a publication for wisconsin’s long-term care profession by … · 2019. 4. 17. ·...

A publication for Wisconsin’s Long-Term Care Profession by WINTER 2019

Including: Election Roundup Q&A with AHCA/NCAL’s Senior Vice

President of Government Relations Clifton (Clif) Porter, II

WHCA/WiCAL Creates Survey/

Regulatory Committee to Focus on Compliance and Advocacy

Addressing Nurse Burnout in Long-Term Care

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With significant changes in store for the profession, with the Patient Driven Payment Model, the formation of new entities like Integrated Special Needs Plans (ISNPs,) trends in value based purchasing, and a multitude of other evolutionary trends that providers are experiencing every day, now more than ever it is critical for us to be in the driver’s seat of our own growth.

By working together, focusing on providing the best possible care to the residents we serve, and clearly, consistently, and effectively telling the great story that we have to policymakers, press, and the public, I am confident that the future is bright for long-term care!

KEY DATES

DATE EVENT LOCATION

March 5WHCA/WiCAL Legislative Day

Wisconsin Capitol

April 10-12WHCA/WiCAL Spring Conference

Hyatt Regency in Green Bay

June 3 and 4AHCA/NCAL Congressional Briefing

Hyatt Regency on Capitol Hill, Washington, DC

July 15WHCA/WiCAL Care Classic

Oaks Golf Course

October 23-25WHCA/WiCAL Fall Convention

Best Western Premier Waterfront Hotel and Convention Center in Oshkosh

John J. Vander Meer, MPAPresident & CEO WHCA/ WiCAL

This past Fall, I was looking through some paper copies of “Wisconsin Association of Nursing Homes” newsletters from the 1980s for background research on some remarks I gave for the presentation of Deb Klatkiewicz, a long-time WHCA Board Member and NHA at Park Manor, who was this year’s recipient of WHCA/WiCAL’s prestigious John S. Falco Award for Distinguished Service.

In one of the newsletters that I leafed through, there was an article about some of the key challenges facing Wisconsin’s LTC profession. The article pointed to the issues of reimbursement, regulations, and workforce as key challenges facing Wisconsin’s nursing homes. While much has changed since those days some decades ago, the broad challenges facing the profession remain largely the same. Yet something seems to be different this time. All of the seasoned hands that I have talked to since taking on my role as the head of the association three years ago have indicated to me that they have never seen the severity of these challenges as they are today.

While there is no question the profession faces significant challenges, I am reminded of a favorite quote that I believe applies to where we are right now in long-term care.

The great American storyteller Mark Twain, when asked by a newspaper reporter for a comment on reports that he was on his deathbed, replied: “The reports of my death have been greatly exaggerated.”

No question, Wisconsin’s LTC provider community faces significant challenges, but by working together, focusing on quality care, and ensuring that our message is delivered loudly, clearly, and effectively, I am confident that the outlook for long-term care in Wisconsin is positive.

In the past couple of years I have seen first-hand the ingenuity, caring hearts, and innovative spirits that the provider community needs to meet the challenges of the future.

WELCOME

Be sure to check out the 2019 WHCA/WiCAL Member Resource Guide!www.whcawical.org/member

Winter 2019 | CONTINUUM 3

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CAPITOL CONNECTION Election Roundup WHCA/WiCAL contract lobbyists Ramie Zelenkova and Katie White of the lobbying firm Hubbard Wilson Zelenkova provide a recap of the 2018 election, which saw Democrats sweep every statewide election, although Republicans maintained control of both chambers of the state legislature. The article also discusses advocacy looking forward to 2019.

STAKEHOLDER SPOTLIGHTQ&A with AHCA/NCAL’s Senior Vice President of Government Relations Clifton Porter IIClif Porter, AHCA/NCAL’s Senior Vice President of Government Relations, weighs in on issues important to Wisconsin long-term care providers. Topics include federal regulations on patient lift operations, the CNA training lockout, the HCBS Rule, and member advocacy at the Congressional level. Porter offers important insight from the national level.

COVER STORY The State of the LTC ProfessionWHCA/WiCAL staff discuss the current state of the profession of long-term care through the lens of the Association’s three foundational pillars – Advocacy, Education, and Excellence. It is critical as an association to acknowledge current challenges, but through the dedication of providers across the state and through a robust advocacy plan, world-class educational offerings, and an unending commitment to pursuing excellence, WHCA/WiCAL is working to position providers to succeed into the future.

LTC LEGAL LETTER WHCA/WiCAL Creates Survey/Regulatory Committee to Focus on Compliance and AdvocacyThe 2019 calendar year brings a new look and focus to Association committees. Committee efforts in the past have tackled issues related to regulatory and survey challenges, but new personnel changes at WHCA/WiCAL provide an opportunity for the newly-formed Survey/Regulatory Committee to focus completely on challenges related to compliance, advocacy, education, and review of survey and regulatory issues. WHCA/WiCAL Legal and Regulatory Advisor Brian Purtell, Chairman of the Survey/Regulatory Committee, discusses the committee’s scope and expectations.

CLINICAL CORNERAddressing Nurse Burnout in Long-Term CareDeb Martin, RN, BSN discusses the issue of nurse burnout in the long-term care profession. Nursing is both one of the most rewarding and one of the most challenging professions. Providers must be aware of the reasons for burnout and learn how to prevent it.

Winter 2019

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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 EditorJim Stoa

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EditorJohn Vander Meer

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PUBLISHED JANUARY 2019

CONTENTS

22


Democrats swept the top of the ticket on November 6th, with Tony Evers and

Mandela Barnes (D) defeating Governor Scott Walker and Lt. Governor Rebecca Kleefisch (R) 50 to 48 percent, by just more than 30,000 votes. Democrat Josh Kaul defeated Republican Attorney General Brad Schimel by a narrower margin, taking 50 percent of the vote and beating Schimel by about 17,000 votes. The race for U.S. Senate had the widest margin; U.S. Senator Tammy Baldwin (D) cruised to reelection defeating Leah Vukmir (R) 55 to 45 percent. The race for State Treasurer, an open seat, went to Sarah Godlewski (D) who took 51 percent of the vote over Republican Travis Hartwig (R) who earned 47 percent.

EVERS NAMES TRANSITION TEAM, TOP STAFFGovernor-elect Evers announced JoAnne Anton as Director of his Transition Team and Maggie Gau as his Chief of Staff. Gau served as Campaign Manager for Evers and prior to that in various legislative and campaign staff positions. Anton served in multiple roles with former U.S. Senator Herb Kohl, most recently as Director of Giving for Herb Kohl Philanthropies. The Evers Transition Team also includes:

Chuck Pruitt, a partner and co-managing director of the A.B. Data Group and former member of the UW System Board of Regents.

Amy Traynor, an Eau Claire teacher and former 2012-13 Wisconsin Middle School Teacher of the Year award recipient.

Jan Allman, the president, CEO and general manager of the Marinette Marine Corp.

Dr. Veronica Gunn, the CEO of Genesis Health Consulting, a board-certified pediatrician, and former VP at Children’s Hospital of Wisconsin.

Kevin Conroy, the chairman and CEO of Exact Sciences.

Gov-Elect Evers has begun to announce cabinet-level appointments, including Joel Brennan as Secretary of the Department of Administration, Mark Afable as the Commissioner of Insurance, Preston Cole as Secretary of the Department of Natural Resources, Kevin Carr as Secretary of the Department of Corrections, Sara Meaney as Secretary of the Department of Tourism, Craig Thompson as Secretary of the Department of Transportation, Rebeccca Cameron Valcq as Chairwoman of the Public Service Commission, and Brad Pfaff as Secretary of the Department of Agriculture, Trade, and Consumer Protection. Additional key staff and cabinet appointments will be announced in the coming weeks. The Evers transition team will include policy teams to assist with state budget and major policy initiatives over the coming months. Governor-elect Evers will formally unveil his 2019-21 budget recommendation next year. Dr. Evers will wait to resign as Superintendent of Public Instruction until

after he is sworn in as Governor, in January. He will then have the ability to appoint his replacement. If he resigned prior to being sworn in, Governor Walker could appoint his replacement. The appointee will hold the position until April 2021, or until a special election is called by the Governor.

