Health Care Center Ad Hoc Committee Meeting Minutes

January 5, 2005

PRESENT: Arthur Carlson, Larry Volz, Tom Bychinski, Paul Endres, Al Dippel, Joan Wheeler, Joan Fordham, Lowell Haugen, Cindy Bodendein, Kerry Beghin, Trish Vandre, Jeanne Leeck, Lisa Buttonow, Gene Wiegand, Bill Orth, Carol Jeffers, Sue Hebel, Kathy Schauf

1. Called to order at 2:08 p.m. by Art Carlson. The open meeting law requirements were met.
2. Motion by Bychinski, second by Volz to adopt the agenda.
   Motion carried.
3. Motion by Haugen, second by Fordham, to approve the minutes.
   Motion carried.
   Gene Wiegand indicated that the Committee so far had heard from different county departments and the services they each provide, have heard from the public, who voiced overwhelming support of the HCC particularly the quality of care and a public feeling that the facility should be maintained and continued. Also heard from a county that has invested in a new facility and their experiences. Thought it would be good to talk with a county who has chose to get out of the business.
4. Presentation by the Human Services Director of Juneau County, Michael Raroff. Decision was made after discussions between the Pleasant Acres Board and the Hospital Board. There was no involvement of different departments and no public hearings were held. County nursing home ran like a private home in that they didn't take difficult to manage people, had no ICF/MR, and no Alzheimer's Unit. County HS department always had to find places for these residents often far away from family so the financial impact on their department was not significant as they downsized. They have had residents placed as far away as Rhinelander. Social Workers must do their assessments by traveling. Juneau County floated the bond to generate money for construction and the Hess Hospital is leasing it over a 20 year period so in essence is paying off the bond. Lease payment equals the amount of the debt service on the bond. The county totally put up a one time cost of $800,000. In 20 years Mile Bluff will purchase the nursing home for $1. Nursing home made a wing into a CBRF which has been helpful to the HS department. Mr. Raroff indicated the CBRF was built because of need and to make money. Question was asked if the NH is making money. Indicated that the hospital wouldn't have done it if they wouldn't make money. Is a Non Profit Corporation. Wasn't sure if they currently have a waiting list, was downsized from 85 to 60 beds. Was built in New Lisbon because land was donated, community offered incentives to build, and they had a large corporation very interested in buying the facility. The quality of care was always excellent. Pleasant Acres never took residents with "challenging" behaviors - aggressive etc. If HCC takes challenging residents will be more difficult for HS to place them elsewhere. Art spoke with a county board member who said there is a contract in which the facility must take all county residents. Sometimes that can't be done because the nursing home may not be equipped to care for them. County residents may be a priority. Many staff became hospital employees - no CNA union so no issues there. Interviewed all that applied for the positions but there wasn't a guarantee of employment. As the NH downsized the HS department did not get any CIP slots. If the resident is on MA, there is no cost to the county if they have to be placed out of county. The problem is finding an out of county facility that will accept the MA resident if they are challenging or a higher level of care. If the resident is under protective placement/guardianship the HS department has to case manage that person which involves a cost. The more challenging resident often takes more staff to handle so that was one of the reasons that county nursing homes run with a county subsidy. Can't staff a facility to manage challenging people with the existing MA rates. Number of NH who will take difficult to place people is dwindling so placement is becoming difficult. Sauk County currently has 11 residents at the HCC, 4 in Central Center, 1 at Rhinelander and 1 at Lakeview (FDD Residents). The Community Support Mental Health population includes 3 at Lakeview, 2 in Clark County and 1 in Rock County. Currently is a longer waiting list of residents who have Alzheimers that have to be placed elsewhere. All populations placed out of county would be approximately 30-40 (this fluctuates). Not sure if New Lisbon facility has specialized Alzheimers Unit. Bethesda is interested in building group homes however are DD clients only. Keefe interviewed area hospitals and no one was interested in partnering with us at that time. Requirements needed for a facility to take in behaviorally challenged residents would include a special license, increase in staff training, environmental changes, increase in police/court resources, staffing issues, psychiatric nurse availability, etc. Nursing Homes are getting a younger, healthier population. If we would look at building a locked unit would get many referrals and would have to involve everyone in the county since would need more police etc. Many staffing/liability issues also. Building has to be built specifically to keep the residents separated. Is not a money making thing. Larry asked about populations of the two counties. Juneau has a population of 24,000 and Sauk is 57,000-58,000. Gene asked what Mike sees in the future. He indicated that the balance of services and funding is often fragile and the littlest thing could change everything. Concerned that TABOR would be death toll for county services. Not real optimistic about the future. Bill Orth indicated that NH used to be the safety net. If aren't enough NH where will they go? There will be more people who need care and less people to care for them. Is a need for more money in the system. Anticipate a reduction in state and federal funding. Mike felt there is a misconception that local government is fat and inefficient. We who work in that area know that not to be true but is difficult for the general population to truly understand where their tax dollars are going. ICF/MR downsizing money is supposed to pay to move residents to the community, however, may not be enough and will rest on the county to make up the difference. Feels that there needs to be some cost benefit consideration given to have everyone live in the community. Is possible, but at what cost? Will cost more in the community than in a NH. Also depends on the infrastructure available in the community - with Home Health etc. Never will have the level of infrastructure in the community to care for everyone given the population growth. In the past companies have come in and built group homes however with the decrease in funding, cost of staffing and staffing issues, and no guarantee that the beds will be full, organizations have become less interested in providing these services. Our ICFMR will be closing, but we need a downsizing plan. Can't just close it without a plan - we have to care for them until there is a place out in the community. May still need to be some sort of regional facility. We may still have a few ICF/MR residents when/if we build however could change that unit to another Alzheimer's unit for instance down the road. Joel indicated that the Juneau County Board had a very difficult time making their decision. Not having a union also made the decision easier.
5. Committee recommendations:
   Mr. Kriegl felt that more explanation is needed by Bill Orth regarding placement of our residents. Bill indicated that the placement costs were based on the assumption that we could place every current resident (103) into the community (all around the state) that we would get state and federal reimbursement and a portion of the cost which would come from the county. $4.5M is county cost per year if we could do that. Largest group (44 most needy) really do need to be in a nursing home so would have to place in NH somewhere - out of county perhaps. NH would have to accept MA rate for them. If those are taken out of the equation reduces the $4.5M to about $1.5M. The remainder of the residents (59) could be supported in the community for $1.5M annually. This assumed that they would be able to place residents somewhere in the state. As new people came in would have to assist families with placement. Fordham asked if it was the county's responsibility to provide the services or to just help people find the services in the private sector. Mandate from the state is to provide the service if it is court order. She felt that in general the role of government is not to do what private industry can do. However, in reality is a lot tougher decision. Felt that if the need is there private individuals will step up and provide the service. Gene indicated that the NH business is not a free market industry - it is the most regulated industry in the world. The intent of the Federal Govenment is to close as many NH as they can. NH residents were placed there out of convenience not need in the past. That is not true today. Fordham feels this decision should not be made solely on financial basis. Question asked if a citizen can't find a nursing home who is responsible? If she can't afford it the family will go into court and declare the person incompetent and then the county will be responsible. Trish felt that the family will try to keep them in the home as long as possible until there is a crisis and then they will be in the system. Joan Wheeler asked about admission policy at HCC. Jeanne indicated we have no admission policy regarding who is admitted. Generally who is referred first, however, we usually take the "crisis" person if we can. Joan felt we may want to say we are taking care of the indigent/most vulnerable first to be the "safety net" of the county. Paul aksed by whose regulatin would you define indigent? Who will judge? "The most vulnerable are the first served" may be a more accurate statement. We are a government facility and can't descriminate by pay source. Our citizens have a right to choose and we can't discriminate. Even though the HCC gets a lot of pressure to run in the black, we do not refuse admissions on the basis of pay source. Tommy felt that we do not want our county to get to the point where we separate the rich and poor and decide admission on the basis of pay source. Larry felt we are here to decide whether or not we want to build a nursing home, not who we will take or not take. Gene read the charge to the committee. "To examine the needs of Sauk County elderly and aging population, to review Sauk County's current response to those needs, to identify the role which the SCHCC should play within the matrix of services in the community and to examine the financial impact of significant changes in the SCHCC operations on other programs, facilities and departments." Gene fel that we have a responsibility to the tax payer to operate in as business like manner as we can. Understanding Joan's point of view that there should be certain priorities to those most vulnerable. To pursue that policy to the exclusion of private pay or Medicare funded beds would be foolish in a business sense. If you are so focused on those unable to pay that you are excluding those that are, you are driving up the subsidy that is required to operate the facility. Kriegl understands Joan to say that we wouldn't exclude those that can pay but also have an understanding of what the mission is. Joan Wheeler said that if we are going to do this it has to be a safety net, we are here to provide for those that can't provide for themselves. Building assisted living etc. would makes sense financially, but make it affordable. Trish said we need to make sure we have a place for those who can't pay and the way to insure that is to have ancillary services available. We need a mis of pay sources to help pay for the services. Gene felt it is in the realm of possibility to combine Section 8 housing with a congregate meal site and home health services or services out of the HCC so we are providing something analogous to assisted living. This would not be lucrative, however would meet a great need. Would take the pressure off the NH because will provide a different range of alternatives for our residents. The HCC mission is to provide nursing care and the county mission is to provide more services and meet more of the overall needs of county residents. Discussion followed regarding the county providing services that the private sector could provide - competition. Joan Fordham felt we have to ahve a mix of pay rates to be a smart business and don't end up with a "ghetto" or have the stigma of a poor housing project. Trish pointed out that the for profit homes can close anytime they want to and where do those residents go if there is not safety net facility? We have to provide the services regardless of pay source.
   
6. Next steps and future plans: Time frame for decision was discussed. Joan Fordham felt we should first decide if we should stay in the business and then another committee would look into building alternatives/kinds of services. Tommy, Larry and Art agreed. Paul felt with some more meetings before the February deadline we can make the decisions. Mr. Kriegl felt it could take many years to decide. Jeanne asked if the figures from HS could be available for the next meeting. Sue indicated they could be. Gene suggested everyone go back and review what they have learned. Next meeting will discuss those ideas and for the next meeting set a proposal for the full board. Next meeting will be January 19, at 1:00pm.
7. Motion by Bychinski, second by Volz to adjourn. Motion carried.

Meeting was adjourned at 4:45 p.m.

Respectfully submitted: Paul Endres, Secretary