National Trends and Legislation in Assisted Living plus Ethical Marketing April 13, 2010 Shane Osborne National Center for Assisted Living Assisted Living Properties Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living • Average years open = 13.3 • Properties have an average 54 units. • Average monthly cost = $3,022 or $36,264 annual (single occupancy.) • Average monthly cost dementia care unit = $4,200. • Ownership of operating units 59% Private For Profit 12.6% Publicly Held For Profit 25.7% Non-profit 1.3% Government sponsored • 97% Sprinkled in common areas & 96% sprinkled in all rooms. • 100% Smoke detectors in common areas & 99% in all rooms. Assisted Living Residents Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living • Average Age = 86.9 • Average Age at Move-in = 84.6 • 73.6% Female; 26.4% Male • Average Income = $27,260 • Average Assets (including home) = $431,020 • Median Income = $18,972 • Median Assets (including home) = $205,000 Prior Residence Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living Private home/apartment Nursing home Retirement/IL Family residence Different ALF or group home 70% 9% 9% 7% 5% Assisted Living Residents Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living • Average Length of Stay = 28.3 months • Median Length of Stay = 21 months • Average annual resident turnover = 42% • 62% within 10 miles of their previous residence. • 22% of residents made the decision to move independently; 49% partially involved; others made the decision for resident 25% of the time. Health Conditions Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living Hypertension Arthritis Alzheimer’s/Dementia Coronary Heart Disease Depression Osteoporosis Macular Deg./Glaucoma Diabetes Stroke 66% 42% 38% 33% 30% 27% 19% 17% 14% ADL Dependence ALF Data from 2009 ALFA, ASHA, AAHSA, NCAL & NIC Survey • • • • • ADL Bathing Dressing Toileting Transfer Eating ALF 64% 39% 26% 19% 12% NF 96% 90% 84% 80% 53% • 81% of ALF residents need help with meds. (Average 9.9 meds daily – 7.6 prescriptions and 2.3 OTCs) Other Care Issues Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living • Residents need assistance with 4.5 IADLs on average with 4 out of 5 needing help with housework, laundry, medications, transportation and meal preparation • 54% use a walking device (cane, walker, etc.) and 22% use a wheelchair • 31% bladder incontinent; 14% bowel incontinent • 92% of communities arrange for /provide hospice care Residents Moving Out Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living Nursing home 59% Home 9% Another ALF 11% Relative’s home 5% Hospital (other than short term) 7% Independent living 4% Hospice 2% Other 4% One-third (33%) of residents die in the assisted living setting. NCAL’s Policy Priorities • Keeping Regulation of Assisted Living at the State Level • Navigating National Health Care Reform • eg. Implementation of Class Act and Employer Mandates • Medicare Part D Co-Pay fix • Arbitration • Employee Free Choice Act • Keeping assisted living included in the CMS definition of HCB settings State Regulatory Trends • Twenty-two states reported AL regulatory/Medicaid policy changes in 2009. Eight states made major changes or overhauled rules. Trends: • Higher standards for Alzheimer’s/dementia care. • Life safety, emergency preparedness. • Disclosure & staff training. • Medication management. NCAL State Regulatory Review available at : www.ncal.org State Regulatory Trends (2) Additional focal points of policy change: • Criminal Background Checks • Resident assessment/service plans. • Medicaid policy. • Move-in/move-out rules. • Reporting requirements. • Resident rights. NCAL State Regulatory Review, 2010 edition available March 2010 at: www.ncal.org Medicare Part D • Medicare Part D Co-Pay Legislation − Partial Fix included in health care reform legislation. − Will eliminate Part D co-pays for dual eligibles in home and community based settings covered under Medicaid waivers - includes about 60% of assisted living dual eligible population. − NCAL took leadership on this issue and lead coalition of national stakeholder groups. • NCAL will seek a fix for dual-eligibles in assisted living settings not covered by this legislation. Medicaid and Assisted Living • Rates often inadequate. • Payment for AL Incomplete (housing, food, utilities not covered; SSI check insufficient to fill gap.) • Many recent Federal initiatives, regulations tend to exclude AL. • NCAL study of State Medicaid rates, payment issues released in last October. NCAL Medicaid Payment & Policy Study “State Reimbursement Policies and Practices in Assisted Living” Available at www.ncal.org. Study sponsored by NCAL and done by Robert Mollica, independent health policy researcher, formerly on staff of National Academy for State Health Policy. Methodology: Updates Residential Care and Assisted Living Compendium: 2007 prepared for ASPE. Source: State web sites; Electronic survey; Telephone calls with staff responsible for HCBS