage, according to the respected Kaiser Family Foundation.”

Similar to his State of the State address, specific details were limited in the Governor’s address, however, it is very clear the budget includes no funding increases for skilled nursing facilities or other Medicaid or Family Care providers. While budget officials have confirmed they project increases in skilled nursing facility resident acuity over the next 2 years, they also acknowledged the 2015-17 biennial budget bill does not provide funding for acuity.

The Department of Administration released a 91-page “Budget in Brief” shortly after the Governor’s speech. The following provides a brief overview of the Governor’s proposed budget: The state’s operating budget for 2015-16 is budgeted at $35.938 billion (all funds), a 2.6% increase over the

James McGinn is WHCA/WiCAL’s Director of Government Relations. He can be reached at [email protected]

Capitol Connection Continued

no requirement for an increase for Family Care providers.

WHCA/WiCAL calls on all of its membership to contact their State Representatives and State Senators to advocate for increasing provider reimbursement. Legislative advocacy is critical to shaping the forthcoming state budget. Members are needed to advocate for their residents, staff, family members and the long-term care provider community. For more information on how you can make sure your voice is heard in Madison go to www.whcawical.org/budget.

GPR over the biennium. The largest factors in this increase are the result of routine caseload, inflation and utilization changes.”

Capitation payments to Family Care MCOs are increased by 3.2% in 2015-16 and by 2.5% in 2016-17.

With limited information and more information to follow, the Governor’s budget recommends “expanding Family Care statewide and transitions the program to a new model providing long-term care, primary care and acute care services to participants through managed care organizations operating statewide.”

The Governor’s proposed budget also includes an elimination of the “Any Willing Provider” requirement. To promote enrollee choice of providers, current law requires Family Care MCOs to contract with any provider willing to

accept the MCOs payment, service, and contract expectations. The proposed budget would eliminate this provision and permit Family Care MCOs to restrict what entities will be allowed to participate in their respective provider networks.

Public hearings of the Legislature’s Joint Committee on Finance are scheduled for the following dates and locations:

March 18: Brillion High School (Calumet County, east of Appleton on Hwy 10)

March 20: Alverno College in Milwaukee

March 23: UW-Barron County (Rice Lake)

March 26: Reedsburg High School (Sauk County, west of Baraboo)

Again, the Governor’s budget includes no proposed rate or acuity increases for skilled nursing facilities, and

During the 2013 WHCA/WiCAL Legislative Day, Greenway Manor Administrator Mark Scoles and then-State Representative Howard Marklein (R-Spring Green) met to discuss critical issues facing Wisconsin’s long-term care providers. In 2014, Marklein was elected to serve the 17th State Senate District, and was selected to be one of the 16 members of the Legislature’s budget-writing Joint Finance Committee.

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Using New Media to Attract New ClientsSocial Media Presents Marketing Opportunities for Long-Term Care

By Adrianne Machina

Have you incorporated social media marketing into your

overall marketing strategy? If you haven’t embraced social media fully, what’s holding you back?

Social media provides a fantastic opportunity to market your facility. Social media:

Can displace expensive print ads;

Can be done by almost anyone – doesn’t require advanced skills;

Turns your best clients into referral sources;

Enables family members to self-educate about their options;

Provides comfort and reassurance to family members they’ve made a good decision;

Can continually attract new residents and new employees;

Reinforces family connections – even when geographically separated.

With all that upside, why wouldn’t you want to use social media?! Well for sure, there’s a risk, just like there’s a risk in anything you do.

You have to stay in compliance with laws like HIPPA.

You have to embrace doing things differently.

You have to train your staff and set guidelines.

You have to be prepared to deal with negative review and criticism.

Social media requires adapting your ways, but this is the new standard. The world has shifted. It’s time you shift your marketing to adapt to this new reality. People expect to be able to stay connected, to be able to find reviews and to peer through your windows virtually – before they ever walk in your door or talk to your intake professionals. It may feel scary and overwhelming at first, but that’s why we’ve dedicated an entire afternoon on April 15, during the 53rd Annual WHCA/WiCAL Spring

Conference to discuss your concerns and help you set a path for success.

According to a Nielsen study, 92% of consumers trust the recommendations their friends and family. Social media is like word of mouth on steroids. You can create an endless stream of referrals by connecting with the right people on Facebook, Twitter and LinkedIn. You can promote your facility and brand by continually publishing content on YouTube, your blog and photo sharing sites.

