Considerations for Critical

Access Hospital Swing Bed UseMinnesota Rural Health Conference

June 23, 2014

Presenters

• Patti Cullen, President/CEO, Care Providers of

Minnesota

• Chris Boldt, Vice President of Operations,

Benedictine Health System

• Cheryl Hennen, Deputy Ombudsman, Office of

Ombudsman for Long Term Care

Session Overview

• Overview of the practice of patient discharges to swing

beds in CAH and consumer post-discharge choice;

• Data review of how this practice is impacting the

financially strapped rural nursing facilities;

• Review/Discuss the impact on families and consumers;

and

• Suggest ways for better collaborations between the

settings of care

Data Review

Since July 1, 2008, what impact do you believe use of

Observation Days by hospitals in your area have had on your

total volume of Medicare days?

Source: Long Term Care Imperative 2014 Legislative Survey

In the past 12 months, has your nursing facility experienced a decrease

in Medicare admissions due to an increase in hospital swing-bed

utilization?

Source: Long Term Care Imperative 2014 Legislative Survey

Swing Bed Patient Days by Region as a Percent

There were 42,425 Swing Bed Patient Days on FY2012

Source: HCCIS Standard Hospital Reports, MDH. FY2012 Patient Days Data.

Average Daily Number of Residents

Residing in a Swing Bed

Source: HCCIS Standard Hospital Reports, MDH. FY2012 Patient Days Data.

Paid Days and Percent of Revenue

Over 89% of Revenue Controlled by State and Federal

Governments

Nursing Facility

Revenue by Percentage

Nursing Facility Paid

Days by Percentage

Source: 9-30-2012 DHS Annual Statistical and Cost Report of Nursing Facilities

Nursing Facilities Census in Minnesota

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

Medicare Days Other Days Private Days Medicaid Days

760,164187,414

4,684,476

10,023,405

923,118 884,905

2,522,949

5,706,773

5.6 Million Fewer Paid Nursing Home Resident Days

1991 2012

Source: Medicaid Cost Reports, Minnesota Department of Human Services

Freestanding Nursing Facilities by Minnesota Region

2013 Operating Margin and Medicare as % Paid Days (Median Value)

Source: 2013 LTC Imperative Nursing Facility Financial Survey Prepared by CliftonLarsonAllen LLP

Medicare as a Percent of Total Revenue for

Freestanding Nursing Facilities in Minnesota

(Median Value)

2012 Margins for Freestanding Nursing

Facilities in the United States

Source: 2013 LTC Imperative Nursing Facility Financial Survey

Prepared by CliftonLarsonAllen LLP

Source: Report to the Congress: Medicare Payment Policy. March

2014. Medicare Payment Advisory Commission (MedPAC).

Projected 2013 Shortfall:

Medicaid Reimbursement and Allowable Medicaid

CostsMinnesota vs. North Dakota

($34.44)

($0.92)

($24.26)

($40.00)

($35.00)

($30.00)

($25.00)

($20.00)

($15.00)

($10.00)

($5.00)

$0.00

Minnesota North Dakota U.S. Average

INFORMATION AND DATA ON SHORTFALLS IN MEDICAID FUNDING BASED ON REPORT PREPARED BY ELJAY,

LLC FOR THE AMERICAN HEALTH CARE ASSOCIATION

Minnesota has closed over 15,000 nursing

facility beds since 1995.

Nursing Facility Beds Continue to Drop Via

Downsizing and Closure

30.631.4

32.1

33.134.034.7

35.5

36.5

37.939.039.6

43.4

40.4

43.944.44545.245.7

30

33

36

39

42

45

48

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

March 15 of Each Year

Ce

rtif

ied

Be

ds

(in

th

ou

sa

nd

s)

Source: Minnesota Department of Health

MA-certified beds down to 30,552 in March 2012

Nursing Facility Occupancy

Source: Combined Association Occupancy Surveys, 240 Responses

Many Nursing Facilities in Rural Areas are One of Three

Largest Employers in their Community

0%10%20%30%40%50%60%70%80%90%

100%

Don't know

Not one of the three largest employers

3rd Largest Emplyer

2nd Largest Employer

Largest Employer

Source: Long Term Care Imperative 2013 Legislative Survey

The Wage Gap

Sources: 2012 LTC Imperative Salary Survey and 2012 MN Health Care Cost Information Service

Hospital Salary Data

Gap=$2.18 per hour or $4,534 per year

Gap=$5.42 per hour or $11,274 per year

Gap=$17.25 per hour or $35,880 per

year

Gap=$15.41 per hour or $32,053 per year

Gap=$2.04 per hour or $4,243 per year

Gap=$5.59 per hour or $11,627 per year

Senior Living Workers Underpaid in the Marketplace

Direct Care Staff Shortages Increasing for Nursing HomesTotal Vacant Direct Care Positions Currently Exceed 1,800

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

R.N. L.P.N. N.A.R. Total

2007 2008 2009 2010 2011 2012 2013

Source: Long Term Care Imperative 2014 Legislative Survey

Source: Minnesota Labor Market Information Office. Geographic and Industry Mobility

of New Nursing Grads, January 2014. Minnesota Employment Review. Alessia Leibert.

Geographic and Industry Mobility of New

Nursing Grads

Long Term Care Post-

Discharge Experiences

Discharge Implications

• Resident/family preference

concerns: SE MN discharge

plan options only included

transfer to swing beds 30/40

miles away. Family preference

was ignored; were wrongly told

there were no local openings.

• Current nursing facility

residents not “allowed” to

return to the “place they call

home” after hospitalization–

misinformation provided about

levels of care available in a

swing bed Vs community

nursing facility.

Discharge Implications

• Hospital discharge planners not

using complete list of options

to share with seniors/their

families;

• Transfers not explained to

family members (personal

representatives)—location of

spouse/family not taken into

account;

• Transfers out of community (30

+ miles) result in elderly

spouses not being able to

visit—quality of life issues for

seniors

Consumer Perspective

• Consumer Rights

• Consumer Perspective

• Consumer appeals

• Transfer trauma concerns

Consumer Rights

• Receive notice (orally and in writing) of proposed

discharge.

• Proper Discharge planning should result in a written

discharge plan

• Right to be informed of options and right to choose.

• Valid, written notice, using the “Important Message from

Medicare (IM). Must include discharge appeal rights.

Discharge Planning

• Section 1861 of Social Security Act: must provide list of

Medicare-certified Home Health Agencies (HHA)

• Section 1861 of Social Security Act: discharge plan

assessment. Must provide list of available Medicare

participating SNF’s that serve the geographic area he or

she requests.

• Managed care organizations (MCO): Must provide

information about (HH) and after-care hospital/post-acute

care facility extended care services available.

Appeal Rights

• Medicare Beneficiaries have a right to appeal a decision

to discontinue coverage of services

• Beneficiary should receive a Notice of Medicare Non-

Coverage from the health care provider at least two days

before the services are scheduled to end.

• Beneficiary may request an Immediate Appeal.

• Stratis Health: Medicare Quality Improvement

Organization in Minnesota. Appeal Line toll-free at 1-

866-894-1327

Possible Solutions

• Improve the education of families and consumers in

advance of hospital stay

• Consider the longer term financial implications (i.e. re-

hospitalizations) when determining post-discharge plan

• Establish a mechanism for improved community-based

collaborations

• Clarify Critical Access Hospital criteria