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    A publication for Wisconsins Long Term Care Profession by

    Winter/Spring

    2010

    2000

    2020

    2030

    19901980

    19701960

    The

    Silver TsunamiHow Will Aging Bab Boomers Change Long-Term Care?

    Including:

    Handling Challenges in the LTC Continuum

    Looing Bac at the 2011-12 Legislatie Session

    Critics o LTC Tort Reorm Should Double Chec Their F

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    Clinical

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    Care Continuum

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    FaceSheets

    Diagnosis

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    WelcomeCreating Continuum

    WELCOME to the inaugural 2012 edition oContinuum magazine, a publication targeting issuesand interests o Wisconsins long-term care providercommunity, its caregivers and residents. You arereceiving Continuum as you and your organizationhave distinguished yoursel as an important and valuedmember o that community.

    The Wisconsin Health Care Association (WHCA) andits dedicated assisted living division, the WisconsinCenter or Assisted Living (WiCAL) conceived andcreated Continuum as an inormational and insightulorum or providers, policymakers, and stakeholders.We viewContinuum as a substantive reection WHCA/ WiCALs member-driven mission o Advocacy Education Excellence. Published semi-annually,the second 2012 issue will be ocused on and releasedshortly beore this alls General Election.

    This issue o Continuum has a primary ocus on the

    Silver Tsunami and the myriad ways in which thetidal wave o Baby Boomers will reshape Wisconsinsand the nations long-term care landscape. It will alsoinclude a retrospective look at the substance and eecto the 2011-12 Wisconsin Budget and LegislativeSession, which included passage o several key measuresthat will enhance the uture o resident care throughmuch needed and long-sought Medicaid, tort andregulatory reorms.

    WHCA/WiCAL extends a special thank you to all

    Continuum advertisers. Your support has enabled usto develop and deliver this attractive and inormativepublication to its readership at no cost. As always, we arevery interested in your comments and recommendationson this and uture issues oContinuum. Please contact WHCA/WiCAL at 1-800-277-9422 or by e-mail [email protected].

    Sincerely,

    Thomas P. Moore

    Executive DirectorWisconsin Health Care Association

    (From let to right) B.J. Dernbach, o Rep. Dan Knodlsoce; Eric Searing, o Sen. Pam Galloways oce; Bill

    Donaldson, legal counsel or the Board on Aging and LongTerm Care (BOALTC); Heather Bruemmer, BOALTCs

    Executive Director; Jim McGinn, WHCA/WiCALs Directoro Government Relations; John Sauer, President & CEO o

    LeadingAge Wisconsin; Tom Ramsey, Vice President o PublicPolicy & Advocacy or LeadingAge Wisconsin; Tom Moore,WHCAs Executive Director and Governor Scott Walker

    beore the signing o the bill into law.

    Were moving!In April, WHCA/WiCAL will be moing its ofces to

    131 W. Wilson St. Suite #1001 Madison, WI 53703.

    Our website address has also moed:

    Both www.WHCA.com and www.WiCAL.org hae been

    merged into one site located at www.WHCAWiCAL.org.

    As alwas, i ou hae an questions, eel ree to gie

    WHCA/WiCAL a call at (608) 257-0125.

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    ContentsWinter/Spring 2012

    6COvER STORy

    The Silver TsunamiHow Will Aging Bab Boomer Change Long-Term Care?Over the past 65 years, members o the Baby Boom generation have changedvirtually everything they have come in contact with. Now, as these estimated77.6 million Americans move toward requiring long-term care, economists, careproviders, the press and the public wonder how the silver tsunami o agingBoomers will change long-term care.

    STAkEHOLDER SPOTLIGHT

    Aging Baby Boomers Bring Long-Term

    Caregivers Challenges to the ForerontDennis Winters, Chie o the Wisconsin Department o Workorce DevelopmentOfce o Economic Advisors oers a statistical analysis o the LTC workorcechallenges acing the Badger State and the nation as a result o the aging BabyBoomer generation.

    MEDIA MATTERS

    Telling the Stories that Need to be ToldWisconsins LTC Wororce Proides Excellent CareWisconsins long-term care provider community truly has some important stories to tell.But the real story that many people have missed this past year is a tale that oten goesuntold. Heres the secret everyday, thousands o our states most disabled and elderly

    citizens receive great care by good people, and nows the time to get the word out.

    CLINICAL CORNER

    Survival Guide: Handling Clinical Challenges inthe LTC ContinuumFrom the Minimum Data Set to Re-hospitalizations, skilled nursing expertTheresa Lang oers a survival guide on handling the clinical challenges memberso the long-term care provider community ace everyday.

    CAPITOL CONNECTION

    Looking Back at the 2011-12 SessionTake a look back at the 2011-12 Wisconsin Legislative Session, which provedto be one o the most successul or the long-term care provider community inrecent memory.

    LTC LEGAL LETTER

    Fact v. FictionCritics o LTC Tort Reorm Should Double Chec Their FactsThis column separates act rom fction in the multitude o charges that have beenmade about 2011 Act 2, the Tort Reorm legislation.