TECHNOLOGY ISN’T RESERVED FOR THE YOUNGWhile your residents may not be tweeting and reading blogs, their families are. The largest growing user base of social media is aged 55+. And in addition to clients, your referral sources are online. You can connect with geriatric doctors and social

Media Matters

workers. You can promote events and build a “tribe” of people whose commitment to care aligns with yours. One of the stats that continues to shock people is the fact that 100% of Internet users consume social media. That doesn’t mean everyone is on Facebook or Twitter, but it does mean that anyone doing an Internet search is highly likely to come across a video, article or picture posted by the general public. The challenge is to be in the right places and to be actively listening, and participating so you can present yourself favorably.

SOCIAL MEDIA STARTS WITH A STRATEGYOne of the biggest challenges that new social media managers face is figuring out what they’re going to talk about. Before you launch your online efforts, you need to start with a strategy. What are you trying to accomplish? What are you going to say? How are you going to continually find new things to share? What is the perception you want people to have about your facility?

Let’s start with what NOT to do. First of all, I want to make sure you understand that there’s a fundamental difference between your social media pages and your website pages. Your websites pages are filled with information about your services, and your people. Don’t repeat that same information in your posts. Social media is not intended to be one long sales pitch about you. If your message is on target, and your readers like what you’re saying, they’ll go visit your website pages and subscribe to your newsletter. Do your selling there.

You must resist the urge to make every blog and social media post about how awesome you are. Instead communicate about a subject of interest to the people you are

trying to reach. Create content that informs and educates and entertains.

SO… WHAT DO WE WRITE ABOUT?You want to keep your posts focused on reaching one specific target audience, but don’t be afraid to get creative! The content you post on social media should be about connecting with your families. Think about the position that your target is in and post content that can help to aid or reaffirm the decisions they make. For example, upload YouTube videos that give advice for how to talk to your relatives about long-term care options, or use your Facebook page to post updates on community events or news about resident activities. Again, put yourself in your target customer’s shoes. What would you want to see on a long-term care blog or Twitter feed?

HERE’S 3 QUICK TIPS TO GET SOME IDEAS FLOWING:News StoriesAre there new government or insurance regulations that impact long-term care? What states are the best for assisted living? Are there new best practices in care? Has there been a break through with a new Alzheimer’s therapy? Use stories like these and add your opinion to really make it your own. Remember, you can use content you find on the Internet, as long as your provide a link to the source material and proper attribution.

Human Interest StoriesShare touching stories that others have created. Inspire people to live their best lives today. Show vibrant people in their 80s and 90s and people who have overcome disabilities to live amazing lives.

Client StoriesPosting updates like “Today is Art’s 80th birthday!” or “Check out

Adrianne Machina has spent nearly 20 years helping entrepreneurial organizations find their niche and systematically grow

their businesses through effective marketing programs and persuasive messaging and will be presenting on social media at WHCA/WiCAL’s 2015 Spring Conference. She can be reached at [email protected].

who just won at Bingo Night!” is a great way to keep family members connected with their loved ones. Of course, you have to be mindful of privacy concerns and personal preferences, but many family members appreciate getting to see what goes on inside your community and what their loved ones are up to. Again, your focus is on connecting. These stories illustrate that committed and concerned about your client’s well-being.

The tone and intent of what you post should be to educate, attract, and inspire. You decide what format and voice that will take. Social media is here to stay, and more mainstream than ever. You may not have Nike’s marketing budget, but you can steal their slogan – JUST DO IT!

We’ll be covering social media in great depth at the social media can be an extremely effective, loyalty-inspiring, low-cost way to reach capacity and make your residents and their families a fan of your facility.

“While your residents may not be tweeting and reading blogs, their families are.”


As ICD-10: Ready, Set, CodeProviders Expected to be Ready October 1, 2015

By Lisa Eick

One constant in the world of health care is change. The dynamics of

the work we do, how we do the work, and how we are paid for our work is continually evolving and requires flexibility as well as adaptability.

As you may recall, health care organizations were gearing up in late 2013 and early 2014 for transitions to ICD-10 (International Classification of Diseases) that were to be implemented in October 2014. In April 2014 that transition was abruptly terminated. On July 31, 2014, CMS announced October 1, 2015 as the new date that all health care providers, vendors, and payers covered by HIPAA regulations must begin using the new ICD-10 codes when providing or billing for services.

Beginning October 1, 2015, the ICD-10CM (diagnosis) codes will be used for all health care settings with the exception of inpatient hospitals which will use the ICD-10PCS (procedure) codes. Providers not

considered a HIPAA-covered entity are not required to make the change to ICD-10, but the ICD-9 coding will become obsolete.

This is of importance for those health care providers that work with workman’s compensation companies as they will need to know if those business entities are making the change to ICD-10. The good news is that CPT coding is not changing for outpatient or physician services.

