The ALF Explosion. Stephen R. La Pierre Senior Vice President Claim/Case Management & Policyholder...
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Transcript of The ALF Explosion. Stephen R. La Pierre Senior Vice President Claim/Case Management & Policyholder...
The ALF Explosion
The ALF ExplosionThe ALF Explosion
Stephen R. La PierreStephen R. La Pierre
Senior Vice PresidentSenior Vice President
Claim/Case Management & Policyholder ServicesClaim/Case Management & Policyholder Services
Penn Treaty Network AmericaPenn Treaty Network America
[email protected]@penntreaty.com
For a copy of my letter to the Editor, email:
Facility Providers . . .Facility Providers . . .
Industry Claims Advisory Work Group FocusIndustry Claims Advisory Work Group Focus
Evolving Facility Provider IndustryEvolving Facility Provider Industry Use of nursing homes changingUse of nursing homes changing
Still primarily long termStill primarily long term
in discharge ratesin discharge rates Explosion in Assisted Living Facility growthExplosion in Assisted Living Facility growth
NumberNumber
VarietyVariety
Challenge for claim staff/ Tools for AdjudicationChallenge for claim staff/ Tools for Adjudication
The BasicsThe Basics
Nursing Homes Nursing Homes
vs. vs.
Assisted Living FacilitiesAssisted Living Facilities
Nursing Homes a/k/aNursing Homes a/k/a
NFNF
SNFSNF
SCFSCF
SLTCFSLTCF
SNRCSNRC
ICFICF
CCCCCC
Nursing FacilityNursing Facility
Skilled Nursing FacilitySkilled Nursing Facility
Skilled Care FacilitySkilled Care Facility
Skilled Long Term Care FacilitySkilled Long Term Care Facility
Skilled Nursing & Rehabilitation CenterSkilled Nursing & Rehabilitation Center
Intermediate Care FacilityIntermediate Care Facility
Convalescent Care CenterConvalescent Care Center
Assisted Living Facility a/k/aAssisted Living Facility a/k/a
ALFALF
RCFRCF
CBRFCBRF
CCRCCCRC
PCFPCF
AFHAFH
• C O N F U S I N G
Assisted Living FacilityAssisted Living Facility
Residential Care FacilityResidential Care Facility
Community Based Residential Care FacilityCommunity Based Residential Care Facility
Continuing Care Retirement CommunityContinuing Care Retirement Community
Personal Care HomePersonal Care Home
Adult Foster HomeAdult Foster Home
“ “Any attempt to understand assisted living Any attempt to understand assisted living and its role in providing long-term care to and its role in providing long-term care to the frail elderly is hindered by the lack of a the frail elderly is hindered by the lack of a common definition of ‘assisted living’.”common definition of ‘assisted living’.”
U.S. Department of Health and Human ServicesU.S. Department of Health and Human ServicesA National Study of Assisted Living for the Frail Elderly: Final Summary ReportA National Study of Assisted Living for the Frail Elderly: Final Summary Report
Catherine Hawes, Ph.D. and Charles D. Phillips, Ph.D., M.P.H.Catherine Hawes, Ph.D. and Charles D. Phillips, Ph.D., M.P.H.Texas A&M University System Health Science CenterTexas A&M University System Health Science Center
Miriam Rose, M.Ed.Miriam Rose, M.Ed.Myers Research InstituteMyers Research Institute
November 2000November 2000
Assisted Living FacilitiesAssisted Living Facilities
Nursing HomesNursing HomesFederal/State regulationsFederal/State regulationsHigh medical orientationHigh medical orientationMD order for admissionMD order for admissionMedical records requiredMedical records requiredFrequency of MD review mandatedFrequency of MD review mandatedQuarterly care plan conferences mandatedQuarterly care plan conferences mandated24 hour licensed staff required24 hour licensed staff requiredStringent staffing requirementsStringent staffing requirementsFull range of therapy servicesFull range of therapy servicesLittle question about personal/provider eligibilityLittle question about personal/provider eligibility
Assisted Living FacilitiesAssisted Living Facilities
Less medically orientedLess medically oriented
Lightly regulatedLightly regulated
Staffing requirements less stringentStaffing requirements less stringent 24 hour staff “that is awake”24 hour staff “that is awake” Staff continuing education not mandatedStaff continuing education not mandated