LEGISLATIVE MAKEUP SEES LITTLE CHANGERepublicans will control the legislature for the upcoming 2019-20 session. Assembly Republicans will control the chamber 63-36. The only Dem pick-up was in the open 14th Assembly Seat, previously represented by Dale Kooyenga (R) who ran, successfully, for State Senate. The open 14th Assembly District was also the closest race of the night; Democrat Robyn Vining beat Republican Matt Adamczyk by 132 votes.Senate Republicans will control the chamber 19-14. Senate Democrats went into the election with 15 seats, but lost the 1st Senate District. André Jacque (R) beat Senator Caleb

Election RoundupBy Ramie Zelenkova & Katie White, Hubbard Wilson Zelenkova

Capitol Connection

During the 2018 Fall Elections, WHCA/WiCAL Leadership and Staff met with then DPI Superintendent, now Gov. Tony Evers (D), as well as Assembly Speaker Robin Vos (R) to talk about the state’s long-term care workforce crisis and the chronic underfunding of the state’s skilled nursing and assisted living facility providers.


Kimberly-Clark Corporation, the session instead focused on shifting some authority from the executive branch to the legislature. Outgoing Governor Scott Walker has signed the measures into law. Gov-Elect Evers said he had a conversation with Gov. Walker requesting that he veto the bills. Most notably for the long-term care sector, Act 370/Senate Bill 886 includes provisions to give the Legislature more oversight and authority over federal waiver requests, pilot programs, rate changes, and Medicaid State Plan Amendments submitted by the Department of Health Services. If there is a fiscal impact greater than $7.5 million over a 12-month period, the Department may not submit a Medicaid state plan amendment, implement a change to a reimbursement rate, or make a supplemental payment to a provider without first submitting the plan to the legislature’s Joint Committee on Finance for a 14-day passive review. Act 369/Senate Bill 884 makes a number of changes to the Department of Justice and Office of Attorney General as well as changes to other state agencies including the Wisconsin Economic Development Corporation. The bill makes a number changes to the administrative rule-making process. The agenda for the extraordinary session initially included a bill to move the presidential preference primary in 2020, but that bill failed, as did a bill aimed at protecting insurance coverage for preexisting conditions. The 2019-21 legislative session begins on January 7, 2019. Mark your calendar for March 5, WHCA/WiCAL’s “Caregiver Day in the Capitol,” as providers from across the state convene in Madison to advocate for LTC budget priorities.

The outgoing Walker administration announced on November 20th that the state will see an estimated $2.1 billion in new general purpose revenue through mid-2021. Spending requests from all state agencies for 2019-21 biennium exceed that projection by just over $1 billion. It is important to note that those requests include not only the Department of Public Instruction, but

Frostman (D) in a rematch, but this time with a different result. In June, Frostman beat Jacque 51.38 to 48.55 percent in a special election, but Jacque beat Frostman in the Nov. 6 election 55 to 45 percent. The number of votes cast in June totaled about a third of those cast in November. There will be more than a dozen new members joining the State Assembly and State Senate.

Representative Robin Vos (R) was reelected to serve as Speaker of the Assembly and Representative John Nygren (R) was reappointed to co-chair the Joint Committee on Finance.

Senator Scott Fitzgerald was reelected to serve as Senate Majority Leader, and reappointed Alberta Darling to serve as co-chair of the Joint Committee on Finance.

Democrats also decided to stick with their same leaders for next session, despite limited gains on election night. Senator Jen Shilling will lead Senate Democrats and Representative Gordon Hintz will lead Assembly Democrats.

JFC TAKES SHAPEThe Senate announced the members who will serve on the Joint Committee on Finance. Senator Alberta Darling was reappointed to serve as co-chair of the committee. The remaining Republican Senate members are Senator Luther Olsen, Senator Tom Tiffany, Senator Howard Marklein, Senator Duey Stroebel, and Senator Devin LeMahieu. The two Senate Democrats will be Senators Jon Erpenbach and LaTonya Johnson. In the Assembly, Rep. John Nygren will serve as co-chair of the committee. Other Republican Assembly committee members include Rep. Amy Loudenbeck, Rep. Mark Born, Rep. Mike Rohrkaste, Rep. Terry Katsma, and Rep. Shannon Zimmerman. Assembly Democratic members are Rep. Chris Taylor and Rep. Evan Goyke.

LAME DUCK SESSIONIn anticipation of losing the executive branch to incoming Democratic Gov-Elect Tony Evers, legislative Republicans convened a lame-duck session on Tuesday, December 4. Originally characterized as an attempt to complete an incentive package for paper product producer

Ramie Zelenkova is a partner at the lobby firm Hubbard Wilson Zelenkova and represents WHCA/WiCAL as a WHCA Lobbyist. She can be reached at [email protected].

Katie White is a contract lobbyist with Hubbard Wilson Zelenkova and represents WHCA/WiCAL as a WiCAL Lobbyist. She can be reached at [email protected].

RamieZelenkovahasoveradecadeofexperienceinlobbying,grassrootsadvocacyandlegislativeresearchandhasworkedtomaintainstrongrelationshipswithlegislativemembersonbothsidesoftheaisle.Ramierepresentsavarietyofclientsinareassuchashealthcare,long-termcare,childwelfareandeducation.Ramie’sexperienceincludesanextensivebackgroundrepresentingclientinterestsbeforetheWisconsinDepartmentofHealthServices,withparticularexperiencerepresentingMedicaidmanagedcaredeliveryinterests.SomeofRamie’srecentaccomplishmentsincludeassistinginthedevelopmentofthestate'sfirstmedicalhometosupportpatient-centeredcoordinatedcare,obtainingMedicaidcoverageforhome-basedmentalhealthservicesforchildren,passinglegislationtoprohibitinsurersfromsettingfeesfordentalprocedures,andpassinglegislationtoallowFamilyCarelong-termcaredistrictstobelicensedHMOs.

also the Department of Health Services (Medicaid), the UW System, the Department of Corrections, and portions of the Department of Transportation, to name a few. Also important to note is that agency requests are just that - requests. It is not unusual for agency spending requests to exceed expected revenues. Governor-elect Tony Evers will be sworn into office on January 7th. As Governor, he will have the final say over what goes into his 2019-21 budget recommendation, which he will submit to the legislature for consideration early next year, likely in February. He will either have to pare back agency spending requests, or find revenue uppers to make his first budget balance. It will then be up to the GOP-controlled legislature to decide if it will work from the base budget, at 2017-19 levels, or from the Governor’s budget recommendation, either way the legislature will have to make similar decisions during the budget process regarding agency budget requests and revenues. If there is gridlock between the GOP-controlled legislature and Governor Evers, a Democrat, state government doesn’t shut down if a budget compromise cannot be reached. There are certainly pressures on state government and elected officials to pass a budget, but they are not compelled to do so in the way the federal government is compelled. The 2017-19 biennium ends on June 30, 2019.


Spring Conference

April 10-12, 2019 Hyatt Regency Green Bay

Don’t miss WHCA/WiCAL’s annual Spring Conference and Exposition, where you’ll experience enriching educational offerings, professional development opportunities, fun and exciting entertainment, and valuable networking opportunities that celebrate your commitment to your residents. The diverse array of educational offerings at Spring Conference will offer the tools and knowledge you need to continue providingthe best quality care to those who need it through the hard work and innovation of long-term care providers.

Wisconsin Center for Assisted LivingWisconsin Health Care Association

Save The Dates

For more information, visit

www.whcawical.org/calendar.

Care Classic

July 15, 2019The Oaks, Cottage Grove

Be sure to join WHCA/WiCAL Members and Business Partners for the 2019 Care Classic, a fun-filled event where camaraderie takes precedence over competition, and even non-golfers are encouraged and welcomed to come and join in the fun! Be sure to attend this great WHCA/WiCAL tradition of 41 years which has raised more than $125,000 in scholarship money for family members of WHCA/WiCAL facility employees.

Fall ConventionOctober 23-25, 2019 Best Western Premier Waterfront Hotel & Convention Center, Oshkosh

WHCA/WiCAL’s annual Fall Convention offers attendees premier educational programming, networking opportunities, recreation and fellowship, and the annual Fall Convention Gold Business Partner showcase. Fall Convention’s continuing educational opportunities and professional development programming ensures that you will gain the knowledge you need to stay at the forefront of the long-term care provider profession.

Caregiver Day at the CapitolMarch 5, 2019Best Western Premier Park Hotel, Madison

The WHCA/WiCAL Caregiver Day in the Capitol will highlight the Wisconsin LTC provider community’s key challenges of the workforce crisis and funding needs through the state’s Medical Assistance programs. The event will be held at the Premier Park Hotel on the Capitol Square in Madison.