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    Continuumis published or the

    Wisconsin Health Care Association

    and the Wisconsin Center or

    Assisted Living

    131 W. Wilson Street, Suite #1001

    Madison, WI 53703

    Phone: 608.257.0125

    Fax: 608.257.0025

    www.whcawical.org

    Managing EditorJohn J. vander Meer

    Publisher

    Dean Gille

    Editor

    Abbie McDowell

    Account Manager

    kris Holden

    Creative Director

    Sara Rice

    Layout & Design

    Daid Cox

    Published by

    1155 Wilburn Road

    Sun Prairie, WI 53590

    608.834.3400

    www.bgsinc.com

    Fore more inormation in advertising

    inContinuumcall 608.257.0125

    2012 Badger Graphic Sstems.

    All rights resered. The contents o this

    publication ma not be reproduced b

    an means, in whole or in part, without

    prior written consent o the publisher.

    PUBLISHED MARCH 2012

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    Over the past 65 years, memberso the Baby Boom generation

    have changed virtually everythingthey have come in contact with.From Woodstock to Wall Street thesocial, cultural and economic orceswrought by the population explosionborn during the years rom 1946 to1964 has shaped American culture

    in ways that will be analyzed anddebated or generations.

    Now, as these estimated 77.6 million Americans move toward requiringlong-term care, economists, careproviders, the press and the publicwonder how the silver tsunami oaging Boomers will change long-termcare. Will the existing long-term careprovider workorce be able to meet

    the increased need? What new orms will long-term care take as a resulto Boomer generation advocacy?How will skilled nursing and assistedliving acilities change as a result othe involvement o Boomers?

    As Boomers approach age 65, andenter the next phase o lie, they arealready hard at work transormingoptions or senior living, said MattThornhill, Founder & President o

    the Boomer Project, a consultingfrm that specializes in marketingto Boomers. They have alreadychanged many aspects o society astheyve moved through various agesand lie stages.

    The Silver TsunamiHow Will Aging Bab Boomers Change Long-Term Care?

    By John J. Vander Meer

    Coer Stor

    Boomers Care For Their

    Aging Parents2011 was the frst year in whichBoomers turned 65, and the frstsense o how Boomers will changelong-term care is being increasinglydiscovered as more and more o themmake arrangements or the long-term care o their own parents. Asthey go on-line to research the long-term care options or Mom and Dad,Boomers are orming perceptions othe ways in which they would like toreceive care as they grow older.

    Going through the process ovisiting acilities with their parents,comparing dierent options on theInternet, helping them navigate theMedicare and Medicaid bureaucracy,

    all while helping to address theirparents on-going health issues willpermanently shape their attitudesabout how they will approach theirown long-term care.

    As a result o those experiencesthey are going to orm very personaland perceptional impressions o what skilled nursing care means tothem, Thornhill said. Ultimately,Boomers want to know, Whats in

    this or me?

    Greg Crist is vice president or publicaairs at the American Health Care Association (AHCA), the nationslargest nursing home association,

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    o which WHCA/WiCAL is a stateafliate. Crist said that nursing andassisted living acilities are ready tomeet the needs o their residentsrom everything rom creaturecomorts to clinical components

    because the long-term care

    provider community hasevolved to meet changingneeds, preerences andexpectations.

    (Baby Boomers) are aculture that grew up onSuperman and the LoneRanger. They have seencomputers go rom the sizeo buildings to a size thatcan ft in the palm o your

    hand. Whether youretalking about the quality othe coee thats available,all the way through thequality o their health care,this is a generation thathas come to expect a lotout o their long-term careoptions, Crist said.

    However, as expectations

    have increased, so havecosts and acuity rates,all while Medicare andMedicaid reimbursementrates have put the squeezeon the long-term careprovider community.

    The acuity and level o services thatwe oer goes ar beyond what they were 25 years ago, Crist said. Intodays strained budgets, 65 percent

    o our residents rely on Medicaid and the demand or services will onlyincrease arithmetically.

    The Cost CrunchRichard Rau, CEO o ClementManor in Milwaukee, has seenthe squeeze that Medicaidreimbursement rates have placed onhis 166-bed skilled-nursing acilityand many other LTC acilities across

    Wisconsin over the course o the 40years that he has worked in long-termcare. While providers have always lostmoney on Medicaid, they have beenable to cover their costs with private-pay residents and adequate Medicarereimbursement. Ater the signifcantchanges to Medicare reimbursementrates in 2011, one wonders i thatwill continue.

    On one hand, Rau said that as theBoomers have become more involvedin their parents care, there has beenan increase in requests or privaterooms and other amenities. Onthe other, the Center or Medicareand Medicaid Services slashed theMedicare reimbursement rates toskilled nursing acilities through theProspective Payment System changes, which went into eect in October2011, cutting reimbursement rates

    on average more than 12 percent inWisconsin acilities.

    Rau and many members o the long-term care provider community havelong advocated or a return to the use othe Boren amendment, a ederal lawthat directly linked Medicaid nursinghome rates with minimum ederal andstate quality o care standards, whichwas in place rom 1980-1997.

    As part o the Omnibus ReconciliationAct o 1980, the Boren amendmentrequired that Medicaid nursing homerates be reasonable and adequate tomeet the costs which must be incurredby efciently and economically operatedacilities in order to provide care andservices in conormity with applicablestate and ederal laws, regulations, andquality and saety standards.

    There must be some connectionbetween the cost o care and theamount o reimbursement availablethrough ederal governmentprograms like Medicare andMedicaid, which so many Americanshave come to depend on, Rau said.

    Aging In PlaceThe Journal o Housing or theElderly states that aging in placeis not having to move rom onespresent residence in order to securenecessary support services in responseto changing needs. And as ederal,state and local governments work totrim costs, and the rail, elderly, anddisabled populations try to maintainindependence, aging in place hassurged in popularity in recent years.