programs. Data collected March – June 2009. NCAL Medicaid Payment & Policy Study Key Findings: • AL Medicaid coverage is growing again (up 9% between ’07 and ’09) after drop between ’04 and ’07 -now about 131,000 nationally. – Medicaid covers about 13% of AL residents (compared to about 63% of NH residents). • 37 states use 1915(c) HCBS waivers; 13 provide coverage directly under Medicaid state plans; 4 include it in 1115 demonstration programs; and 6 use state general revenues. States may use more than one funding source. – Oklahoma began Medicaid waiver coverage in AL in 2009 NCAL Medicaid Payment & Policy Study • Tiered rates the most common methodology for reimbursing assisted living providers (19 states). Flat rates are used in 17 states. • 23 states cap the amount that may be charged for room and board. • 24 states supplement the beneficiary’s federal Supplemental Security Income (SSI) payment of $674, which states typically use as the basis for room and board payment. SSI combined with state supplements ranges from $722 to $1,350 a month depending on the state. Some states provide no supplement. NCAL Medicaid Payment & Policy Study • 25 states permit family members or third parties to supplement room and board charges. • 23 states require apartment style units; 40 allow units to be shared; and 24 allow sharing by choice of the residents. • Screening for mental health needs is performed by case managers and assisted living community staff in 9 states; by case managers only, in 10 states; and by assisted living staff only, in 9 states. • Mental health services are arranged by assisted living communities in 16 states; case managers in 20 states; and may be provided directly by assisted living communities in 3 states. NCAL Medicaid Payment & Policy Study Trends: The shift to HCB settings • Medicaid nursing facility census: 896,495 in Dec. 2008: – 8.3% less than Dec. 2001. • Number of assisted living residents receiving Medicaid LTC services: 131,000 in 2009: – 43.7% more than in 2002. • Medicaid spending for NH care is still much greater, but spending for HCB care is growing much faster: – From FY 2001–2007, Medicaid spending for HCB care rose 81.5% while spending for NH care rose 9.8%. – In FY 2007, $16.7 billion spent on HCB care v. $46.9 billion for NH care. LTC Housing Supply: Beds Per 1,000 People 65 and Older Licensed AL/RC NFs U.S. 25.7 44.1 Oregon 45.3 25.5 Michigan 36 36.4 Alabama 15.2 42.1 Oklahoma 19.4 61.5 Source: “State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert Mollica, National Center for Assisted Living/AHCA, September 2009. Available at www.ncal.org. HCBS as a Percentage of Medicaid Long Term Care Spending Percent HCBS U.S. 31% Oregon 57% Michigan 19% Alabama 13% Oklahoma 29% Source: “State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert Mollica, National Center for Assisted Living/AHCA, September 2009. Available at www.ncal.org. Key questions • How will federal Medicaid rules define community settings? • Will declining state revenues limit AL rates? − If so, are ALFs likely to drop out? • Will AL contribute to further decline in NF use? • As Congress contemplates further stimulus of HCB care, what role will AL play? • Should federal housing subsidies be considered? Employee Free Choice Act AKA, the Union Card Check Bill • Would allow unions to organize without a secret ballet election. Employees would just need to sign a card. Takes away privacy. Would affect every union in the country. Takes away the election process. Requires binding arbitration. • President Obama has promised to sign the card check legislation into law. • NCAL opposes this bill, which was reintroduced in both the House and the Senate on March 10, 2009. Arbitration Legislation • The legislation would eliminate the use of predispute arbitration agreements by all LTC facilities nationwide. • Reintroduced in March 2009 in both the House and Senate. The Fairness in Nursing Home Arbitration Act also applies to assisted living. • In 2008, it passed the House and Senate Judiciary Committees, but did not make it to the floor of Congress. • President Obama has said he would sign the measure into law. • NCAL/AHCA opposes the legislation. Three Federal Agencies Working on National Assisted Living Study • Largest examination of assisted living by the Federal Government Pilot Tested in 2009 National Field Survey begins in April 2010 Findings Published in 2011 • Agencies involved include: − Office of the Assistant Secretary for Planning and Evaluation (ASPE) − National Center for Health Statistics (NCHS/CDC) − Agency for Healthcare Research & Quality (AHRQ) AHRQ’s Consumer Disclosure Initiative • In July 2008, AHRQ launched the Assisted Living Disclosure Collaborative. This 18-month project will result in a tool that would allow consumers to compare and select assisted living communities around the country. • Final model tool was completed in December 2009 and will be pilot tested in 2010 in Phase II. • Phase III work will begin in 2010 