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Q&A

Clif Porter, II is the Senior Vice President of Government Relations at the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL), which represents more than 12,000 for-and not-for-

profit nursing homes, assisted living residences, and facilities for the care of people with intellectual and developmental disabilities. Porter has been serving the needs of seniors in the Long Term Care field for more than 25 years. He began his career as an Administrator in Training at a Skilled Nursing Facility in 1989 and served as Assistant Administrator and Administrator of several Skilled Nursing Centers from 1990 through 1998. Now serving as the top lobbyist in AHCA/NCAL, Porter works to promote the association’s legislative agenda.

After significant Association input, the Department of Labor has proposed a rule to ease restrictions on 16- and 17-year-old workers in healthcare settings, and in particular, the rule would allow these teen workers to operate patient lifts. Can you discuss the current status of the rule, and what providers can expect moving forward?

In 2010, the Department of Labor (DOL) passed a rule that prohibited 16- and 17-year-olds from operating power-driven patient lifts. AHCA/NCAL had many discussions with the Department explaining that the alternative—manual lifts—is much more dangerous, and this rule significantly disrupted the professional opportunities for youth interested in exploring a career in long term care. In response to our advocacy

and concerns from Congress, in 2011 DOL issued a non-enforcement policy specifying it would not assert a violation when a trained 16- and 17-year-old assisted a trained adult operating a patient lift in certain circumstances. While this non-enforcement policy was an improvement, it still left our nursing home and assisted living members without the flexibility to fully staff their younger employees. This fall, the DOL issued a proposed rule that would remove the prohibitions on 16- and 17-year-olds operating power-driven patient lift. The Department stated they are proposing this change to improve employment opportunities for youth, help alleviate the workforce shortage, and acknowledge the lack of evidence that 16- and 17-year-olds operating power lifts results in injuries. The public comment period ended on December 11, and AHCA/NCAL supports the proposed change. DOL must then review all comments and decide whether to finalize the changes. This could come as soon as Spring 2019, or the Department may wait. AHCA/NCAL will continue to advocate for and monitor this issue for the membership.

Wisconsin providers already suffering from CNA worker shortages have been hurt by a rigid CNA training lockout, where facilities that are assessed civil monetary penalties above a certain level automatically lose their authority to train CNAs for two years. With nearly 50 percent of Wisconsin facilities unable to be clinical, training and testing sites, Wisconsin Congressman Sean Duffy has introduced legislation to address this concern, and both WHCA/WiCAL and AHCA/NCAL have been involved in advocacy on this matter. Can you discuss the current status of the bill and its prospects of reaching the President’s desk?

Q&A with AHCA/NCAL’s Senior Vice President of Government Relations Clifton Porter II

Stakeholder Spotlight

The Duffy bill is an incredibly important piece of legislation related to modernizing this regulation. At one time in 1987 a $10,000 fine was very rare. Since then, the fines have grown and have now been indexed to inflation and have skyrocketed. Now you have more and more people caught in this particular dragnet around being excluded from CNA programs. That fine amount applies to any deficiencies, period. If I get a deficiency because a sprinkler head isn’t working and I get a $10,000 fine, my CNA program is virtually eliminated for two years. If there’s a history of continued violations directly related to patient care, I think it’s reasonable to say they shouldn’t be teaching a CNA class. That makes sense. But to say that any deficiency, even those that are entirely unrelated, eliminates a facilities ability to train nursing assistants is well past its course. What the Duffy legislation does is essentially rationalize that.

At the end of the day, any fines eliminate the ability for a center to train nursing assistants, particularly in labor markets like Wisconsin and many other rural areas across the country.

This Congress is over January 1, so this bill is not going to the President’s desk this year. We are actively working with the Ways and Means Committee, as well as leadership on both sides of the aisle, to reintroduce and move this bill next year. I’m optimistic about our chances to get this passed.

What can WHCA/WiCAL members expect regarding the provider community’s continued advocacy to review and revise the broad-reaching Requirements of Participation?

The most important thing providers can


Continued on Pg. 16

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do is invite their member of Congress to their facility and sit down with them to walk through an admission of a patient. I really do think there should be an emphasis on educating members on how and why the regulatory environment we live under is constricting. It can take three hours to complete nurse assessments, filling pharmacy orders, requesting lab work, etc. It will be an enlightening experience for them. It’s also important to really sensitize folks, in particularly, in rural markets where labor is a real problem, to sit down and explain to them why it’s a problem because we are competing with the hospital down the road. They need to see those real-world problems firsthand. The things we have asked for in the ROP are more than reasonable. We have not asked for regulations to be eliminated. We have asked for six percent of the regulations to be amended and changed since they are unnecessary, outdated and duplicative. 94 percent of the regulations we’ve accepted.

What can WHCA/WiCAL members do to help advance these important policy priorities?

The most important advocate is the one at home for the member of Congress. Our team represents our Wisconsin operators in DC. But when members of Congress hear about a problem from people at home firsthand, there’s absolutely a different sense of urgency that that legislation or concept has when it comes back to DC to be worked on. When someone from Pewaukee, Wisconsin says, “Come to my facility to see how all this regulatory burden takes away from patient care, and on top of that Amazon just opened a warehouse and is paying 15 bucks an hour. We have real problems here congresswoman or congressman, and this is one way to help us,” that kind of explanation and advocacy is vital because we are then the echo of, as an example, Pewaukee, versus the other way around. A great example of local advocacy at work is what happened with the Duffy legislation. John Vander Meer and his

team elevated the issue to us and said that Duffy was interested. We endorsed it and worked with them and continue to work to advance this legislation.

Could you provide an update regarding any traction AHCA/NCAL has received on limiting the impact of onerous provisions for assisted living and skilled nursing facilities included in the federal Home and Community-Based Settings Rule?

Over the past couple of years, AHCA/NCAL has had several face-to-face meetings with CMS staff discussing our concerns with the rule. We have also had meetings with senators, congresswomen, and congressmen about our concerns and supported them sending a letter to CMS requesting more information on the rule’s implementation. From our advocacy, we’ve seen statements from CMS confirming that assisted living communities and memory care are not automatically institutional and should be given a fair review. We’ve also seen CMS push back the implementation deadline to 2022 and begin providing more technical assistance to states to ensure they are appropriately implementing the rule. NCAL also collaborated closely as a member of the Center for Excellence in Assisted Living to create a summary of best practices on secured egress, which was instrumental in CMS’s additional guidance. Currently, AHCA/NCAL has voiced concerns with the heightened scrutiny review process, and CMS has stated that new guidance should be published soon. The Association also works closely with all our state affiliates, including WiCAL, to connect them with resources and information to support their advocacy with the state.

While much of our federal advocacy work more directly affects skilled nursing facilities, what would you say to Assisted Living providers who are interested in getting more involved at the federal level?

The critical thing to keep in mind is this: we have an aging boom that’s


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The WHCA/WiCAL PAC gives members the opportunity to join together and raise awareness about the long-term care profession. The 2018 election cycle brought many new faces to the state legislature, and a new governor to the East Wing of the State Capitol.

But thanks to the WHCA/WiCAL PAC’s strategic giving plan, long-term care providers are in a strong position to advocate with established legislative leaders, along with new allies.

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MAKE YOURVOICE HEARD

Contribute Today!

Help us reach our goal of $20,000!

The WHCA/WiCAL PAC gives members the opportunity to join together and raise awareness about the long-term care profession. The 2018 election cycle brought many new faces to the state legislature,

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The State of the LTC ProfessionBy WHCA/WiCAL President & CEO John Vander Meer, WHCA/WiCAL Director of Quality Advancement and Regulatory Affairs Tina Belongia, and WHCA/WiCAL Director of Public Affairs Jim Stoa

Wisconsin’s long-term care providers continue to experience an unprecedented caregiver workforce crisis which has led to 1 in 5 caregiving positions remaining vacant. Census continues to be of grave concern to many facilities who find they are unable to fill their beds, or that they cannot accept new admissions due to low staffing levels. A sobering consequence of the current environment for long-term care providers in Wisconsin is that since 2016, 19 skilled nursing facilities and more than 100 assisted living centers have closed their doors. Many feel the pressures of a changing landscape.

Long-term care providers, in their unwavering dedication to serving our state’s most vulnerable populations, remain steadfast in their dedication to residents, staff, and local communities.