    More than nine out o 10 say thateven with a debilitating illness, theyplan to live at home. This plan isoten reerred to as aging in place,Thornhill said.

    In previous generations, the rail andelderly would routinely move in withtheir children, or receive care rom a

    spouse. While millions o rail andelderly people receive care throughthis traditional model, and millionsmore will continue to receive carethrough this model, because Boomersdidnt have as many children, and 1out 3 boomers is not married, moreBoomers are expected to need long-term care services.

    In Wisconsin, the advent o theFamily Care program was intended

    to oer elderly and disabled peoplea variety o alternatives to assistthem in staying their homes so as tomaintain their independence, sustaintheir connection to existing amilyand community-based care-givingnetworks and limit the cost o care.However, the explosion in the cost oFamily Care led Wisconsin GovernorScott Walkers administration to

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    impose caps on the program last year,which are expected to be lited beorethe end o the legislation session.

    In January, the WisconsinDepartment o Health Serviceslaunched a website outlining

    initiatives that DHS is proposing toachieve sustainability in the stateslong-term care programs.

    The DHS proposals include the ollowingrecommendations (among others):Helping people remain in their

    own homes or as long as possible;Ensuring utilization o inormal

    and less intensive supportsin the community to helpindividuals and their caregivers

    remain healthy and sae at home without the need or morecomprehensive long-term caresupports and services;

    Ensuring that individualsreceive the level o sel-directedsupport services they request bystrengthening program integrityand accountability.

    We reviewed Family Cares level o

    cost eectiveness and spending, andsurveyed individuals on the waitinglist about the needs they have,said DHS Secretary Dennis Smithin a press release announcing thelaunch. We also worked extensively with consumers, advocates andpartners to develop reorms thatensure Wisconsins long-termcare programs are sustainable....Nationally, Medicaid is the largestpayment source or long-term care.

    When ederal matching unds orMedicaid declined signifcantly ayear ago, Governor Walker and theLegislature committed $1.2 billionin new state unds to help meetthose fscal challenges. Even withthose additional unds, the stateslong-term care programs mustbe reormed, because populationgrowth and changing demographics

    will increase demand, leaving thelong-term care programs at risk. Wisconsins population age 65 orolder will double by 2035.

    In order to make aging in place asustainable option, advocacy groups

    including the American Association oRetired Persons point to the need orgreater availability o transportationoptions to make it easible or railand elderly to live independently.

    The great majority o older adultshave a strong desire to live in theirown homes and communities,stated a December 2011 AARPReport entitled, Aging in Place: AState Survey o Livability Policies and

    Practices. However, unsupportivecommunity design, unaordable andinaccessible housing, and a lack oaccess to needed services can thwartthis desire. Starting in 2011, growtho the older American population will accelerate, in part because theleading edge o the baby boomergeneration will reach age 65.

    Changing Needs

    As a result o the market research, ocusgroup interviews and data analysisconducted by the Boomer Project,Thornhill said his organization hasisolated fve primary ways in whichthe Boomer generation will changehealth care:

    1. Seniors will live with healthierold age, as prescription medicationsoer people a greater ability tomanage several chronic healthconditions simultaneously.

    2. The transormation o health caredelivery models will continue inthe direction o a more patient-centered care model.

    3. The location and composition ohealth care models will continue todramatically evolve with existinginrastructure being retroftted toaccommodate modern sensibilities,new development projects created

    around community-based, ratherthan institutional models, andskilled nursing acilities partneringwith adult day care companies toprovide in-home care.

    4. The role o age segregation vs.intergenerational dynamics is

    going to change. In some cases,Thornhill said that smallergroup homes are encouraginggreater interaction with manygenerations in the confgurationo the development o a LTCacility or campus.

    5. There are expected to besubstantial changes in perceptionso death and dying. As a resulto changes in intergenerationalliving and people establishing

    connections with their childrenand grandchildren, seniors arebecoming less desperate aboutextending their fnal years olie, Thornhill said. It was onlyin the last 50 or 60 years thatpeople became obsessed withextending the last couple o yearso lie and we see that changing,Thornhill added.

    With the advent o pharmaceuticalmedications that have reduceddiseases rom death sentencessome years ago, to chronic healthconditions, Crist said another serieso problems will arise.

    While Americans are livinglonger, theyre not necessarily livinghealthier, said Crist, who points toconditions like obesity and wondershow that will aect the quality o lie

    o aging Boomers.

    Workorce IssuesIn a recent jobs report, the U.S.Bureau o Labor Statistics (BLS)projected that the health care andsocial assistance sector will gain themost new jobs 5.6 million o the20.5 million new jobs the agencypredicts will be created between

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    2010 and 2020. Studies show Americans aged 65 and older areexpected to represent 19 percent othe population by 2030 a jumprom 12.4 percent in the year 2000.The need or more health care

    workers over the course o thenext 20 years is undeniable,said Dennis Winters, Chie othe Wisconsin Department o Workorce Development Ofce oEconomic Advisors. Under normalcircumstances, the issue wouldcharacteristically remedy itsel.However, the next 20 years will be arrom normal due to the demographicskewing brought about by the agingBaby Boomers.

    Rau said during his career in long-term care, he has consistently seen adirect correlation between economicconditions and the quality o thelong-term care provider workorce.