Functional range from very independent to Functional range from very independent to occasional assist with ADLsoccasional assist with ADLs
Eligibility is a moving targetEligibility is a moving target
Nursing Home - PastNursing Home - Past
Only alternativeOnly alternative
Long term placementLong term placement
Low discharge rateLow discharge rate
Family guilt/ reluctant to admitFamily guilt/ reluctant to admit
Negative stigmaNegative stigma
Assisted Living Facilities - PastAssisted Living Facilities - PastEvolved from Board & Care homesEvolved from Board & Care homesLooked like a nicely decorated Nursing HomeLooked like a nicely decorated Nursing HomeEmergency call systems in all roomsEmergency call systems in all roomsRecreational and social programmingRecreational and social programmingThree meals per day – special dietsThree meals per day – special dietsDid not serve high acuityDid not serve high acuity
Nurse supervision on at least 2 of 3 shiftsNurse supervision on at least 2 of 3 shifts Nursing assistantNursing assistant
Call lightsCall lightsOccasional ADL assistanceOccasional ADL assistanceDining assistanceDining assistance
Many ALFs would discharge clients who became Many ALFs would discharge clients who became cognitively impaired, incontinent or required constant cognitively impaired, incontinent or required constant ADL assistanceADL assistance
Nursing Homes - TodayNursing Homes - Today
Primarily long term stayPrimarily long term stay
Increase in discharge ratesIncrease in discharge rates MedicareMedicare Hospital transitional careHospital transitional care
Remain Highly regulatedRemain Highly regulated
Stagnant facility growthStagnant facility growth19951995 16,700 homes16,700 homes
19991999 18,000 homes18,000 homes
20042004 16,100 homes16,100 homes
20072007 <16,000<16,000
600011500
18000
36000
0
10000
20000
30000
40000
1990 2000
Years Measured
ALF Explosion
Number of ALFs
2007
36,000 strong36,000 strong
Broadening target market/continuumBroadening target market/continuum ILF, ALF, Cognitive UnitILF, ALF, Cognitive Unit
Hotel / Resort-like marketingHotel / Resort-like marketing
More palatable option for kids/parentsMore palatable option for kids/parents
Blurring the line between Independent & Blurring the line between Independent & Assisted livingAssisted living
Assisted Living Facilities - Assisted Living Facilities - TodayToday
Assisted Living Facilities - TodayAssisted Living Facilities - Today
Measured by Service & PrivacyMeasured by Service & Privacy
High ServiceHigh Service1 FT RN on staff1 FT RN on staff
Nursing care by facilityNursing care by facility
Plus low service listPlus low service list
Low ServiceLow Service24 hr supervision 24 hr supervision
HousekeepingHousekeeping
2 meals/day2 meals/day
Personal Care w/Meds, Personal Care w/Meds, bathing, dressingbathing, dressing
High PrivacyHigh Privacy>80% private rooms>80% private rooms
[Large growth today][Large growth today]
11%11%
18%18%
Low PrivacyLow Privacy<80% private rooms<80% private rooms
12%12%
59%59%
1998 study – first ever empirical nationwide data
Determining Provider EligibilityDetermining Provider Eligibility
Changing Utilization PatternsChanging Utilization Patterns
What does this all mean to LTCi What does this all mean to LTCi claim operations?claim operations?
The Challenge:
Provider Eligibility ChallengeProvider Eligibility Challenge
Older policy languageOlder policy language Detailed & specific?Detailed & specific? Not detailed & specificNot detailed & specific
Do your policies specifically exclude ALFs?Do your policies specifically exclude ALFs?Do ALFs qualify as NHs under your policies?Do ALFs qualify as NHs under your policies? LicensureLicensure Staffing [levels/inhouse/contracted]Staffing [levels/inhouse/contracted] Services/recordsServices/records
Is the facility standalone/distinct partIs the facility standalone/distinct part /shared area?/shared area?
Utilization Pattern ChallengeUtilization Pattern Challenge
ALFs more attractive / palatableALFs more attractive / palatable
Has it become easier for children to place their Has it become easier for children to place their parents in a facility earlier than in the past?parents in a facility earlier than in the past?
Is this placement for convenience or need?Is this placement for convenience or need?