We view our successes – and opportunities for growth – through the lens of our provider members, who deserve and demand effective strategic advocacy efforts, informative and timely education opportunities, and resources to advance care excellence.

ADVOCACYOne of the most important methods of promoting the interests of long-term care providers and the residents we serve is by sharing the stories of the long-term care provider community with local and state elected officials, as well as other stakeholders, to ensure they understand the challenges involved with reimbursement, the long-term care workforce shortage, and other issues.

During the 2017-19 legislative session, long-term care providers played a pivotal role in many legislative successes, most notably a state budget which included a 2% increase in each year of the biennium for SNF Medicaid reimbursement and a $60 million (all funds) increase for Family Care over the biennium.

Legislative successes do not just happen. Long-term care providers came together and executed

Cover Story

Article II, Section 3 of the United States Constitution states that the president

“shall from time to time give to the Congress Information of the State of the Union, and recommend to their Consideration such measures as he shall judge necessary and expedient.” In the same spirit, Article V, Section 4 of the Wisconsin State Constitution requires the governor to “communicate to the legislature, at every session, the condition of the state…”

‘State of the Union’ and ‘State of the State’ addresses have been used as platforms for many state and national leaders to lay out ambitious agendas. The addresses also offer an opportunity for thoughtful contemplation of past accomplishments or shortcomings, and to consider solutions for the future.

They are at once both reflective and forward-looking.

WHCA/WiCAL’s bylaws include no such provision. But as we approach a new state budget cycle, and as we consider how the past years have shaped the landscape of our profession and, in turn, realigned our goals and ambitions for 2019 and beyond, your association wants to provide members and stakeholders our own analysis of the State of the Profession of Long-Term Care.

ADVOCACY. EDUCATION. EXCELLENCE.You’ve seen these words under the WHCA/WiCAL logo. These three words serve as the pillars of our foundational mission – what we do as an association to ensure long-term care providers have the resources and the platform to continue providing high quality care to Wisconsin’s frail elderly and disabled citizens.

As we view the state of our profession through the perspective of providers, it is important to acknowledge current challenges that sometimes may seem insurmountable.


discussions with members of Wisconsin’s Congressional Delegation on needed regulatory changes, including Congressman Sean Duffy introducing legislation to stop the CNA training lock-out, which bans facilities from being training, testing and clinical sites; as well as the introduction of a federal rule reversing the policy restricting the ability of minors to operate patient lifts.

Member-driven outreach:Central to WHCA/WiCAL’s advocacy efforts is engaging and mobilizing members to stay informed and get involved. Your association has developed a legislative outreach clearinghouse web page, which includes the resources you need to contact your legislators. For more information, visit www.whcawical.org/statebudget.

While we encourage an ongoing dialogue with your local elected leaders, please mark your calendars for these important consolidated outreach efforts:

2019 Caregiver Day at the Capitol – March 5, Best Western Premier Park Hotel, Madison

2019 Congressional Briefing – June 3-4, 2019, Hyatt Regency, Washington, DC.

EXCELLENCEThe legendary coach of the Green Bay Packers, Vince Lombardi once said: “Perfection is not attainable, but if we chase perfection, we can catch excellence.”

With the changes that are well underway in the area of quality advancement for Wisconsin’s skilled nursing and assisted living facilities – the time to chase perfection is now, more than ever.

The bottom line in this world of quality metrics, readmissions, the Patient Driven Payment Model (PDPM), bundled payments and a litany of other changes – all facilities must have a laser-like focus on their internal quality metrics and survey compliance, or they put themselves at serious risk of being left out of provider agreements and alternative payment systems.

National Quality Awards:The AHCA/NCAL National Quality Award Program provides a pathway for providers of long-term and post-acute care services to journey

a disciplined, holistic outreach plan to make sure that legislators from every corner of the state knew of the importance of investing in the future of long-term care.

State budget.WHCA/WiCAL is confident that success from the last biennial budget cycle will serve as a springboard for the upcoming legislative session. As a result of buy-in from other associations, we believe we are in a strong position to advocate for Skilled Nursing Medicaid reimbursement reform and a sustained increase to Family Care, joined on a united front with other voices of Wisconsin’s provider community.

Our 2019-21 state budget request includes our best recommendation to address the ongoing long-term care workforce crisis, which has only worsened. A recent survey of Wisconsin’s LTC providers found that 1 in 5 caregiver positions is vacant, up from the survey’s findings of 1 in 7 caregiver vacancies in 2016. While we don’t need to explain to our members the depth of this crisis, we continue to impress upon legislators the dire need to address Wisconsin’s long-term and post-acute care workforce shortage.

Family Care Payment Reform: WHCA/WiCAL, along with a coalition of long-term care provider associations, is requesting $61.7 million GPR in the 2019-21 biennial budget for a fixed-amount increase to direct care and services for Family Care managed care organizations (MCOs). We have requested that these funds be allocated directly to care and service providers, which will allow providers to increase caregiver wages. To reflect the state’s continuing commitment to the Family Care program, the $61.7 million GPR would build on the direct care workforce funding provided in the last budget that we are asking to be included in the base of the 2019-21 biennial budget.

SNF Workforce Payment Reform Policy:WHCA/WiCAL’s joint SNF Medicaid reimbursement budget ask includes requests to:

Fund the Nursing Facility Direct Care - Nursing Target at the Median.

Increase the Nursing Facility Direct Care - Other Target by $5 per Resident Day.

Increase the Support Services Target by $5 per Resident Day.

Increase Funding for Four Nursing Facility Labor Regions to the Statewide Direct Care Target (Rural Counties; Brown/Kewaunee/Oconto Counties; Eau Claire/Chippewa Counties; and Fond du Lac County).

Provide a 4.5% Inflationary Increase in the 2nd Year of the Biennium 2020-21:

Include a budget provision to protect LTC funding - if the SNF-FFS Medicaid actual spending is less than the amount authorized by the 2019-21 Biennial Budget Act, the difference shall be added to the authorized nursing facility funding increase approved for the subsequent fiscal year.

Policy.A new political landscape in Madison requires long-term care providers to evaluate new opportunities and challenges. WHCA/WiCAL has worked to build and grow relationships with legislators and leaders on both sides of the partisan divide, and we believe we are well-positioned to help policymakers understand the need to come together to support key policy priorities of long-term care providers.

CNA Training Bill:Outside of budget priorities, WHCA/WiCAL’s top legislative priority from last session was to align Wisconsin’s CNA training hourly requirements with the federal standard of 75 hours. Despite getting the bill through the State Assembly on two separate occasions, the proposal ultimately died on the floor of the State Senate. With broad support in both houses, and with a statewide grassroots network of support, we are hopeful that leaders from both parties will see the value in helping to address the long-term care workforce shortage through this policy change.

Agency Staffing Fairness:WHCA/WiCAL’s government affairs team has already held productive meetings with legislators who are interested in implementing a policy to limit the disparity between staffing agency costs and what they pay workers. In a period of great need for frontline caregivers, this proposal would help employers find new workers without having to pay exorbitant costs.

Federal policy:WHCA/WiCAL continues productive Continued on Pg. 18


Stakeholder Spotlight Continued

instinctive responses to these one-off issues that may occur.

We also need to be out there making sure we are delivering quality. We need to be out there delivering on outcomes. We need to be out there decreasing hospitalizations, decreasing the use of antipsychotic drugs, and managing pressure ulcers and healing them in our facilities. We need to be doing all the things we are already doing and doing it well.

At the end of the day, if our quality is solid and improving, we are in a much better position to deal with any attack. Because even on the one-off situations we can say that’s horrible, that’s a problem, and it needs to be addressed, but that IS the exception, not the rule. Here’s the rule, and here’s the data that shows we ARE improving.

Can you offer a preview of the 2019 Congressional Briefing, held June 3-4 in Washington, DC?

Congressional Briefing will be increasingly focused on the challenges that operators are focused on in the marketplace. Real world, real-time examples. In prior years we were dealing with pieces of legislation threats that were in our face that required immediate attention. This coming year the focus will be telling our story and making sure that members of Congress completely understand the operating environment that we are in and that we continue to build what I like to call the “railroad infrastructure” to bridge our sector from today into the future. It’s a long view, and we need to continue to tell that story so that we are viable for when those years come. Because the real question is how we remain viable near-term and try to create stability for the long term. So it will be less of a reactive Congressional Briefing based on immediate threats and more of an environmental overview of where we are, why we are here, and why we need to continue to incrementally work on building a long-range future for our sector.

occurring in our country, and it will be initially felt in the less regulated areas of aging services – i.e., independent and assisted living. We are seeing a proliferation of development of both independent, assisted living and memory care facilities across the country. These are privately developed and usually privately funded. There also, as folks well know, is a component of Medicaid in certain states that fund certain assisted living programs. The reality that we need to be very vigilant and mindful about is that as this proliferation occurs, there will be an increasing appetite to regulate these entities and to control or influence the growth of these types of facilities even at the local level.