    You can talk about the agingpopulation, but you also have to talkabout the aging workorce as well,Rau said emphasizing the importance

    o training and recruiting qualifedpersonnel to sta long-term care

    acilities in order to meet the growingneed. I have always said that thetoughest job in a nursing acility isthat o the nursing assistant.

    Crist said while AHCA is comortablewith the availability o sta in general

    positions in skilled nursing such asdirectors o nursing, licensed practicalnurses and registered nurses, however, hehas more long-term concerns regardingattracting physicians and other highlyskilled practitioners to the feld.

    Were creating jobs (The long-term care provider community)created 60,000 jobs in this sector in2011, Crist said. But the number ogerontologists and geriatricians is more

    concerning. You have to get theminterested in a feld by sixth grade.

    The Future o Nursing HomesDespite eorts to limit the growtho costs by expanding in-homecare options and the changingconfgurations o the traditionalnursing home model, long-term careexperts agree that in the coming yearsit will become increasingly difcult

    or skilled nursing acilities to meetthe demands o an aging population.

    According to Medicare.gov: In2011, about nine million menand women over the age o 65 willneed long-term care. By 2020, 12million older Americans will needlong-term care. Most will be caredor at home; amily and riends are

    the sole caregivers or 70 percento the elderly. A study by the U.S.Department o Health and HumanServices says that people who reachage 65 will likely have a 40 percentchance o entering a nursing home.About 10 percent o the people whoenter a nursing home will stay therefve years or more.

    The medical model o a nursinghome is getting to be an endangered

    species, said Rau, who points toinitiatives like the Green HouseProject, which is an innovativemodel or residential long-term carethat involves a total rethinking o thephilosophy o care, architecture, andorganizational structure normallyassociated with long-term care.

    In recent years there has been amovement toward greater exibility

    in the settings in which rail, elderlyand disabled people receive care. With the increasing specializationo services, Rau said the traditionalmodel o the nursing home isbecoming less and less prevalent.

    Moreover, with an increasing need orrehabilitation services and the changingmodels through which people receiveend-o-lie care, The long-term caresystem is going to be dramatically

    dierent fve years rom now, Rau said.

    John J. Vander Meer is theDirector o Communications

    or the Wisconsin Health CareAssociation and the WisconsinCenter or Assisted Living. Hecan be reached at

    [email protected].

    For assistance, contact us at

    1-800-242-7001Scott Naze, President (ext. 817) Janet Hays (ext. 838)

    Dave Hosack (ext. 859) Kim Adey (ext. 833)

    www.securityins.netP.O. Box 510925, New Berlin, WI 53151-0925

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    Aging Baby Boomers BringLong-Term CaregiversChallenges to the ForerontBy Dennis Winters

    Staeholder Spotlight

    The next socio-economic phaseo the Baby Boomers is uponus. Just as they changed the worldcoming in en masse, they will changeit going out. The oldest o the some 80million United States Boomers turned65 years o age in 2011. The growthrate o this senior humanity will builduntil 2020 and then scale o through

    2030. In 2009, 13.5 percent oWisconsins population was 65 yearsor older. By 2030, the percentage willrise to 21.4 percent. That will increasethe ranks o Wisconsin seniors bysome 638,000, to over 1.4 million.

    We know that the Abbies (agingBaby Boomers) will demand a changein the goods and services provided.Signifcant changes will have to be

    made to buildings and inrastructure.Mobility barriers, communicationsaccess, crime prevention, and healthcare provision will all have to adapt tothe Abbies aculties.

    As the number o Abbies swelland the ranks o the aged increase,demands on health care systems willincrease like no time in our history.Abbies vim and vigor may be morerobust than previous generations,but it is inevitable that this cohort will realize the physical and mentalaects o aging. Along with aging

    come increased needs or acute care,ongoing treatments, therapies, andpersonal care.

    In addition to this bubble ohumanity reaching old age, averagelie expectancy has increased overtime. In 1960, as the Boomers werebeing born, lie expectancy was 69.9years. As o 2010, lie expectancy hadincreased to 78.7 years, almost a ten

    year gain in one generation. Longerperiods spent at older ages will meanincreased demand on average orgeriatric health care, particularly long-term care.

    Recognizing the pending increaseddemand or health care and healthcare workers, the Ofce o EconomicAdvisors at the Wisconsin Departmento Workorce Development (OEA)projects that health care occupations will constitute 11 o the 15 astest

    growing occupations rom 2008to 2018. Home Health Aides andPersonal & Home Care Aides arethe top two. Moreover, along withRegistered Nurses, Home Health Aides and Personal & Home CareAides will have the most job openingsduring the 2008 to 2018 period.

    To urther illustrate the point,consider fgures 1 & 2. Figure 1 showstwo things. The frst item is shown by

    the dashed line. This line representsthe demand and supply or registerednurses without consideration othe Abbies induced demographicskewing. It shows demand andsupply increasing with populationunder known provision and supplydevelopment levels, resulting inequilibrium o the demand andsupply o nurses.

    Introducing the Abbies bubble yieldsthe Base Demand and Base Supplycurves under known care provisionsby age cohort. It portrays the increasein health care demand by Abbies and

    fgure 1 fgure 2

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    the constraints on supply by eweryoung people training or the nursingproession. Under the Abbies scenario(one that demographics data tellsus is real), the gap in the demandor nurses and the supply o nurseswidens to huge proportions. By 2030,

    OEA projects a 27 percent gap in thenumber o registered nurses requiredto meet demand under currentprovision rates. That amounts toalmost 18,000 ewer nurses than the83,000 required in 2030.