People sell home and move in expecting to be People sell home and move in expecting to be eligibleeligible
Non-eligible spouse moves in with eligible Non-eligible spouse moves in with eligible spousespouse
Bundled charges [covered & non-covered]Bundled charges [covered & non-covered]
Tools For Adjudication
Tools for AdjudicationTools for Adjudication
Policy LanguagePolicy Language
Facility LicenseFacility License
Facility Marketing Material/web-siteFacility Marketing Material/web-site
Facility Floor PlanFacility Floor Plan
Resident AgreementResident Agreement
Telephone inquiry / Facility AssessmentTelephone inquiry / Facility Assessment Staffing[nurses/cna/unskilled]Staffing[nurses/cna/unskilled] Level of services [by staff or contracted]Level of services [by staff or contracted] Medical Director [on staff or contracted]Medical Director [on staff or contracted]
Let policy be your guideLet policy be your guide
Nursing Facility:Nursing Facility: A home, residence or institution, other than a hospital, which A home, residence or institution, other than a hospital, which is primarily engaged in providing nursing care and related services on an is primarily engaged in providing nursing care and related services on an inpatient basis under a license issued by the appropriate licensing agency. It inpatient basis under a license issued by the appropriate licensing agency. It may be a freestanding facility including the following:may be a freestanding facility including the following:
(a) Nursing Facility;(a) Nursing Facility;(b) Skilled nursing home;(b) Skilled nursing home;(c) intermediate nursing care home; (c) intermediate nursing care home; (d) (d) Assisted Living Care FacilityAssisted Living Care Facility; ; (e) Residential Health Care Facility; or(e) Residential Health Care Facility; or(f) Alzheimer's care facility(f) Alzheimer's care facility
Comprehensive definition . . . Comprehensive definition . . . AnAn Assisted Living Facility Assisted Living Facility will also be considered a will also be considered a Nursing HomeNursing Home and eligible for and eligible for the Policy’s full Nursing Home benefit ifthe Policy’s full Nursing Home benefit if it is licensed by the appropriate federal or it is licensed by the appropriate federal or state agency to engage primarily in providing care and unscheduled services to state agency to engage primarily in providing care and unscheduled services to resident inpatients and it:resident inpatients and it:
1.)1.) provides twenty-four (24) hour a day care and services sufficient provides twenty-four (24) hour a day care and services sufficient to support needs resulting from inability to perform Activities of Daily Living and/or to support needs resulting from inability to perform Activities of Daily Living and/or Cognitive Impairment;Cognitive Impairment;
2.)2.) has a trained and ready to respond employee on duty at all times has a trained and ready to respond employee on duty at all times to provide care and services;to provide care and services;
3.)3.) provides three (3) meals a day and accommodates special provides three (3) meals a day and accommodates special dietary needs; anddietary needs; and
4.)4.) has the appropriate methods and procedures to provide has the appropriate methods and procedures to provide necessary assistance to residents in the management of prescribed medications.necessary assistance to residents in the management of prescribed medications.An Assisted Living Facility may sometimes be called a Residential Care Facility or an An Assisted Living Facility may sometimes be called a Residential Care Facility or an Adult Congregate Living Facility. Any facility, or section thereof, known by one of Adult Congregate Living Facility. Any facility, or section thereof, known by one of these names, or any other name, will be considered eligible if it meets the Policy these names, or any other name, will be considered eligible if it meets the Policy definition of an Assisted Living Facility.definition of an Assisted Living Facility.If a facility or institution (such as a congregate care facility or life care community) has If a facility or institution (such as a congregate care facility or life care community) has multiple licenses and/or multiple purposes, only the section, wing, ward or unit multiple licenses and/or multiple purposes, only the section, wing, ward or unit (including a separate room or apartment) that specifically qualifies as a Nursing (including a separate room or apartment) that specifically qualifies as a Nursing Home or an Assisted Living Facility will be eligible for benefits.Home or an Assisted Living Facility will be eligible for benefits.
Excludes ALFsExcludes ALFs"Nursing Care Facility""Nursing Care Facility" means a facility that: means a facility that:
(a) is licensed or certified by the state to provide nursing care as its main function; (a) is licensed or certified by the state to provide nursing care as its main function; (b) provides continuous room and board for at least 3 people;(b) provides continuous room and board for at least 3 people;(c ) provides supervised care by an on-duty RN or LPN; (c ) provides supervised care by an on-duty RN or LPN; (d) maintains daily medical records; and (d) maintains daily medical records; and (e) maintains control and records of medications given.(e) maintains control and records of medications given.