SO, WHAT IS THE REASON FOR THE CHANGE FROM ICD-9 TO ICD-10? ICD-9 was developed more than 30 years ago and is now considered to be inadequate given the changes and advances in health care and technology. ICD-10 has been available and in use by other countries since 1979, which means that the United States cannot compare U.S. morbidity diagnosis data to international data.

The new code sets have updated medical terminology, classification of diseases and procedures. These changes

Clinical Corner

will allow for better data comparisons in tracking health conditions, improve clinical decision making, help to more quickly identify fraud and abuse, improve disease research, and help to better design payment systems and claims processing.

There are a number of differences in the structure of ICD-9 and ICD-10. The changes allow for more specificity in diagnosis. Most clinical documentation captures the specifics of an injury or diagnosis, but the ICD-9 codes are limited in scope.

The new codes will allow for improved and more detailed code descriptions for the purposes of diagnosis and will now include descriptions of comorbidities, manifestations, etiology or causative factors, as well as anatomical location, degree of functional limitation, biologic and chemical agents, and phase or stage of the disease to name a few. ICD-10 also expands to include laterality of affected body parts or joint related involvement in a disease process or injury.

The ICD-9 codes total approximately 14,000, and the new ICD-10 codes total approximately 69,000 codes. Ultimately, is it anticipated that the expansion of the codes will improve diagnosis, treatment, and outcomes and form a more complete picture of an individual across all aspects of the health care system.

Lisa Eick, RN, is an Education and Compliance Specialist with CE Solutions. She can be reached at [email protected].

COMPARING ICD-9 AND ICD-10:

CHARACTERISTIC ICD-9 CM ICD-10 CM

Code Length 3-5 characters 3-7 characters

Composition

Digit 1 = alpha or numeric

Digit 2-3+ = numeric

Digit 1 = alpha

Digit 2 = numeric

Digit 3 = alpha or numeric

Space for new codes

None None

Details in the code

Limited detail for many

Many more specific details (examples): Comorbidities, Manifestations, Etiology, Complications, Detailed anatomic location, After effects of disease, condition, injury, degree of functional impairment, Biologic and chemical agents, Stage or phase of disease, Lymph node involvement, Lateralized or localized involvement, Procedure or implant related, Age related, Joint involvement.

Laterality NoneIdentifies right versus left in most cases.

Sample code: 81315 - Open fracture of head of radius

S52122C - Displace fracture of head of left radius, initial encounter for open fracture type IIIA, IIIB, or IIIC

Source: Adapted from CMS ICD-10 Implementation Guide, Comparing ICD-9 and ICD-10 https://implementicd10.noblis.org/understand_comparison/?guide, Accessed 3/19/2014.

Many organizations had started preparing for the transition to ICD-10. For organizations that have not begun preparing for this change, the following list includes action steps from CMS on how to get started:

Establish a transition team and project coordinator.

Develop a plan for the transition to include timelines for task completion and assign responsibilities.

Determine the effect ICD-10 will have on the organization; for example what departments currently use ICD-9 coding?

Work with software vendors that are using ICD-9 to determine transition plans for ICD-10. This includes payers and billing agencies.

Communicate the organization’s plans for transition to ICD-10 to everyone involved.

Begin education and training early in the process to ensure readiness for the transition to ICD-10.


$0.00

Median Hourly Wages in Wisconsin, 2013

$5.00

$10.00

$15.00

$20.00

200% of theFederal Poverty Line

Certified NursingAssistants

All Occupations

$10.42$12.39

$16.32

Source: Paraprofessional Healthcare Institute

Long-term care professionals often say that the most difficult job

in a skilled nursing or assisted living facility is the role of a certified nursing assistant (CNA) or other front-line caregiver. Caring for frail elderly and disabled residents is challenging work that requires patience, a positive attitude and frequently a strong back and heart.

Many CNAs say working with their residents is very rewarding; yet with a median CNA wage of $12.39/hour in Wisconsin, and many starting wages at or below $10 per hour, those rewards don’t translate into competitive take-home pay for Wisconsin’s 65,690 front-line long-term caregivers. However, according to recently released data the State of Wisconsin is currently ranked as the second-worst Medicaid reimbursement system in the country, and has been rated at similar levels over the past 10 years, according to analyses conducted by Eljay, LLC,

The Caregiver ShortageLow Reimbursement, Competition, Regulatory Climate Limit WorkforceBy John J. Vander Meer