    Figure 2 illustrates the even morechallenging issue concerningregistered nurses in long-term caresettings. The rate o growth or nursesin the nursing home and extended

    care and home health care settingsoutpaces the overall demand increaseor nurses across all settings. Almost12,000 o those 83,000 registerednurses demanded in 2030 will beneeded in the Nursing Home &

    Extended Care setting, and nearly5,000 will be needed in the HomeHealth Care setting by 2030. Furtherillustrating the challenges o satisyingthe demand or senior care supportstafng, the growth rate or HomeHealth Aides and Personal & Home

    Care Aides greatly exceeds that oregistered nurses.

    Over course o the 2008 2018 OEAoccupational projections period, thegrowth rate or registered nurses isestimated at 19.7 percent. Homehealth aides and personal and homecare aides growth rates, by contrast,are 38.3 percent and 34.0 percent,respectively. This amounts to anincrease o 21,000 home health aides

    and personal and home care aides,divided evenly between the two, injust 10 years.

    The need or more health care workers over the course o the

    next 20 years is undeniable. Undernormal circumstances, the issuewould characteristically remedy itsel.However, the next 20 years will be arrom normal due to the demographicskewing brought about by the agingBaby Boomers. Health care will be

    one o the primary needs or thisaging cohort. The demands on healthcare systems and providers to meetthose needs will be unprecedented.As we have seen with other programsor seniors, addressing the situation isbest done sooner than later.

    Dennis Wintersis Chie o theWisconsinDepartmento WorkorceDevelopmentOce o Economic

    Advisors

    Serving Facilities in South Central WI

    125 S. Thompson Rd. | Sun Prairie, WI 53590

    Phone: (608) 837-8002 | Fax: (608) 837-8005

    www.oconnellpharmacylongtermcare.com

    Going the extra mile is our way of doing business!

    Blister Pack, OPUS cassette, Strip Packaging & Pre-lled syringes

    Printed MARs which can include photos of both the drug & resident

    In-service training for facility staff

    Facility consultations, on-site reviews & reports provided by pharmacists

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    Telling the Stories thatNeed to be ToldWisconsins LTC Wororce Proides Excellent Care

    By John J. Vander Meer

    Public relations is about reputation the result o what you do, whatyou say and what others say aboutyou... Public relations practice isthe discipline which looks aterreputation with the aim o earningunderstanding and support andinfuencing opinion and behavior.

    Institute o Public Relations

    The year 2011 was a pivotal timeor Wisconsins long-term care

    provider community.

    While at the ederal level, providerswere orced to sustain the greatest ratecut ever in Medicare reimbursementrates, at the state level, WHCA/WiCAL and its allies secured severalimportant policy changes aimed atimproving the quality and reducingthe cost o providing care to the BadgerStates most rail, disabled and elderlypopulation. These legislative successesresulted rom the tireless advocacy oour members and sta working withpolicymakers and elected ofcialso both political parties to enactcommon-sense reorms o the statesbroken survey process that emphasizequality improvement over punitiveenorcement.

    Wisconsins long-term care providercommunity truly has some importantstories to tell. But the real story thatmany people have missed this pastyear is a tale that oten goes untold.

    Heres the secret everyday,thousands o our states most rail,disabled and elderly citizens receivegreat care by good people.

    A 2011 national study by Eljay, LLP,a national accounting and long-term care consulting frm, oundthat Wisconsin has the second worstMedicaid Assistance reimbursementsystem or nursing homes in thecountry. While important correctiveaction was taken in 2011 by theState Legislature and the Walker

    Administration to partially fxaspects o long-term cares undingdisparities, years o underundinghas let Wisconsin long-term careproviders vulnerable to urtherunding cuts. However, in spite oyears o underunding, a surveyconducted by the American Association o Retired Persons(AARP) ound that Wisconsin isranked fth best in the country or

    aordable, high-quality care or itsmost vulnerable citizens in 2011.

    With the Baby Boomer generationmoving closer to the age o requiringlong-term care, the providercommunity in Wisconsin, as well asaround the nation, is acing signifcant

    challenges o limited spatialavailability, stafng shortages, anddiminished accessibility o operatingrevenue. Yet, everyday, assisted livingand skilled nursing acility personnelprovide the desperately needed careor the people who need it the most.

    Earlier this year I joined WHCA/ WiCAL as the organizationsCommunications Director. Themost important part o my job isto make sure that providers receivethe inormation that they need tomake inormed decisions about legaland regulatory issues in a timelyashion through www.whcawical.org,

    WHCA/WiCAL publications includingContinuum and our weekly electronicnewsletter, Friday Update. The othercritical part o my job is to help tellstories about the issues acing long-term care patients and providers.

    Heres the secret everyday, thousandso our states most

    rail, disabled andelderly citizensreceive great care bygood people.

    Media Matters

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    WHCA/WiCAL encourages youto make the voice o the providercommunity heard in Wisconsin.Long-term care aces someserious challenges that demandserious solutions not politicalgrandstanding and histrionics.

    Only by working together can weensure that policymakers and electedofcials understand the importanceo protecting our states most rail,disabled, and elderly population bysupporting the people who care orthem everyday.

    Perhaps one o the most tellingaspects o the community o peoplethat I am proud to serve is that long-term care isnt an industry. Wedont make things, we help people.Were a provider community.