The question really boils down to will our operators get ahead of the game and prevent an assisted living construct on the regulatory side that looks like a skilled nursing facility. Assisted living doesn’t want that to happen because one, it impedes resident care and two, and more importantly, it costs a lot of money to comply with those regulations.

I think the main thing that AL providers need to understand is that there is always a bad story in the country. That story will be leveraged to push and advance some regulatory construct. Our message has been simple - the states should regulate these entities, and they do, and they should continue to do so. Frankly, a state-based solution for an assisted living facility is more precise than a federal one. The states should be vigorous in their oversight of assisted living facilities. Most states have regulations related to assisted living facilities that they have to comply with. They have a survey process, etc. This is the kind of arrangement you don’t want the federal government involved in.

The key message here is to let the federal legislators know that there is a state construct in place, what that looks like, and proactively educate them about the measures and protections that are in place from a policy perspective to protect residents.

Now that the 2018 election results are in the books, how will the change in the composition of Congressional make-up affect the shared priorities of AHCA/NCAL and WHCA/WiCAL?

The Association and our members in Wisconsin have done an excellent job building and establishing relationships with members from both sides of the aisle.

A couple of things I’d like to underscore. The appreciation and understanding of the Medicaid program is a much higher priority with the Democrats. I don’t really see the exercise we went through in 2017, when there were some proposed significant changes to Medicaid, as a massive risk for us in 2019. Simply because we have a Democrat House that gets it. They are going to protect Medicaid, and in protecting Medicaid, our members’ interests will be protected. But there will be a lot of other pressures. There will likely be pressure around more regulations coming out of the House than what we experienced with the Republicans.

We are going to have more work to do with our members of Congress, particularly with the Democrats, to understand our regulatory constructs. We also need to be clear about all of the challenges we are facing. So this isn’t really about a Republican or Democrat message.

When we have new leadership and a new committee chairman, our job to educate becomes more urgent. We need to get out there and educate these new Democrat members, leaders and committee and sub-committee chairman that are now the majority. They need to understand workforce challenges. And they need to understand that our margins, according to MedPAC, are 0.7 percent. They need to understand the regulatory construct. They need to understand the survey constructs. They need to understand it all. And we need to bring them up to speed quickly so that when these pressures arise, which they will, policies are not rushed, and there are some thoughtful, rational policies instead of


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toward performance excellence. The program is based on the core values and criteria of the Baldrige Performance Excellence Program.

Member centers may apply for three progressive levels of awards: Bronze—Commitment to Quality, Silver—Achievement in Quality, and Gold—Excellence in Quality. Each level has its own distinct rigors and requirements for quality and performance excellence.

Three Wisconsin centers were recognized in 2018 for their quest for quality. These centers embraced the Baldrige framework and recognize the importance of systematically identifying both organizational strengths and key opportunities for improvement. They are using the information to improve work processes and achieve higher levels of performance – which are both necessary in our highly competitive market. Our 2018 National Quality Award winners were Avanti Health and Rehab (awarded the Bronze Award), Hope Senior Living (awarded the Bronze Award), and Columbus Health and Rehab (awarded the Silver Award). They join 13 other member centers as “active” Quality Award recipients.

AHCA/NCAL Quality Initiative:The AHCA Quality Initiative is a national, multi-year effort to further improve quality of care in America’s long-term and post-acute care centers. Since the launch of the Initiative in 2012, members have been challenged to meet measurable targets in key areas such as hospitalizations and antipsychotics usage. While significant improvements have been made, more must be done. The next phase of the effort continues to challenge providers to achieve quantitative results in four areas by March 2021. These areas are top priorities for the Centers for Medicare & Medicaid Services (CMS), Accountable Care Organizations (ACOs) as well as Managed Care Organizations (MCOs) and are aligned with federal mandates that link financial outcomes to quality performance.

WHCA/WiCAL Quality Committee:The WHCA/WiCAL Quality Committee is made up of members with diverse backgrounds. This group of dedicated operators, clinicians, and business partners will be tasked with promotion of the National Quality Awards, along with the following Quality Initiatives:

Hospitalizations: Hospitalizations have the potential for negative physical, emotional, and psychological impacts on individuals in skilled nursing care and cost the Medicare program millions of dollars. This issue is the foundation of the Skilled Nursing Facility (SNF) Value Based Purchasing (VBP) Program, a CMS e¬ffort that links financial outcomes to quality performance starting on Oct. 1, 2018. GOAL: Safely reduce long-stay and short-stay hospitalizations by improving 10%—or maintain a rate of 10% or less.

Customer Satisfaction: The happiness and peace of mind of patients, residents, and their families is paramount to skilled nursing care providers. Measuring and reporting satisfaction can help nursing centers identify and improve resident outcomes and organizational success. GOAL: Improve long-stay and short-stay satisfaction by 10%—or achieve a rate of >90%.

Functional Outcomes: The Medicare Payment Advisory Commission (MedPAC), the IMPACT Act, and CMS all called for the development of functional improvement measures based on the self-care and mobility sections of the Continuity Assessment Record and Evaluation (CARE) tool. Maintaining or improving mobility and self-care abilities is important to healthy aging and maximizing independence. GOAL: Improve functional outcomes (self-care and mobility) by 15%.

Antipsychotics: The use of antipsychotic medication to treat behavior associated with dementia is not supported clinically and is considered off-label by the FDA. Antipsychotics increase the risk of death, falls with fractures, hospitalizations and other complications resulting in poor health and high costs. GOAL: Safely reduce the off-label use of antipsychotics by 10%—or maintain a rate of 8% or less in long-stay residents and maintain a rate of 1% or less in short-stay residents.

Skilled Nursing Centers:Although Phase II of the SNF Requirements of Participation became effective Nov. 28, 2017,

many centers felt the effects well into 2018. Centers developed new processes related to transfers and discharges and baseline care plans. They worked countless hours completing a facility assessment and developing a Quality Plan. On top of these major changes impacting centers, SNFs were also faced with a new comprehensive survey process. Wisconsin SNFs rose to the challenge and have worked tirelessly to adapt and overcome.

As of the end of the third quarter of 2018, Wisconsin SNFs were averaging 5.2 citations per annual recertification survey, as compared to a national average of 6.58.

Although WHCA/WiCAL staff have heard from members that the lack of daily exits and communication in the first few days of the survey has been stressful, centers relay that surveys have been more resident-focused versus documentation focused. Centers that utilize the resident initial interview and observations, as well as the long-term care survey pathways, have reported a sense of strong survey readiness. Centers also report utilizing these tools as part of their routine quality improvement efforts.

In February of 2018, because of the change to the new survey process, CMS froze all centers’ survey rating scores to allow sufficient survey results to accumulate from the new process surveys. This left all centers with a rating derived from results from the two most recent standard surveys prior to Nov. 28, 2017, as well as deficiencies arising from complaint investigations during the two-year period prior to Nov. 28, 2017. CMS intends to update the survey ratings of all facilities in the spring of 2019.

Another change that impacted SNFs was the transition to Payroll-Based Journal (PBJ) staffing data used on NHC and the Five-Star Quality Rating System. The following measures on NHC are now routinely updated based on PBJ data submitted from centers:

Physical therapist hours per resident day RN hours per resident day Total nursing hours per resident day

(RN + LPN + nurse aide hours) RN staffing star rating Staffing star rating Overall Five-Star rating

With the update to how the staffing rating is calculated, AHCA reported that 46.8% of centers across the nation saw a change in the RN staffing

Cover Story Continued


Continued on Pg. 26

star rating and 47.1% of centers saw a change in the staffing star rating. For both the RN staffing rating and the staffing rating, approximately half of centers gained one or more stars and half lost one or more stars. It is important that centers continue to monitor their staffing levels closely, submit their staffing data timely, and run validation checks on the submitted data to ensure the posted staffing rating adequately reflects the staffing situation in the center.