Cover Story

classes that Dove offers is $625, and costs $115 for state testing. The classes involve 120 hours of coursework, which usually takes up to 4 weeks during which the candidate is not getting paid. However, the state only reimburses a fraction of those costs. “The state only reimburses CNA training programs $200.55 of the total cost, that’s less than 1/3 of what it costs to train and test a CNA,” Kiley said. “That cost needs to be adjusted so we can either lower the cost of the class or provide the class for free.” Kiley said the CNA training program used to require 75 hours of training like most other states in the country, but the training requirement was raised to 120 hours without providing additional resources to pay

LTC providers are often unable to provide wage rates that attract and retain qualified CNAs, and other frontline caregivers in positions critical to maintaining quality care for residents in the Badger State’s nearly 400 skilled nursing facilities and more than 3,000 assisted living facilities. So far, the process to develop the 2015-17 Biennial State Budget has not offered providers much that would help address this critical challenge. Gov. Scott Walker’s proposed budget contains a 0 percent increase in reimbursement for skilled nursing facilities, and there are no guarantees that the 3.2 and 2.5 percent increases in capitation rates in the first and second years of the biennium for Family Care MCOs will mean any reimbursement increase for assisted living providers. CAREGIVER PAY“You have to have a competitive pay structure,” said Clint Maun, a

nationally recognized expert in LTC workforce issues. “I don’t think you can pay what everybody else pays. If we want to attract people to this profession you have to pay 65

percent of the median wage. Somehow we need to pay CNAs a competitive wage because we’re certifying these people. These are higher value jobs.”

Providers like Bob Mulder, an owner/operator of Mulder Health Care Facility, a 93-bed skilled nursing facility in West Salem, expressed a sentiment shared by many

facility administrators when he said the nightly cost of many hotels rival Wisconsin’s Medicaid reimbursement rate to skilled nursing facilities, despite the fact that “we provide 24-hour care. The state’s Medicaid reimbursement rate affects what we’re able to pay front-line caregivers.”

According to a 2013-14 cost and reimbursement information on Wisconsin’s skilled nursing facilities (the most recent data available): Wisconsin nursing facilities,

on average, lose $52.11 per day for each Medicaid resident they serve. For the average nursing facility, that results in an annual loss of more than $1 million

to provide care to its Medicaid residents.

Medicaid recipients as of July 2012 (18,766 residents), including Family Care enrollees, comprise about 65 percent of all residents served in nursing facilities.

The difference between the total cost of the care that facilities provided their Medicaid residents and the Medicaid reimbursement they received for providing that care is nearly $330 million.

Mulder and many other LTC administrators said that as the economy has improved since the end of the Great Recession, it has become increasingly difficult to attract and retain qualified CNAs, particularly as they are able to locate employment in other professions that pay more and carry fewer barriers to employment.

“Companies like Kwik Trip hire starting employees at $2 more per hour than we’re able to hire … that’s certainly enough to make their heads turn,” said Mulder, who worries about a wage war lurking on the horizon as a result of inflation. This issue is further complicated by the fact that many prospective employees have to go through an important, yet costly training and certification before even being able to work.

Jeremy Kiley, Regional Director of Operations for Dove Health Care, which operates several facilities in the Eau Claire/Chippewa Falls area, said the actual cost of the

Continued on Pg. 20


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Governor Walker outlined his vision for Wisconsin during his

budget address this February. His speech officially kicked off “Budget Season” for us in Madison. For the next few months, legislators from both sides of the aisle will roll up their sleeves and work on the state budget.

After his address, the governor’s budget proposal was delivered to the Legislature where it was immediately introduced in the budget-writing Joint Finance Committee (JFC). This introduction formally moved the governor’s plan to the Legislature so lawmakers can analyze it and propose modifications before we vote for approval. It is now the Legislature’s turn to build upon the governor’s solid starting point.

In addition to ongoing priorities such as growing our economy, developing our workforce and transforming education, Governor Walker’s budget includes many reforms to health care in Wisconsin. Governor Walker is proposing a statewide expansion of Family Care, protections for seniors, preservation of key safety nets like

eliminates the requirement for MCOs to obtain a permit from the Office of the Commissioner of Insurance (OCI), but specifies that if the Family Care program operates statewide then MCOs are insurers and may be regulated as such by OCI.

As co-chairs of the Joint Finance Committee, it is our job to protect Wisconsin taxpayers. We are carefully reviewing the governor’s proposals, but we need your help. Please let us know how we can improve the governor’s budget plan. We welcome calls, emails, letters, and hearing from you in person. At the end of March, we will be traveling to the “four corners of the state” to hear Wisconsinites’ opinions about the Governor’s budget proposal. We hope you can attend one of our hearings.