    And as a provider community, weneed to make sure that our storiesare told. While patient privacy mustbe careully protected, ar too otenthe good work that the thousandso certifed nursing assistants, skillednursing sta and assisted livingcommunity activity coordinators, who passionately care about ourstates most disabled and elderlyresidents, goes unnoticed.

    While there is no excuse or providingpoor quality nursing care, long-termcare providers are hard-workingpeople who try to serve their residentsin the best way that they know how.

    In the coming election year, Wisconsins radio and televisionairwaves will be beset with politicalattack ads on both sides. Some groupsand individuals may choose to attacklong-term care providers as a whole tograb headlines and get their ace on

    the local news.We know that thats not the whole story.

    There are many tools in the publicrelations toolkit that LTC acilitysta and administrators can useto help tell these stories: invitingmembers o the news media to covercommunity events, conductingacility tours with local dignitaries,drating guest columns or the local

    newspaper, encouraging memberso the community to write letters tothe editor, sending out press releasesabout acility news and events, andutilizing social media as a way toacilitate interaction with residentsamilies to name a ew.

    John J. VanderMeer is theDirector oCommunications

    or the WisconsinHealth Care

    Association andthe Wisconsin

    Center or Assisted Living.He can be reached at

    [email protected].

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    Critical Thinking to Root Cause

    Analysis Assessment and evaluation hasprogressed to critical thinking andmost recently has expanded to rootcause analysis. Documenting andcommunicating root cause analysis

    is key to positive resident outcomes.

    THE FUTURE

    Money Follows the Person/PACE/

    Family Care.Numerous programs are in place and will continue to receive unding tokeep recipients in the lowest level ocare possible or at home with serviceto prevent institutional care. These

    programs are continuing to expand with requests or the programsrequently exceeding availableunding. On a state and ederal level,such programs are the goal.

    Reduction in PaymentsThe recalibration o the RUG-IVreimbursement methodology onOctober 1, 2011 resulted in paymentreductions averaging over 11 percentor Medicare Part A, although in

    Wisconsin these reductions exceed14 percent or some acilities. Thishas caused renegotiation o ancillarycontracts such as therapy and pharmacywhile maintaining quality o care.

    As we continue into 2012, there arestill many unanswered questionsregarding payments to numerousprovider types by Medicare andMedicaid. The Physician Fee Screen

    reductions and therapy cap exceptionprocess have been fxed through2012 ollowing action at the ederallevel in February ollowing action atthe ederal level? Another doctor fxhas been adopted to address March 1and on. In an election year, however,these fxes are requently temporaryand are not permanent solutions tothe issues at hand.

    Preventable Conditions/Acute

    Care ReadmissionsTransient medical sta wherephysicians make monthly or weeklyrounds in SNFs will be replaced withmore physicians/physician extendersbeing SNF-based. This will be seen

    in the orm o a hospitalist or thenursing acility. Why is this occurring? As acutecare providers are being fnanciallypenalized or readmissions, theyare looking or ways to preventreadmission to acute care.

    Managing the person at home, inthe SNF, or other living situation isa must or the fnancial well-being othe acute care organization. Being inthe SNF, monitoring residents morerequently, including daily or twiceper day, will lead to managemento the resident while preventing anacute readmission.

    Acute care providers are beginning togather data on SNF discharges andreadmission, identiying those SNFsthat are unable to manage changes

    in condition resulting in trips to theER and acute re-admissions which isaecting reerrals to the SNF.

    Another strategy to manage hospitalreadmissions is the use o observationstays. Observations stays result inlack o access to Medicare SNFbenefts or many benefciaries. Manybenefciaries do not understand theimpact o observation stays on theirfnancial liability. Observation as

    a Medicare Part B service includesco-insurance o 20 percent, as wellas medications not being coveredresulting in the benefciaries need tosubmit medication charges to theirMedicare Part D plan or payment.

    International Classifcation o

    Diseases (ICD-10)ICD-10 is scheduled to beimplemented on October 1, 2013.This will require extensive statraining including changes in existingclinical and billing sotware.

    Electronic Medical RecordsEMR implementation continues tomove orward on a national basis.How and when the impact will bemandated in the LTC continuum isstill being worked out.

    ConclusionIn 1998, Dr. Spencer Johnson wrotethe book, Who Moved My Cheese. Since

    that time, this twenty minute read hasbeen translated into 42 languages and23 million copies have been sold. Itis a must read or all SNF managersat least annually. I we embracethe ollowing principles regardingchange, we will be survivors in thisroller coaster world o regulatory andreimbursement change.

    Change Happens

    Anticipate Change

    Monitor Change

    Adapt To Change Quickly

    Change

    Enjoy Change!

    Be Ready To Change Quickly &Enjoy It Again

    Theresa Lang,RN, BSN,

    MAPA, RAC-C,

    WCC, VicePresidento ClinicalConsulting,Specialized

    Medical Services, Inc.She can be reached [email protected]

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    and over 60 straight hours o oordebate and passed the bill limitingcollective bargaining or publicemployees and requiring higherhealth and pension contributionsrom public employees. With respectto the length o the Assembly debate,

    a Legislative Reerence Bureausearch could not locate any recordsor reports o a longer oor sessiondating back to at least 1915.

    With Democratic Senators in Illinois,Republican leaders o both Housesposted a notice that a conerencecommittee had been created toaddress the dierences between thetwo Houses regarding the Governorsproposed budget adjustment bill.