Assisted Living Centers:On the Assisted Living front, membership in WiCAL’s PEAL program (Performance Excellence in Assisted Living) is up 15 percent. This increase is a testament to our members’ quest for continuous improvement and customer-driven focus. PEAL is a voluntary quality initiative program open to all WiCAL members.

Participating facilities receive training and educational tools in recognized performance excellence and quality improvement processes. PEAL members are also a part of WCCEAL (Wisconsin Coalition for Collaborative Excellence in Assisted Living). WCCEAL is a group of dedicated people organized to improve the outcomes of individuals living in Wisconsin assisted living facilities including Community Based Residential Facilities (CBRF); Residential Care Apartment Complexes (RCAC); and Adult Family Homes (AFH).

The WCCEAL program is gaining national attention and is expected to continue to gain significance, having received a substantial grant award to further the project from the Wisconsin Partnership Program, designed to support and extend innovative health projects.

DHS is proposing a financial incentive for MCOs in an attempt to develop the Assisted Living-MCO provider network and encourage certified assisting living communities to focus on quality improvement. The proposal would still need approval from CMS and includes a budget of 0.1% of the Pay for Performance (P4P) budget (approximately $2.1 million). The incentive would be a two-prong approach giving an incentive to the MCO based on the number of members who are residing in:

An Assisted Living Center (ALC) that qualifies for an abbreviated survey and is compliant with HCBS setting rules. To be eligible for an “abbreviated survey” an ALC must be licensed for three years, have no enforcement action for

three years, and have no substantiated complaints in three years.

An ALC that is a member of WCCEAL (Wisconsin Coalition for Collaborative Excellence in Assisted Living) and is in good standing in the program.

The incentives would be determined by pulling a listing of all MCO members (residents) living in certified ALCs in the state of Wisconsin. This list would be pulled on a random date (most likely during the mid-year). Once this list is pulled, the incentive will then be calculated based on the following:

DQA report showing ALCs that qualify for an abbreviated survey

WCCEAL report showing ALCs in “good standing”

HCBS Residential Setting report showing ALCs in non-compliance

DMS reports for validation

While we would rather see the incentive payments be directed back to the participating assisted living centers, we are encouraged by the continued focus on quality in assisted living centers and know that our members will continue to strive to deliver outstanding care to the people they serve.

EDUCATIONAs LTC facilities prepare for the challenges of 2019, a core mission of WHCA/WiCAL is to ensure that the association provides effective, engaging, and affordable educational offerings that prepare our member facilities for the issues they face in the coming year.

In 2018, WHCA/WiCAL was pleased to hire Tina Belongia, WHCA/WiCAL Director of Quality Advancement and Regulatory Affairs. Belongia has served at every level of clinical regulatory operations and LTC nurse consulting in long-term care in Wisconsin during her career. Over a career that has spanned the continuum of clinical operations, Tina has represented dozens of buildings all across the state of Wisconsin. She is familiar with every survey region in the state, has significant expertise and familiarity with state and federal regulations, and can provide members with key strategic guidance related to clinical matters, the survey process, and the long-term care sector as a whole.

In order to ensure that the association is helping members prepare for the key operational, clinical and

regulatory challenges, WHCA/WiCAL has placed Tina in charge of the development of the association’s educational curriculum, including webinars, regional workshops, one-day sessions, and our session agendas for Spring Conference and Fall Convention.

Season TicketFor the third year in a row, WHCA/WiCAL will offer the Season Ticket Package, a benefit exclusively available to member facilities. This package provides a comprehensive and multi-disciplinary approach to all of the topics that skilled nursing and assisted living centers will need in the new year.

The 2019 Season Ticket includes the following educational offerings:

Emergency Preparedness: Plan It, Test It, Be Ready!

Understanding & Preparing for the Patient Driven Payment Model (PDPM)

The 3rd Annual Quality Symposium Annual WHCA/WiCAL Survey Update

Workshops

Each of these educational offerings is selected by and determined with the review and consideration of members of the WHCA/WiCAL Education Committee. The Education Committee is a member-driven committee designed to provide concrete feedback on which educational topics are most useful to members, and provide input on the presenters and learning objectives most relevant to Wisconsin’s LTC provider community.

For more information on the Season Ticket Package, or any of these individuals educational offerings go to: www.whcawical.org/seasonticket.

Emergency Preparedness:The first installment of the Season Ticket is a three-part Emergency Preparedness webinar series. During this series, WHCA/WiCAL’s invited speakers and presenters will provide all the necessary background on the emergency preparedness rule, introduce and conduct a tabletop exercise scenario, and evaluate facilities on their performance in the


SEASON TICKET PASS



SECTION 1 SEAT 1ROW 1

SEASON TICKET PASS



The 2019 calendar year brings a new look and focus to Association

committees. Certainly, there have been committee efforts toward regulatory and survey related issues. But personnel changes within the Association, notably the addition of Tina Belongia as Director of Quality Advancement and Regulatory Affairs, bring new opportunities for committee realignment. Tina now oversees the Quality Committee, tasked with advancing care quality and current standards of clinical practice within member facilities. The Quality Committee’s sole focus on quality advancement provides a new opportunity for a new Survey/Regulatory Committee, which will focus directly on survey and regulatory compliance issues.

COMPLIANCEThe committee will conduct regular review of survey statistics and related data to identify increasing or recurring compliance issues, with a goal of communicating this data to members as well as exploring means and methods for member facilities to address the most problematic survey compliance issues.

EDUCATIONEfforts will include providing recommendations to the Education Committee for programming for Spring Conference and Fall Convention, as well as recommending or developing regional workshops to assist members in their survey preparation and compliance efforts.

REGULATORYWhile the focus will lean heavily toward survey compliance issues, the committee will also tackle pressing regulatory issues affecting member facilities. As there are frequent opportunities for comments on proposed regulations or revisions on both the state and federal level, participants will weigh the

at this meeting where CMS officials, state survey agencies, ombudsman, and state association representatives meet to dialog on nursing home issues. Survey, Life Safety Code, and managed care issues are the frequent topics discussed at these meetings, but association personnel will look to the Committee members to shape the agenda and issues of greatest interest for this unique opportunity to dialog with CMS regional and central office personnel.

Committee sub-groups will be developed as needed to work collaboratively during the below dates. The Committee encourages any and all members to join and participate in this important committee.

FEBRUARY 26Survey/Regulatory Committee Held via Teleconference. 11:00 a.m.

APRIL 30Survey/Regulatory Committee Held via Teleconference. 10:00-11:00 a.m.

AUGUST 27Survey/Regulatory Committee Held via Teleconference. 10:00 a.m.

DECEMBER 3Survey/Regulatory Committee Meeting In-Person. 10:00 a.m.

Members interested in participation can learn more or sign up for the Committee by emailing [email protected].

need for input – and at what level – as well as assist in the development of submitting formal comments in the rulemaking process on behalf of the Association.

As an example, it is anticipated that in early 2019, CMS will release proposed modifications to the nursing home Requirements of Participation. The publication of the anticipated proposed changes will trigger a public comment period. The Survey/Regulatory Committee will be the vehicle for review and reaction to these anticipated changes. Depending on the content, Association comments will be developed to support, oppose or request modification to the proposed regulations. It may be necessary to encourage and guide individual members to submit comments also, and the Committee will be instrumental in providing guidance and suggested content for members to aid in such a submission.

SURVEYThe charge of the Committee is further to develop and seek reform to the survey and enforcement process. Big picture type changes are needed, with active and engaged members needed to formulate concrete changes that can help ease the draconian survey and enforcement process while assuring proper regulatory oversight. Such change requires strategic efforts and certainly the current administration in Washington represents a potential opportunity to deviate from “the way it has always been done…”

ADVOCACYFinally, the Committee is expected to provide feedback both following and in advance of the association’s annual participation in the CMS Region V meeting held in Chicago in the month of December. WHCA/WiCAL once again represented Wisconsin’s facilities and remains vocal

Brian Purtell is the Legal and Regulatory Advisor for WHCA/WiCAL. He can be reached at [email protected].

WHCA/WiCAL Creates Survey/Regulatory Committee to Focus on Compliance and AdvocacyBy Brian Purtell, WHCA/WiCAL Legal and Regulatory Advisor

LTC Legal Letter


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The profession of nursing is one of the most difficult professions in the

world. No matter what area of practice you choose, others are regularly making demands on your time, your knowledge, and your expertise. This can become overwhelming and at times make you question your choice and true mission. In general, we need to be aware that on occasion, it may seem overwhelming and we may question the profession, but we must not allow it to become unmanageable and to affect our well-being.