and focus on the consumer piece of the this initiative. • NCAL will continue to actively participate in this AHRQ initiative. NCAL Life Safety Initiatives • Concern among fire marshals, experts about decreased ability of AL population to evacuate without assistance is challenging current life safety standards. NCAL taking proactive steps. • National Fire Protection Association committee has just accepted NCAL Life Safety Code proposals for existing buildings. • NCAL also soon will submit proposal for new construction to International Building Code committee. • Objectives: Ensure safety; avoid shift to institutional standards, costly retrofitting; harmonize two major codes impacting AL. Federal Regulation of AL? • Trend toward AL residents with more health needs and more residents with dementia is leading states to increase AL regulation, increasing pressure for greater uniformity of state regulation. • Many leaders in the new Congress are on record as supporting greater federal oversight of AL (e.g. Henry Waxman, Pete Stark). • Most in public policy circles agree that assisted living could be one headline away from federal oversight. • NCAL will be at the table if a debate over federal regulation occurs. Federal Agencies with Assisted Living Initiatives • Centers for Medicare & Medicaid Services (CMS) Defining HCB Settings • HHS Office of Inspector General (OIG) State Oversight of Waiver Providers Examining AL Providers’ Use of Home Health • Environmental Protection Agency (EPA) Disposal of Unused Drugs Energy Use and Energy Star Programs Litigation Trends Source: “CNA: Reducing Risk in a Changing Industry: CNA HealthPRO Aging Services Claims Analysis 2004-2008,” CNA Financial Corporation, 2009. General trends: • Frequency of incurred aging services claims (reported claims with an indemnity and/or expense payment) stable from 2004 to 2008. • Severity of closed claims is increasing. • SNFs have highest average severity within not-forprofit segment, followed by CCRCs. • AL facilities have highest average severity within forprofit segment, followed by SNFs. Litigation Trends (2) Most Frequent Allegations at AL Facilities* Resident fall 45.9% Abuse 10.3% Improper care 8.8% Pressure ulcer 7.2% Unsafe environment of care 6.7% *Source: CNA: Reducing Risk in a Changing Industry, 2009. Litigation Trends (3) Allegations at AL Facilities – Highest Average Total Paid for Closed Claims* Elopement $337,344 Pressure ulcer $276,612 Failure to monitor $240,517 Improper care $214,815 Abuse $203,229 Resident fall $202,415 *Source: CNA: Reducing Risk in a Changing Industry, 2009. Litigation Trends (4) Injuries at AL Facilities – Highest Average Total Paid for Closed Claims* Death $308,564 Pain and suffering $236,377 Amputation $188,080 Sexual assault $184,918 Head injury $148,650 Co-morbidities $147,817 *Source: CNA: Reducing Risk in a Changing Industry, 2009. Looking Ahead: What is Clear • • • • • • • E-Prescribing Electronic Health Records More on-line disclosure of information New service models and delivery sites Increasing acuity Increased state oversight Staffing challenges Looking Ahead: What is Unclear Uniform assessments Uniform outcome measurements LTC financing reform Federal regulation Legal changes How CMS will define HCBS settings The declining economy’s impact on assisted living Surviving the Recession • Nationally, occupancy levels have only decreased by 1% so the impact of the downturn has been minimal. • New building is slow because of the lack of capital. • The Unknowns: Have we hit the bottom of the downturn? Will the decline in housing prices mean that our residents will spend down more quickly? If unemployment continues to rise, will more unemployed adult children keep their parents at home? The Power of Ethical Marketing The LTC Continuum AL NF Sub Acute Remember To Be Realistic. Ask Yourself… • Where do I want to live when I’m 85? Nursing home Assisted living facility Your own home Attitudes and Perceptions Kaiser Family Foundation Research • 35% think nursing homes do a good job of serving health care consumers. • 50% think assisted living providers do a good job of serving health care consumers. Driving Forces in the Long Term Care Marketplace • The “Age of the Elderly” & senior affluence. • Growing desire to stay at home longer is leading to higher resident acuity at move-in. • The lines have blurred among provider types and that trend will continue. • Consumers are more educated and have access to more information especially via the Internet. • More public dollars flowing to home- and community-based settings. • Boomers are in the driver’s seat. • Seniors are more independent physically and mentally. Seniors’ Impressions Of Moving Seniors relocating face: Giving up their own home Making new friends Fear of losing personal control Realizing a decline in doing things for themselves Changing familiar routines Severing of emotional attachments (Journal of Gerontological Nursing, Oct. 2004) New Residents’ Greatest Fears • