DATE: November 22, 2005
PRESENT: Linda Borleske, Joan Fordham, Joan Wheeler, Art Carlson, Paul Endres, Larry Volz, Kathy Schauf, John Earl, Lowell Haugen, Judith Stoeckmann, Al Dippel, Tommy Bychinski, Sue Hebel, Cindy Bodendein, Bill Orth, Trish Vandre, Diane Keylock
1. Called to order at 6:00 p.m. by Paul Endres. The open meeting law requirements were met.
2. Motion by Borleske, second by Carlson to adopt the agenda. Motion carried.
3. Motion by Earl, second by Dippel to approve the minutes. Motion carried.
4. Public Comment - Tom Kriegl asked to read questions regarding the comparison of SCHCC to Columbia County HCC. A copy of the questions was handed out so Mr. Kriegl chose not to read them or comment at this time.
5. Communications. Committee members will study the questions and a written response will be given to the full board. Kathy received notice from Wendy Fernside from the Dept. of Health and Family Services regarding the Nursing Home Conversion Demonstration Project. The application deadline has been extended to June 30, 2006.
6. Tommy Davidson will be on the agenda for the December 15 meeting.
7. John Alt and Stacy Clement - MATC, Reedsburg. Commented on the wonderful partnership that MATC has had with the Sauk County Health Care Center especially in relation to the clinical site provided by the HCC for student nurses. Concerned about the future of the HCC and the possibility of closure. There is land available for a possible building site and future expanded partnership. Have been able to provide a dedicated CNA Training space which helps fill the need for CNAs in the community. Nursing students are at the HCC for a 6 week rotation and are on-site 2 days a week. The facility is close to the campus and provides a very good clinical site. Last year 37 nurses graduated. To graduate more nurses MATC would need more clinical sites, space and staff. 96% of the graduates stay in this area and work. The graduates have the highest passage rate for State Boards. Use many facilities in the county and surrounding areas for clinical sites. Work closely with Greenway Manor in Spring Green and run a CNA class in that facility. If the board is considering building a new Health Care Center consider the MATC campus area. Feel that the decision could be mutually beneficial and are ready to stand by us and assist in any way they can.
8. Phone presentation by Stephanie Sue Stein, Director of the Milwaukee County Department on Aging. Became an independent partner of county government in 1991 with a budget of $12M. In 2006 the budget is $165M and have less tax levy than in 1991. Are one of the 5 counties operating a Family Care Management Organization which provides Family Care for people 60 and over. Waiting lists were an ongoing problem so worked on that problem through joining statewide advocates including the Coalition of Wisconsin Aging and the Wisconsin Coalition for Advocacy. Milwaukee began managed care in July, 2001. Were serving about 2500 people with COP and waiver programs with 2500 on waiting lists. July 2003 were serving 5200 people and no waiting list. Had to build the entire system from scratch with no county contribution. Balance of payments for long term care Medicaid in most every state is 70% Nursing Home and 30% home and community based care. Oregon asked the federal government for waiver to spend their Medicaid money differently by adding line to budget stating that they would spend all the long term care money in the least restrictive environment. Received waiver and combined all long term care dollars at state level in one budget with one administrator, program, set of rules and philosophy. Washington State soon followed. Mandate is to serve people in homes or communities as long as possible. Advocates continue to push for reform because they feel the public, families and service providers want to keep people in their homes as long as possible and also care in institutions is very costly. Federal government has realized that they can effect system change by providing money to change the balance of long term care funding. Wisconsin is using their system change grant in the current budget to look at how we can do things differently by putting out the RFP. Change is all about the money. A lot of money is saved under the Family Care Program. Closed the 18th nursing home in Milwaukee County since Family Care began, and expect more in the next year. Have been able to relocate all displaced residents. The system and service model has to change. There are very few people who need 24 hour awake skilled nursing care. We all need to find a way to combine housing and services to be accessible but not mandatory. Need to improve affordable options, services and ways of communicating the options available.
Questions answered: In the past few years are more changes in how health care is provided especially for those without their own resources. This will continue to expand. Our challenge is to design something that is effective for years to come. Political changes affect the path of long term care reform, however changes are coming. We have to figure out what our citizens want and move that agenda. Family care is successful but not available for all counties in Wisconsin. The state has put out a request for proposals and wants input from counties on how to move long term care into managed care. There is no template like there was for Family Care so counties need to express their interest and ideas. It is an attempt to bring private agencies in. State is moving ahead as far as planning is concerned. Is still need for nursing home care, however not in the form we are used to. There were about 42 nursing homes in Milwaukee County and are only 25 left. All of those closed were either for profit or not for profit. Advice regarding building a nursing home would be not to build. There are different options available which could make a lot of money available for community care. Could imagine looking at state of the art places with assisted living/some skilled care etc. Felt there are not going to be skilled nursing homes in the future as we know them - will be a need for skilled care, but will look different. Every situation is different so need to know our constituents and their needs. Budget going from $12M to $165M with county government only providing some funding for transportation and operation of the Senior Center. Family Care saves state government $1.9M. The savings in Medicaid dollars causes more money to be available to others. Funding of Medicaid is 60% Federal and 40% State. Family Care is COP waiver turned into managed care turned into an entitlement. No one can be turned away if they meet the requirements. Pay for the services only in assisted living, CBRF's and RCAC's. Do not pay for room and board. Richland County is also a family care county and is surviving but only serves about 300 people. State is saying that smaller counties may have to join with each other to sustain services.