The long-term care profession can be one of the most rewarding areas to practice, as well as one of the most stressful. There are multiple demands placed not only from the ones we are caring for, but from the families and loved ones of our patients and residents. In long-term care, patients are requiring assistance physically and cognitively around the clock. These demands, along

with multiple other factors, can lead to a feeling of burnout.

For long-term care providers, it can be hard to hang onto a good nurse. According to a 2014 report from McKnight’s, the turnover rate in long-term care is a significant problem, ranging from 55% to 75%.

Why are nurses leaving? For lots of reasons, including lack of a strong career path, the desire for a fresher, more exciting environment, and not enough personal and professional development. However, three out of four nurses cited the effects of stress and overwork as a top health concern in a 2011 survey by the American Nurses Association.

So what exactly is burnout? Burnout is a state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that has failed to produce

the expected reward. People most likely to burn out are those who are the most “dedicated and committed to their positions, have poor work/personal life boundaries and who have an over-excessive need to give.”

Let’s take a moment and look at the definition of burnout:

“Devotion to a cause” Nurses are extremely devoted individuals who possess a passion for caring and strive to make their caring attitude a “way of life”. There are times that that devotion and caring attitude is not being rewarded to the extent that is needed to refuel that passion.

Nurses have a “dedicated and committed” attitude toward their jobs and the people that they care for. Nurses are innately ‘givers”.

Addressing Nurse Burnout in Long-Term CareBy Deb Martin, RN, BSN, Account Executive CE Solutions

Clinical Corner

Continued on Pg. 24


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With all of those characteristics that nurses possess, is there any question why the turnover rate is 55-75% in long-term care? These factors make it very important to recognize the characteristics that exist in nurses and implement measures to identify and decrease burnout for your staff.

Impact of Burnout to the Long-term care organization:

According to a 2017 study by RNnetwork, 70% of nurses reported feeling burnt out, and half have considered leaving the profession. Long hours and high stress were reported as factors. Low nurse morale has a negative impact on the overall culture of the organization. As a nurse leader, feelings of burnout will be passed along to the staff they are supervising which in turn will contribute to additional staff turnover.

There is also a financial impact of staff burnout to the organization. The Center for American Progress estimates that the cost of replacing an employee is approximately 20% of their annual salary. Preventing staff burnout and turnover presents a financial advantage to an organization. Lack of stable staffing is definitely a factor in employee and patient satisfaction.

Often, the result of fatigued staff who are feeling burnout can lead to errors in patient care and an increase in patient accidents.

Signs of staff stress and burnout: Lowered enthusiasm for the job Avoiding social activities Withdrawing from work

committees Missing scheduled shifts Requesting to leave early Increase in complaining Disagreements with co-workers

Research conducted by a team at Ball State University found that out of a group of 120 nurses working in the Midwest, the majority reported poor health habits as well as high levels of stress.

Ninety-two percent of the nurses surveyed said their stress levels ranged from moderate to very high. When it came to managing that stress, 78% said they failed to get the recommended eight hours of sleep per night, while many also reported not exercising regularly (69%) and binge drinking (22%).

The study also found when nurses were confronted with workplace stress, many ate more junk food (70%) or used food as a coping mechanism (63%).

Unsurprisingly, the nurses who had the highest levels of stress but the poorest coping mechanisms had the worst health outcomes and highest health risks than those in other groups, said lead researcher Jagdish Khubchandani, Ph.D.

HOW TO ASSIST STAFF WITH COPING WITH STRESS AND AVOIDING BURNOUT.Prevention and early identification of signs and symptoms is key to avoiding burnout and promoting a healthy environment for your nurses, staff, and patients.

Teach self-care strategies and make wellness a priority with your staff. Ideas include:

Develop a wellness committee which is in charge of promoting healthy habits. Include promotion of physical wellness and mental wellness.

Schedule team-building activities

to help staff have a feeling of belonging and cohesiveness.

Check in with staff to ensure they are doing well physically and emotionally.

Organizational measures to decrease burnout and facilitate wellness can include:

Training – offer staff education on a routine basis. This enables them to have the knowledge to handle and embrace patient care opportunities that they are presented with.

Hiring Practices – Evaluate your interviewing process to ensure that the person is a good fit for the job they are being considered for.

Scheduling - schedule shifts to avoid long stretches of working overnights, break up 12 hours shifts into 6 hour shifts to facilitate family time and rest.

Employee Recognition - routinely recognize staff for their dedication and passion

Benefits - low pay is tied to high turnover. When possible, offer retirement plans and health benefits.

Employee focus programs - Arrange access to exercise options, health screenings, smoking cessation programs, and professional development opportunities.

Employee feedback - make regular employee reviews a priority to discuss job performance and to review personal goals.

Deb Martin RN, BSN is an Account Executive for CE Solutions. Deb started out her nursing career in the NICU. She also was a Sales Account Executive with a

leading pharmaceutical company and a Director of Nursing at a Skilled Nursing Facility for 10 years.

“As a Nurse, we have the opportunity to heal the mind, soul, heart and body of our patients, their families, and ourselves. They may forget your name but they will never forget how you made them feel.”-Maya Angelou

Clinical Corner Continued


2018 - 2019“a commitment to care”

GOLDGOLDBUSINESS PARTNERS

ELITE BUSINESS PARTNERS

CE SOLUTIONS1111 W. San Marnan DriveWaterloo, IA 50701(866) 650-3400Deb [email protected]

M3 INSURANCE828 John Nolen DriveMadison, WI 53713(608) 288-2740Chris [email protected] Pat [email protected]

MARTIN BROS DISTRIBUTING6623 Chancellor DriveCedar Falls, IA 50613(608) 343-3194Christy Edwards [email protected] [email protected]

MCKESSON MEDICAL SURGICAL8121 10th Avenue NorthGolden Valley, MN 55427(800) 328-8111Kristen [email protected]

NAVIGATOR GROUP PURCHASING, INC.25-A Vreeland RoadSuite 200Florham Park, NJ 07932(800) 642-3020Laurie [email protected]

SPECIALIZED MEDICAL SERVICES, INC.5343 N. 118th CourtMilwaukee, WI 53225(414) 476-1112Steve Marshall [email protected]

WHCA/WiCAL Service Corporation131 W. Wilson StreetSuite 1001Madison, WI 53703(608) 257-0125Jena [email protected]

WIPFLI LLP10000 Innovation DriveMilwaukee, WI 53226(414) 431-9300Larry Lester llester@wipfl i.comwww.wipfl i.com

PRIME BUSINESS PARTNERS

ENERGY PERFORMANCE LIGHTING 243 Bonnie Road Cottage Grove, WI 53527(608) 661-5555 X205Rodney Heller LC, CLEPrheller@energyperformance.netwww.energyperformancelighting.com

SELECT BUSINESS PARTNERS

ARTHUR J. GALLAGHER RISK MANAGEMENT SERVICES 245 S Executive DriveSuite 200Brookfi eld, WI 53005 (262) 792-2262Therese O’[email protected]

BROTHERS INTERIORS400 S. 5th StreetWauwatosa, WI 53204(414) 750-2523Kathy [email protected]

NASSCO, INC.5365 S. Moorland RoadNew Berlin, WI 53151(262) 432-4977Danell [email protected]

ST. CROIX HOSPICE7200 Hudson Blvd., Suite 230 Oakdale, MN 55128 (855) 278-2764Chris [email protected]

GOLD BUSINESS PARTNERS

ADVACARE SYSTEMS(888) 233-7677Josh [email protected] [email protected] www.advacaresystems.com

ADVANCED LIFELINE RESPIRATORY SERVICES (502)426-1958Bowin Tichenor [email protected]

AMERICAN DATA(608) 643.8022 John [email protected]

AMERICAN MEDICAL TECHNOLOGIES(412) 699-0425Beth Sherman [email protected]

BASIC AMERICAN MEDICAL PRODUCTS(920) 904-0989Jacqueline Greenfi eldjgreenfi eld@grahamfi eld.com www.grahamfi eld.com

DIRECT SUPPLY INC.(414) 760-8421Savannah [email protected] [email protected]

DYNAMIC MOBILE IMAGING(414) 335-7605Joe GuthrieJguthrie@dynamicmobileimaging.comwww.dynamicmobileimaging.com