A Nursing Care Facility does not includeA Nursing Care Facility does not include: (a) rest homes; (b) homes for the aged; : (a) rest homes; (b) homes for the aged; (c ) retirement homes; (d) community living centers; (c ) retirement homes; (d) community living centers; (e) Assisted Living Facilities(e) Assisted Living Facilities;; (f) adult day care or educational care facilities; (f) adult day care or educational care facilities;
(g) residential sections or wings of Nursing Care Facilities; or (g) residential sections or wings of Nursing Care Facilities; or (h) places used primarily for the care and treatment of alcoholism,(h) places used primarily for the care and treatment of alcoholism,drug addiction or mental or nervous disorders.drug addiction or mental or nervous disorders.
Less definitiveLess definitive
""Nursing Care Facility" Nursing Care Facility" means a facility that:means a facility that:
(a) is licensed or certified by the state to provide nursing care as (a) is licensed or certified by the state to provide nursing care as its main function;its main function;(b) provides continuous room and board for at least 3 people;(b) provides continuous room and board for at least 3 people;(c ) provides supervised care by an on-duty RN or LPN; (c ) provides supervised care by an on-duty RN or LPN; (d) maintains daily medical records; and (d) maintains daily medical records; and (e) maintains control and records for medication.(e) maintains control and records for medication.
Covered / Non-covered ?
Look to the LicenseLook to the License
Marketing MaterialsMarketing Materials
BrochuresBrochures
Web-sitesWeb-sites
Resident AgreementsResident Agreements
But First!!!But First!!!
LegLeg
CheeseCheese
TentTent
MotorMotor
FlowerFlower
StampStamp
CupCup
KingKing
ForestForest
Menu Menu
Resident AgreementResident Agreement
Details on nature of chargesDetails on nature of charges CoveredCovered Non-coveredNon-covered
Description of level of services providedDescription of level of services provided
Room Rate$139/day
Level of Care Fees
$10/day
Medication Administration
Fees
Community Fee
Take out Paper and PencilTake out Paper and Pencil
Write down as many Write down as many of the 10 words as of the 10 words as you can rememberyou can remember
Don’t look at your neighbors paper!!Don’t look at your neighbors paper!!
LegLeg
CheeseCheese
TentTent
MotorMotor
FlowerFlower
StampStamp
CupCup
KingKing
ForestForest
Menu Menu
Facility AssessmentFacility Assessment
StaffingStaffing RatiosRatios CredentialsCredentials Employed / ContractedEmployed / Contracted
ProgrammingProgramming RecreationalRecreational SocialSocial
Levels of CareLevels of Care Define levels availableDefine levels available Identify physical location/levelIdentify physical location/level
Contracted ServicesContracted Services Medical DirectorMedical Director Pharmacy/PharmacistPharmacy/Pharmacist DietaryDietary TherapyTherapy
Hybrid ScenariosHybrid ScenariosILF- “pseudo-ALF” offering assistance through contracts with ILF- “pseudo-ALF” offering assistance through contracts with HHAHHA
ILF does not qualify as an ALFILF does not qualify as an ALF Will ALF policy cover ?Will ALF policy cover ? Policyholders home is ILF?, will HHC policy pay for care?Policyholders home is ILF?, will HHC policy pay for care?
Continuing Care CampusContinuing Care Campus Policyholder “buys in” at time of admissionPolicyholder “buys in” at time of admission Guaranteed services in SNF/ALF/HHC on campusGuaranteed services in SNF/ALF/HHC on campus Question: How to calculate benefits at time of need?Question: How to calculate benefits at time of need?
ILF apartments dually licensed as ALF ILF apartments dually licensed as ALF Policyholder receives intermittent IADL/ADL assistancePolicyholder receives intermittent IADL/ADL assistance What charges are eligible? R & B? Service only? All? Nothing?What charges are eligible? R & B? Service only? All? Nothing?
SummarySummaryALF category is explodingALF category is explodingMore attractive for retirementMore attractive for retirementBlurring the line of eligibilityBlurring the line of eligibility Enter independentEnter independent Receive intermittent servicesReceive intermittent services
Use the tools of adjudicationUse the tools of adjudicationHistoric actuarial assumptions for Historic actuarial assumptions for utilizationutilizationConsider this evolution in new product Consider this evolution in new product developmentdevelopment
Grand Prize Question