As with any proposed budget, the Legislature will reshape and improve the Governor’s proposed budget as it goes through the legislative process. Contrary to partisan rhetoric, no Legislature has ever rubber stamped a governor’s proposed budget. Under our watch, JFC will carefully scrutinize all of Governor Walker’s proposals, including those regarding health care issues. After our committee makes changes to the governor’s proposed budget, the Senate and Assembly may also make further modifications to Wisconsin’s 2015-2017 State Budget.

Medicaid, and a biennial allocation of approximately $30 million to Disproportionate Share Hospital Payments.

Currently, many of the governor’s proposals fall under the jurisdiction of the Department of Health Services (DHS). Family Care is specifically affected, as the proposal seeks to expand the program to every county in the state. Additionally, the proposal allows DHS to add primary and acute health care services to Family Care’s benefits.

Managed care organizations (MCOs) also see numerous changes under the budget proposal, including the expansion of MCO services statewide. Moreover, the proposal

Co-Chairs of the Joint Finance Committee Cut ThroughState Budget ProcessCo-Chairs of Powerful Joint FinanceCommittee Address State Medical Budget

By Rep. John Nygren and Sen. Alberta Darling

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Ultimately, Governor Walker will get the final say, as he can veto portions of the budget. However, we are confident that the work our committee puts into the budget will result in a document that is not only the best for Wisconsin residents, but is also one Governor Walker will be able to proudly sign.

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As a long term care provider you have a very difficult mission. Your challenge is to provide the best care possible to a population with ever increasing medical and behavioral needs in an extremely litigious atmosphere and while under regulatory scrutiny second only to that faced by the nuclear energy industry. It is important that when you need a lawyer to defend you against allegations of abuse or neglect you turn to a team of professionals who make it their mission to defend long term care facilities who face legal challenges throughout Wisconsin.

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Cover Story Continued

for the costs of training, which has increased the expense of training for both providers and students.

“The money isn’t great, but the process is making it more difficult to get the training,” said Mark Scoles, administrator of Greenway Manor, a 60-bed skilled nursing facility in

Spring Green, who has worked in the field of long-term care for 40 years. “I can see why some could go to Culver’s and avoid the hassle.” CNA AVAILABILITYUnfortunately for LTC facility administrators – not to mention the people who need LTC services – the number of available front-line caregivers is going in the wrong direction. According to numbers from the Wisconsin Department of Health Services, since 2012, the number of new aides has decreased 18 percent, and the number of CNA certification renewals has gone down by 14 percent. A recent survey of 198 LTC facilities conducted by an alliance of Wisconsin’s

provider associations found: 1 in 9 CNA positions are unfilled; Between CNAs, Licensed

Practical Nurses (LPNs), or Registered Nurses (RNs) there are 770 vacant FTE positions;

This translates into more than 30,000 work hours.

The reasons these jobs go unfilled depends to a certain extent on the region of the state, but across Wisconsin there are several recurring themes. La Crosse County currently has an unemployment rate of under 4 percent. Add to that the fact that there are two sizable hospitals and satellite clinics all competing for the same

labor pool, it’s no wonder recruitment and retention of CNAs is increasingly difficult for LTC facilities. Mulder said that with hospitals hiring more CNAs, they are in a better financial position to offer higher wages, signing bonuses and tuition reimbursement for CNAs to complete their RN and LPN degrees and certifications. “In the last 5 years, it has increasingly taken more effort to fill open positions. Ten years ago, it wasn’t as big of a problem; 10 years ago skilled nursing facility CNA wages and benefits were considerably more competitive with other job options that were available,” said Kiley, who has been working in the LTC profession for 16 years. “Other industries/sectors have closed the gap and people are choosing other opportunities. We have several companies in the area that draw our CNAs out of the LTC sector for better wages and benefits.”

Barbara Walters, administrator for Rennes Health and Rehab Center – East, a 129-bed skilled nursing facility in Peshtigo, has arrived at a similar conclusion in her efforts to secure

qualified CNAs in Marinette County on the opposite side of the state.

Continued on Pg. 24

19.6%

71.2%

61.7%

42.1%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Other

Competition withother employers/Non-competitive

wages and benefits

No qualifiedapplicants

No applicants

What are the reasons you havevacant or open positions?

Source: 2015 Wisconsin Long-Term Care Provider Community Coalition Survey of 198 facilities.