ENCORE REHABILITATION SERVICES(502) 400-6361Ryan [email protected]

FORBO FLOORING SYSTEMS(800) 842-7839 Lisa [email protected] ooringna.com

FRESENIUS KIDNEY CARE(800) 377-4607Samantha [email protected]

HEALTHCAP RISK MANAGEMENT & INSURANCE(734) 929-6422Stephanie [email protected]

HEALTHCARE SERVICES GROUP(920) 216-2458Jason [email protected]

IDEACOM MID-AMERICA(651) 292-0102Meagan [email protected]

INTEGRA HEALTHCARE EQUIPMENT(888) 828-7729Brett [email protected]

INTERNATIONAL MANPOWER CONNECTION, INC(818) 922-0522Albert [email protected]

KRAEMER BROTHERS, LLC(608) 546-2411 Greg [email protected]

MEDLINE(262) 412-4001Mark Mega [email protected] www.medline.com

MJ CARE, INC.(414) 329-2500Jane [email protected]

MMICMinneapolis, MN 55435(952) 838-6700AJ [email protected]

MOBILEXUSA(866) 682-5454Lindsey [email protected]

NEW HORIZON FOODS(763) 218-3098Amy Wemple RD, [email protected]

NORTHWEST RESPIRATORY SERVICES(800) 232-0706Mark [email protected]

NUTRITION CARESYSTEMS, INC.(800) 761-9200Lisa Stewartlstewart@nutritioncaresystems.comwww.nutritioncaresystems.com

OMNICARE, A CVS HEALTH COMPANY(888) 545-6664Eric [email protected]

PATHWAY HEALTH SERVICES, INC. (651) 407-8699Stacy [email protected]

PREFERRED PODIATRY GROUP, P.C.(262) 995-3340Briana [email protected]

PRIME TIME HEALTHCARE(402) 933-6700Richard [email protected]. primetimehealthcare.com

REHABCARE(502) 596-7640Jen [email protected]

REINHART FOODSERVICE(608) 793-9278Katie [email protected]

RELIANT REHABILITATION(972) 200-4271Debbie [email protected]

SCHENCK SC(920) 996-1102Brian [email protected]/long-term-care-facilities

SELECT REHABILITATION LLC(262) 665-9089Rich [email protected]

SYSCO BARABOO(608) 477-5694Lea [email protected]

TEMP SOCIAL WORK(651) 504-8010Julie Reedy, [email protected]

THINK ANEW(601) 853-1953Stacey [email protected] www.thinkanew.com

UVANTA PHARMACY(847) 297-9400Julie [email protected]

VOHRA WOUND PHYSICIANS(773) 575-5201Jeanie [email protected]

ZIEGLER(414) 978-6557Nick [email protected]

Cover Story Continued

tabletop exercise, as well as use the lessons learned from the exercise for the testing and strengthening of participating centers’ emergency preparedness plans.

This webinar series is designed to be useful for multiple members of the leadership team in a facility. As these sessions are being conducted via webinar, it allows for the planning and coordination of emergency preparedness, so that it isn’t just a facility’s administrator attending an in-person session, but an interdisciplinary exercise for anyone in a facility who is responsible for preparing for a situation that should be included in the emergency preparedness plan for your facility.

Patient Drive Payment Model:CMS announced in 2018 the most significant change to reimbursement policy for Medicare with the introduction of the Patient Driven Payment Model (PDPM). This new system, which is based solely on resident characteristics, represents the most significant change in how SNFs are paid since the SNF PPS was first implemented in October 1998. American Health Care Association officials have consistently emphasized that based on their conversations with CMS officials, there will be no delay in the Oct. 1, 2019 implementation of the changes associated with this new payment model.

The key implication for the transition from RUGS-IV to PDPM is that the new system rethinks the whole therapy delivery model from the time of admission. In the current system, payment is primarily determined by the number of therapy minutes. Under PDPM, therapy is removed as a basis for payment, and patient characteristics drive payment.

As a means of ensuring that members are ready for the significant transition to PDPM, WHCA/WiCAL is offering an intensive all-day session, during which we will delve into how facilities can go about moving away from a payment model driven by therapy minutes to a payment model based on patient diagnosis and characteristics.

WHCA/WiCAL is pleased to offer this presentation with the assistance of the venerable expertise of Pat Boyer, of Wipfli LLC. The presentation will also include the technical clinical understanding of Caryn Adams, also of Wipfli, who will present on the ICD-10 coding implications for the PDPM.

3rd Annual Quality Symposium Quality is a baseline indicator for the success of any LTC facility. Whether you’re talking about resident satisfaction, survey compliance, or health system contracts – a facility’s quality measures are central to the sustainability of any LTC facility.

As a means of providing ongoing resources to member facilities, WHCA/WiCAL launched the annual Quality Symposium three years ago. This year’s Symposium will offer valuable opportunities to gather new tools and resources, network with peers and stakeholders, and invest in a facility’s clinical or operations human capital to successfully navigate the challenging environment SNFs face.

The 2019 symposium will focus on topics such as the Five-Star Quality Rating System, utilizing performance appraisals as a tool to improve performance, improve goal setting and enhance communication, and other hot topics. The WHCA/WiCAL Quality Symposium is a worthwhile event for directors of nursing, administrators, regional clinicians and operators and all those involved in resident care to collaborate and learn. Attendees will return to their facilities with new ideas and approaches that make them more effective and efficient.

Annual Survey SessionsMaintaining and advancing survey compliance is essential for Wisconsin skilled nursing facilities. That’s why WHCA/WiCAL has launched the Annual Survey Session to help facilities gain a deeper understanding related to the legal, clinical, and operational trends they need to be aware of as they approach their survey window.

Utilizing the knowledge and experience of WHCA/WiCAL’s Legal and Regulatory Advisor, Brian Purtell, as well as the clinical and compliance acumen of Tina Belongia, WHCA/WiCAL’s Director of Quality Advancement and Regulatory Affairs, these annual sessions examine the top 10 F-tags being issued in the state of Wisconsin during the long-term care survey process, provide key observations and updates with SNF/NF surveys, and look toward the nearing Phase III Requirements of Participation (RoP) implementation deadline.

This program will include an emphasis on proactive action steps and best practices providers can implement to prepare their staff for survey, as well as how to address resident and family concerns proactively so as to avoid complaint surveys.

John J. Vander Meer is the President & CEO for the Wisconsin Health Care Association and the Wisconsin Center for Assisted Living. He can be reached at [email protected].

Tina Belongia, BSN, RN is Director of Quality Advancement and Regulatory Affairs for WHCA/WiCAL. She can be reached at [email protected].

Jim Stoa is the Public Affairs Director for WHCA/WiCAL. He can be reached at [email protected].

It is WHCA/WiCAL’s goal to provide educational offerings that give you the information you need when you need it. Based on member feedback, community trends, and input from experts like Tina and her peers across the country, we are confident that the 2019 slate of educational opportunities is informative and valuable to help providers gain the knowledge and education they need to succeed and thrive. If you have any additional thoughts on programming, please do not hesitate to contact Tina at [email protected].

The state of our profession differs depending on who you talk to, and when you talk to them. The state of the profession in Ashland may not be the same as the state of the profession in Kenosha, or Manitowoc, or Spring Green. As your association, we are committed to meeting the needs of ALL members, and the needs of EACH member. We believe that, through a strong foundation of Advocacy, Education, and Excellence, we can help members be in a position to achieve their goals and usher in a bright future for long-term care.

When our formula for success centers on the shared goal of providing the highest quality care possible, we cannot fail.


more material.

$1Every investedin online training results in $30

in produc�vity.

72%COMPETITIVE EDGE.

of companies believe that online learning provides a

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Online learning increases reten�on rates

25% TO 60%.Source: IBM studySource: CertifyMe.net Source: The Research Institute of America

Staff education. It’s part of business. CE Solutions’ learning management system offers

a system focused on senior care needs.

CE SOLUTIONS

We Train Your Brain!

Contact Deb [email protected]

Partner with Navigator Group Purchasing, Inc.

An MHA Company

TRANSPARENCY > FLEXIBILITY > SAVINGS > INSIGHTS

800-642-3020www.NavigatorGPO.com

Navigator is the experienced leader in skilled nursing, senior living, and CCRC purchasing services. We provide maximized savings opportunities and value for Navigator members through:

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