    The conerence committee removedall appropriations rom the bill, butincluded the provisions limitingcollective bargaining and increasedcontributions or health and pensionbenefts. The bill required a simplemajority to vote to pass the bill. TheSenate voted 18 to 1 and passed themodifed bill, which was approved bythe Assembly.

    While the budget adjustment billdominated the news, Governor Walker also presented to theLegislature his proposed 2011-13biennial budget bill. The biennialbudget bill is typically the longestand most complex bill o the session.The Governors budget ocused onthe states $3.6 billion defcit, and theGovernor indicated that his budgetwould reduce all unds spending andgone are the segregated raids, illegal

    transers, accounting gimmicks, andtax or ee increases.

    Governor Walker signed the budget billon June 26 and this column does notpermit a review o the votes and debateo the measure by the Joint FinanceCommittee, the Assembly and theSenate. It should be noted, however,the budget bill included: a request by

    With respect to the Senate recallelections, 4 Democrats haveannounced their intentions tochallenge the 4 Republican Senators.Lori Compas (D-Ft Atkinson) willrun against Senate Majority LeaderScott Fitzgerald in the 13th Senate

    District, State Representative DonnaSeidel (D-Wausau) will challengeSenator Pam Galloway (R-Wausau)in the 29th Senate District, ormerState Representative Kristen Dexter(D-Eau Claire) will challengeSenator Terry Moulton (R-ChippewaFalls) in the 23rd Senate District,and ormer Senator John Lehman(D-Racine) will challenge SenatorVan Wanggaard (R-Racine) or the21st Senate District.

    So ar, ormer Dane CountyExecutive Kathleen Falk, Secretaryo State Doug LaFollette, and stateSen. Kathleen Vinhout (D-Alma)have announced their candidaciesor the Democratic nominationor Governor. No candidates haveannounced plans to challenge Lt.Governor Kleefsch. (These are thecandidates that have entered the

    races as o the time o Continuumspublication.)

    In addition to the recall elections, I will conclude with a reminder thatthe general and presidential primaryvote will be held on April 3, andthe all elections are scheduled orAugust 14 (primary) and November6 (general and presidential elections).

    the Department o Health Servicesto increase nursing home acuityprojections by 1 percent in 2011-12($7.3 million all unds) and 1 percentin 2012-13 ($14.7) to avoid a reductionin nursing home rates, created a $7uniorm ee or criminal background

    checks with the Department oJustice, and provided Residential Care Apartment Complexes (RCACs) thesame protections under current lawrelating to noneconomic damages andconfdentiality o health care servicescontained in the tort reorm law.

    The summer months continued Wisconsins national news coverageas 9 State Senators were subject torecall elections, 6 Republicans and

    3 Democrats. The recall electionsresulted in 2 incumbent RepublicanSenators being deeated, narrowingthe Republican control o the Senateto a 17-16 majority.

    With respect to the all session o theLegislature, the Legislature passedand Governor Walker signed intolaw the Strengthening Our NursingHomes Act, reorming a duplicative

    and outdated nursing homeenorcement process. The measuredid not repeal any regulation orexpectation; it simply eliminatedthe potential or being assessed or adouble penalty or a single incidento alleged non-compliance.

    Although the Legislature hasreconvened, politics continues inWisconsin. Petitions were circulatedin November to mid-January to

    recall Governor Scott Walker, Lt.Governor Rebecca Kleefsch, andRepublican Senators Scott Fitzgerald,Pam Galloway, Terry Moulton,and Van Wanggaard. While theGovernment Accountability Board isin the process o certiying the recallpetitions, it does indeed appear thatspecial elections will be held in springor summer this year.

    James McGinnis WHCA/WiCALs Directoro GovernmentRelations. Hecan be reached at

    [email protected].

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    The comprehensive modifcationo certain statutes impacting

    lawsuits in Wisconsin, the 2011 Act2 tort reorm package, containedprovisions that have implicationsa wide sector o individuals andbusinesses, as well as provisions thatdirectly and indirectly aect thelong-term care provider community.

    During the debate and subsequentto passage, there has been signifcant(mis)inormation about the contentand impact o the provisions. Much othe criticisms contained, intentionallyor otherwise, misconceptions ormischaracterizations o the provisionsand the impact on accountability oproviders or their acts or omissions.

    To counter the rhetoric rom the special

    interests that seek to undo provisionsthat will beneft quality improvementand will hopeully permit stability inthe insurance market to minimizeoperational challenges, providers needto be versed in the acts.

    Caps on Certain DamagesMyth: Putting limits on damages willprevent nursing home and assistedliving providers rom being heldaccountable.

    Fact: Act 2 simply extended the capson non-economic damages that havebeen in place or suits against hospitalsand doctors or years to apply to actionsbrought against additional health careproviders, including nursing homes,Community Based ResidentialFacilities (CBRFs), Residential Care

    Update to Health Care

    Service ReviewMyth: Changes to the health careservices review confdentialityprovisions permit providers to hideinormation rom residents andamilies and will preclude wrongdoers

    rom being held accountable or theiractions.