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WAGE INFORMATION FOR PERSONAL CARE AIDES, 2013WAGE LEVEL STATEWIDE HOURLY STATEWIDE ANNUAL

Entry $8.46 $17,590Average $10.32 $21.460

Experienced $11.25 $23,400

NUMBER OF JOBS FOR PERSONAL CARE AIDES, WISCONSIN, 2013-2015ESTIMATED EMPLOYMENT

PERCENT CHANGEAVE. # OPENING

PER YEAR2013 201538,897 41,474 6.63% 1,502

NUMBER OF JOBS FOR PERSONAL CARE AIDES, WISCONSIN, 2012-2022ESTIMATED EMPLOYMENT

PERCENT CHANGEAVE. # OPENING

PER YEAR2012 202247,289 59,756 26.36% 1,585

Source: worknet.wisconsin.gov


R equests for a resident’s medical records can come from many

sources. The absence of a clear procedure for processing requests can cause regulatory or other exposure to providers.

In 2010, Cignet Health served as the cautionary tale for all covered entities when it was fined a total of $4.3 million for failing to comply with HIPAA’s medical-records-disclosure requirements. The Office for Civil Rights (OCR) for the U.S. Department of Health and Human Services alleged that Cignet had violated HIPAA by improperly denying 41 patients’ access to their medical records. OCR cited Cignet $1.3 million for these violations, but the failure to release records upon request was not the organization’s only mistake: Cignet’s failure to cooperate with OCR during the investigation resulted in an additional fine of $3 million.

Skilled nursing facilities (SNFs) and assisted living facilities (ALs) can learn some lessons from Cignet’s mistakes. First, if you are the subject of an OCR investigation for alleged HIPAA violations, cooperate by responding to OCR’s demands timely and appropriately. Second, and more relevant on a regular basis, ensure that you have the proper procedures in place for responding to an individual’s medical-records request.

purposes when the resident no longer can exercise such rights.

The procedures also should define what constitutes a record. Again, this involves the interrelation of several sources. HIPAA requires providers to identify a “designated record set” which guides what constitutes a record. Under Wisconsin law, provider-specific regulations describe what must be contained in a “medical record,” which again will frame the basis for what information must be disclosed. Clearly articulating what constitutes an individual’s “record” will provide consistency in the types of records disclosed. Just because a document carries a patient’s name does not automatically make that document part of a record that must be disclosed upon request. Ancillary materials, including utilization review or efforts for improving the quality of health care, should be maintained separately from the individuals’ records.

Providers are strongly advised to require that all records requests be submitted in writing. This written request, at a minimum, should detail the requestor’s identity; the specific information sought, the date of the request, the means for determining whether there is authority to release the records, and the details tracking any responses to the request. Depending on the nature of the request, counsel or risk management may need to be consulted. To ensure compliance, providers also should have a process in place for reviewing requests received and information provided.

LTC Legal Letter

Medical Record Requests:Who Gets What and When?Clear Processing Procedures Needed toLimit Regulatory Exposure

By Brian Purtell and Esa M. Movroydis

In developing internal procedures, providers must assure compliance with federal HIPAA laws (if a covered entity), state laws, and provider-specific laws and regulations. In doing so, providers should identify: (1) how requests are made and how they are internally processed and recorded; (2) who is entitled to a record; (3) what records are covered; (4) the timing for responses to assure compliance; and (5) the costs associated with reproduction.

The provider’s procedure must explain clearly how requests should be processed to assure both that timely responses are given and that record releases are provided consistent with applicable law. While all staff does not need to know every aspect of the process, they should, at a minimum, be able to direct requestors to the individual in charge of responding to medical-records requests.

Internal procedures must spell out who is entitled to records. This determination is provider-specific and involves an interrelation of state and federal laws and regulations. Clearly, individuals requesting copies of their own records have the broadest rights of access, however, there still are some limitations to disclosure. Requests from legally recognized agents, e.g. guardians and health care agents appointed under a Power of Attorney for Health Care, generally stand in the shoes of the resident for access-rights

Requests by family members or others involved in care are more complicated. A provider should not release records to someone other than the resident or legal representative without the resident’s or legal representative’s authorization.

The rules for access differ depending on whether the individual whose records are involved still is alive. Under Wisconsin law, a decedent’s records may be released to a “person authorized by patient,” which includes the personal representative, spouse, domestic partner or anyone previously designated in writing. If no spouse or domestic partner survives a deceased patient, “person authorized by the patient” also means an adult member of the deceased patient’s immediate family. HIPAA extends access to “persons involved in care.” Depending on the circumstances, disclosures to spouses, parents,

Penalties exist on both state and federal levels for failure to provide timely access to authorized record requests. Providers are encouraged to review their current policies and processes to verify compliance with applicable regulations and laws and to assure that access rights are respected while still protecting against improper releases.

children, domestic partners, other relatives, or friends of the decedent may be permissible, provided the information disclosed is limited to that which is relevant to the person’s involvement in the decedent’s care or payment for care (unless doing so is inconsistent with any prior expressed preference of the deceased individual that is known to the covered entity).