Bill Orth indicated that if family care was doing so well it would be statewide. Does save money per person, but you can't have waiting lists and there isn't enough state and federal money to expand it across the state. Family care counties save on services for residents because they bargain for lower rates for those services. Look for the least expensive level of care that is still quality care. There are pros and cons to family care. Some say quality isn't as good. Often times the resident is in a community based facility rather than "home". Allows for more services to be provided for the person in the home which is cheaper than having that person in a nursing home. Family care is just for long term care services and the Medical Assistance Card is still used for Dr. etc. State wants better fiscal management of acute and primary care by including it in managed care. If enough nursing home beds are not available, the resident would have to be placed out of county or even out of state.
9. Review, discussion and consideration of board presentation documents. Five alternatives were presented which were compiled by county department heads. Each one will be discussed using the criteria listed on a separate page. Also included were Jeanne's alternatives and Joan's survey regarding the aftermath of privatizing county nursing homes. Goal is to come up with a policy recommendation to give to the board.
Alternative #1 - Status Quo:
Cost - will require remodeling/updating to meet minimum requirements at cost of approximately $8M. Ongoing inefficiency, staffing issues.
Future consequences - Increased dependency on tax levy, continually rising operating costs, limit consideration of other aspects, fragmentation of services, lack of being responsive to future needs, limiting marketability to clients and possible buyers, capital life span/usability.
Constraints and Political Feasibility - Can afford but is not cost effective. We need to make a decision since has been discussed for 10 years. With the use of federal grant money, Bill Orth is currently involved with eleven other counties along with three partnerships to reply to the RFP for planning money. Group will develop a plan for how we would propose to implement a managed long term care system in the involved counties. Will meet for 18 months. At end of 18 months will be another RFP process where state will ask how much your plan will cost. Will award grants- if legislature approves - to begin the service delivery process. Still looking at 5 - 10 years into the future. In a Family care system you are responsible for paying for the nursing home care so goal is to not put people in the nursing home unless they absolutely need it. Would eventually mean less nursing home beds. RFP that is now out there would like to bring in management of acute and primary care also. Not enough money to address the current waiting lists so this RFP is not demanding that the waiting list be taken care of. Total managed care counties - Eau Claire, Dane County and one in Milwaukee are experiencing some cost savings, however none manage all the population. All either just physically disabled or just elderly. None manage the developmentally disabled population which is the most expensive and difficult to manage. Managed care buys services from providers and tells them what rate they will pay. If the provider doesn't accept the rate they don't get the contract.
Stability - Yes, is stable
Reliability - Will continue to work
Invulnerability - Will continue to perform
Flexibility - Limited
Risk - Not high chance for failure
Communicability - Easily communicated option - to board and constituency. With some reservations.
Merit - Addresses problem - yes
Compatibility - Yes
Reversibility - Already there.
Alternative #2 - Down size HCC:
Cost - Will require remodeling/updating of existing facility. Also includes list of options appropriate with alternatives, dementia beds, assisted living etc. Possible state funding to downsize. May not be cost savings to downsize since some costs are level and still have to provide enough staff to care for fewer individuals and revenue goes down. Would include the $8M plus money to renovate for alternatives. State money to downsize is one time only.
All alternatives assume that efforts will be ongoing to address existing gaps in the Long Term Care Continuum with available resources and the development of a single point of entry system and the transition to "managed care".
Future Consequences - Still ongoing inefficiencies and staffing issues, increased dependence on tax levy, increased operating costs.
Constraints and political feasibility - Will need to have a portion of the payor source be private pay, need to encourage development of all payor mixes. Would not be feasible if private pay were not included. Sliding scale can be used. If at all possible, options added would be available on a sliding scale fee. Would also encourage continuing with accepting residents based on need and our ability to care for them, not the payor source. Also, is large senior contingency out there who have been relatively silent. If this committee doesn't do the right thing, they have the time and resources to fight for what they want.
Cost - Same as alternative 1
Stability - Yes
Reliability - Yes
Invulnerability - Will continue to perform
Flexibility - Yes
Riskiness - Loss of beds in area
Communicability - May be harder to communicate as some aspects are more difficult to understand.
Merit - More merit than alternative 1, will leave some things to be desired
Compatibility - Yes
Reversibility - Not reversible, can't go back. Once the beds are not licensed, can't get more. However can use some beds for different purposes such as Alzheimer unit.
The next meeting will include phone conference with Mr. Davidson and continue discussing the alternatives.
10. Next meetings will be on December 15 and 29 at 6:00 p.m.
11. Motion by Carlson, second by Volz to adjourn. Motion carried.
Joan Fordham, Secretary