    Fact: Wisconsin statutes section146.38 provides confdentialityprotection or the Health CareServices Review, sometimes reerredto as peer review. The policy behindthe protection is that health careproviders should be aorded a orum

    to engage in quality reviewwithout ear that such eorts willused against them in other settings.This has been in existence or decadesbut has long needed an update toreect todays health delivery system.Past eorts to update provisionshave stalled or been vetoed, despitebipartisan support in the Legislature.Changes sought have ocused onaddressing the erosion o protectionover the years; clariying the providers

    covered; and permitting greatersharing o data and inormationamong providers, systems, and withconsultants, a recognized, moreeective means to improve qualityand outcomes.

    Act 2 updated and improved thelaw by clariying what providers arecovered, what activities are subject

    Apartment Complexes (RCACs), andAdult Family Homes (AFHs).

    Prior to the passage o Act 2, there wasno limit on the level o damages thatcould be recovered in legal actionsagainst Wisconsins LTC providers.The exposure tounlimited liability

    has contributed toan environment thatosters litigationand instability inthe availability andaordability oproessional liabilityinsurance coverage. Act 2 extends toLTC acilities thesame limits on non-

    economic damages that previouslyapplied to hospitals, physicians andother care providers. It is important tonote that Act 2 did not impact or placeany limits on economic damages.

    Act 2 also changed the way that Wisconsin permits the impositiono punitive damages, those damagesthat are awarded above and beyondcompensatory damages to punisha wrongdoer. These changes are o

    general application to all suits, andlimit punitive damages to twicethe compensatory damages. Thesechanges are not health care-specifc,yet eorts to date to repeal theselimits are oddly and narrowly aimedat a single sector, the LTC providercommunity.

    FACT V. FICTIONCritics o LTC Tort Reorm Should DoubleChec Their Facts

    By Brian Purtell

    LTC Legal Letter

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    to confdentiality, and permittedcollaborative eorts within theconfdentiality protections. A notableaspect o this is that nursing homes,CBRFs, AFHs and (later) RCACswere added as health care providersor purpose o this provision. The

    changes to section 146.38 are intendedto allow greater collaboration, enhancecandid exchange o ideas and analysiso opportunities or improvement.

    Critics o the 146.38 changes claimthat the modifcations will allowprovider to shield inormationrom patients/residents, therebyallowing providers to hide criticalinormation related to negativeoutcomes. A great deal o conusion

    and misinormation is centered on theunderstanding o the term incidentreport, and the accessibility andadmissibility o certain reportsthat meet the new defnition o anincident or occurrence report withinChapter 146. The new law clarifes animportant provision that encouragesproviders to address identifed qualityissues by protecting certain internalreporting and review.

    Critics, however, appear to gloss overthe actual defnition o incident oroccurrence report which reads: a

    written or oral statement that is madeto notiy a person, organization, oran evaluator who reviews or evaluatesthe services o health care providersor charges or such services o anincident, practice, or other situationthat becomes the subject o such areview or evaluation. Critics ailto apply, or intentionally disregard,the actual defnition, and assert that

    care providers or what many elt was an error rather than a criminalact, proponents sought to makeclear that medical errors should notbe addressed in the criminal code.The change, however, in no wayimmunizes individuals who cause

    harm to patients or residents.

    There was an addition made to thecriminal code section entitled abuseand neglect o patient and residentthat clarifed the provision thatmakes it a crime i someone abuses,with negligence or neglects a patientor resident. Specifcally, it addedthat this provision does not applyto a health care provider acting inthe scope o his or her practice or

    employment who commits an actor omission o mere inefciency,unsatisactory conduct, or ailure ingood perormance as the result oinability, incapacity, inadvertency,ordinary negligence, or good aitherror in judgment or discretion.Essentially, the law was modifed tomake it plain that clear true mistakesshould not subject sta to crimes. Actso intentional and reckless abuse or

    neglect are unaected by the change.

    The late-New York Senator DanielPatrick Moynihan once said:Everyone is entitled to his ownopinion, but not to his own acts.In the orthcoming recall elections,tort reorm will likely be brought upas one o the prominent issues o thecampaign. WHCA/WiCAL hopesall sides will engage in debate on theacts, not inated suppositions based

    on political expediency.

    anything called an incident reportis covered under the defnition andwill thereore be shielded by coveredproviders.

    The disregard o the actual defnitionis urther compounded by the act that

    all providers subject to the WisconsinCaregiver law must use a orm titledMisconduct Incident Report. Again, just because the term incident isused does not automatically placea document into the confdentialcategory that prohibits providersrom using it or purposes other thanHealth Care Services Review. Thesereports sent to DHS are reviewedby the Ofce o Caregiver Qualityas to the individuals conduct, and

    as applicable, by the Division oQuality Assurance as to the providerscompliance. The accessibility odocuments presented and generatedin either or both reviews remainsunchanged.

    Despite assertions by opponents, Act 2did not limit causes o action and didnot strip access to reports and recordsprecluding accountability. A residents

    medical record is the residents,and can be shared with anyone theresident authorizes, including alegal representative. Resident recordrequirements vary by provider, butall are expected to include detailsregarding incidents and accidents.

    The law did clariy and make a specifcchange to the admissibility o incidentor occurrence reports. Specifcallythat these reports cannot be used in

    a criminal or civil matter, but theadmissibility o these has always beensubject to a case-by-case analysis.

    Myth: Act 2 immunizes a health careprovider rom criminal prosecutionor harm to a patient/resident.

    Fact: Following several instanceso criminal prosecution o health

    Brian Purtell isWHCA/WiCALsLegal Counseland WiCALsExecutiveDirector. He canbe reached [email protected].

    Everyone is entitledto his own opinion,but not to his own

    acts.

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