Procedures must specify a timeline for responses, which may depend on provider type. HIPAA generally requires record request responses within thirty days, although federal requirements for skilled nursing facilities shorten the response time to two days.

Providers are expected to provide records in the form and format requested, i.e. hard copy versus electronic, if feasible for the provider. Charges for reproduction should be identified in advance and applied, and they should be limited as set forth by applicable law.

Brian Purtell is the Director of Legal Services for the Wisconsin Health Care Association and the Wisconsin Center for Assisted Living and the Executive

Director of the Wisconsin Center for Assisted Living. He can be reached at [email protected].

Esa M. Movroydis is an Attorney with DeWitt, Ross, Stevens. She can be reached at [email protected].



“We have been experiencing a shortage in candidates for CNA positions for the past 10 years, but it has gotten worse in the last 2 years,” said Walters, who since 1974, has served in virtually all of the critical positions within a skilled nursing facility, including starting out as a CNA while attending college in Oshkosh. “I do believe that we are competing with service industries for employees. I have heard CNA candidates say they can find less physically and emotionally demanding work for the same amount of money as we are able to pay them. Being in a rural area increases the problem as we don’t have as many candidates to choose from.” Maun said during the economic downturn many low-skilled people sought out positions in skilled nursing or assisted living facilities as there are always jobs available. However, as the economy has improved, more workers have been drawn away from the profession – just as the trickle of aging Baby Boomers into facilities swells into a flood. According to employment projections released by the U.S. Bureau of Labor Statistics last year, between CNAs, personal care and home health aides, the United States will need more than 1.3 million new paid caregivers to meet demand over the next decade. In Wisconsin, projected demographic shifts could magnify these challenges even further. A report published in Dec. 2013 that was prepared for the Wisconsin Department of Administration projected: Wisconsin’s senior population –

age 65 and over – will increase rapidly in every five-year interval, from 777,500 in 2010 to 1,535,500 in 2040, nearly doubling in 30 years.

The elderly population – age 85 and over – will rise steadily from

118,500 in 2010 to 145,500 in 2025, then nearly double to 283,500 in the following 15 years. From 2010 to 2040, this age group will increase by 140 percent.

In recent years, an increasing number of trained CNAs have looked to the position as a stepping stone rather than a career choice. Some have used their CNA training to move on to work as LPNs and RNs, which require training as a CNA before moving onto those other roles. “The work of a CNA is physically and emotionally challenging, and many people feel they aren’t financially compensated adequately for the type of work they perform,” Walters said. “We are in a very highly regulated profession and as such, it places additional stresses on CNAs.” REGULATIONOne example of the excessive regulation that LTC administrators point to is a Federal rule promulgated by the U.S. Department of Labor in 2011, which restricts the ability of CNAs who are under 18-years-old from using a patient lift without being supervised by an adult.

“This rule has an impact on the number of minors we can employ on a shift so that we can insure that we have enough staff who are capable of operating the lifts so that residents don’t have to wait to be transferred,” Walters said. Kiley said Dove Healthcare’s policy regarding the hiring of minors, who at one time were a critical labor source in LTC facilities, has evolved with their growing CNA staffing needs. “When the rule change came down, we decided to not hire certified nursing assistants under the age of 18. We have since changed our policy at some of our facilities and now have to monitor them to ensure that they don’t use patient lifts while on duty. Patient lifts are extremely safe. It is far more dangerous to let those under the age of 18 transfer without lifts. It’s a strange rule.” Mulder said his facility simply stopped hiring minors because of the hassle. “High school students are not able to work for us anymore,” Mulder said. “They can drive a car – why can’t they use a patient lift?”

Continued on Pg. 26

THE GOVERNMENT’S ROLEFinding qualified workers is a challenge in any field, but when your ability as an employer to pay prospective employees is strictly limited by the value government officials are willing to pay for your service, it creates nearly insurmountable barriers.

Dale Kelm, owner/operator of Birch Haven Senior Living, which includes four Community Based Residential Facilities ranging between 8- and 17-beds located in Ashland, said

he would be happy to extend any reimbursement increase for assisted living providers to his employees. Many LTC facility operators say the same thing. “I would have no problem if reimbursement increases were tied to staff wages and training,” said Kelm, who has worked in the LTC profession since 1991. “I’m here to provide a quality service – I would love to pay my staff more money.” Kelm points out that an increase in wage rates for low-income CNAs providing care in LTC facilities could

mean a commensurate decrease in the cost of the public assistance those individuals need.

“When you’re making a lower wage, offering more money to do the job could take people off public assistance,” Kelm said.

With the increasing level of patient acuity that assisted living facilities face in their residents – particularly in the form of residents with dementia – Kelm said he receives no increase in reimbursement for dementia care-certified CNAs, which he would be willing to pass on to his employees who obtain higher certifications.

“The state should step up,” said Maun, who pointed to the need for greater reimbursement using public policy tools such as a wage a pass-through as a means of ensuring rate increases go directly to front-line staff. “I would probably have the Legislature or regulatory groups conduct in-depth summits of not only the administrative personnel, but also front-line CNAs so as to encourage employee retention. I would come up with an incentive payment based on employment retention levels.” Kelm said that for his part-time employees, going over 30 hours a

418

176

1581

0

200

400

600

800

1000

1200

1400

1600

1800

FTE is de�ned as Full Time Equivalent-any position that is at least 40 hours per week. A FTE is calculated as follows: number of hours each week for each position divided by 40 hours (i.e. 60 hours per week divided by 40 hours=1.50 FTE’s)

R.N. L.P.N C.N.A

Number of Vacant FTE in WI Nursing Facilities

Source: 2015 Wisconsin Long-Term Care Provider Community Coalition Survey of 198 facilities.

87,797

0 20,000 40,000 60,000 80,000 100,000

Direct-Care Workers

Retail Salespersons

Wisconsin’s Largest Occupational Groups

Teachers fromPre-K to 12th Grade

Metal Workers &Plastic Workers

RNs and LPNs

Truck Drivers

76,180

73,910

70,920

63,330

60,040

Source: Paraprofessional Healthcare Institute

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week can be particularly concerning because many of them attain health benefits through BadgerCare, which has income restrictions for those who can receive benefits. “They are very aware of what their benefits are and they are very concerned about losing their health coverage,” Kelm said. On the other side, as a result of the requirements and penalties for employers included in the Affordable Care Act, many employers are concerned about the additional costs associated with health benefits as well. While on the one hand employers are required to pay for employees who work more than 30 hours a week, they are not being a paid reimbursement rates that enable those employers to afford coverage for their employees. POLICY SOLUTIONSAs members of the Legislature’s powerful budget-writing committee consider priorities within the 2015-17 Biennial State Budget, Wisconsin’s provider community ask that Legislators consider the impact Medicaid reimbursement has on the wages facilities can offer front-line caregivers, not to mention the millions of dollars that have been taken from LTC providers over the years in budget transfer schemes involving the “bed tax skim.” With retiring caregivers and increasing demand for LTC services

as a result of the aging Baby Boomer population, providers say they want to help offer solutions to these challenges, but ultimately need state leaders to address the shortfall of front-line LTC caregivers. Walters looks to greater reimbursement of providers and prospective CNAs for their training costs as one solution. “I think it would be easier to find candidates if there was some type of grant program to assist CNAs with the costs of training,” Walters said. “Not only are the initial fees high, but they need to take time off of work for the classroom and clinical training, which also contributes a financial hardship for many of them.” Kiley sees opportunity in offering greater flexibility for CNA training requirements. “We need to find a way to eliminate the up-front costs, and find a way to provide paid training,” Kiley said. “Willing participants simply cannot afford the costs of the classes, testing, not to mention not getting paid for an entire month of training. We need more reimbursement for training CNAs. We need competitive wages and benefits. We also need to look at revising the training requirements. What about less classroom training and more clinical experience on the floor?”

On the Federal side, Mulder said he looks to immigration reform as a means of accessing a new labor pool. “We need more people in the labor force.”

STAFFING = QUALITYUltimately, long-term care is labor intensive, with personnel costs comprising 70 percent of the total cost of providing care and treatment to nursing facility residents. Moreover, finding the right people to fill these critically important positions is central to providing quality care in Wisconsin’s skilled nursing and assisted living facilities. “Staffing is extremely important, when you’re short of staff, others have to pick up the load, and then people get burned out and quit,” Scoles said. “Then you need more help. Let’s not forget all the paperwork in health care, my nurses help when we are short of CNAs, but then their charting might get behind.” Assembling the staff for a facility that requires care for individuals 24 hours a day, 7 days a week, and 365 days a year can be extremely difficult. “Quality suffers if you don’t have your full staff available every day,” Mulder said. Kiley summed up Wisconsin’s CNA shortage problem with this simple truism… “You simply have no care without caregivers,” he said.


John J. Vander Meer is the Director of Communications for the Wisconsin Health Care Association and the Wisconsin Center for Assisted Living.

He can be reached at [email protected].

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Wage Gap: LTC Workers Underpaid Comapared to Competition

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$11.51

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27 CONTINUUM | www.whcawical.org

Continuum Spring 2015

Documents

Transcript of Continuum Spring 2015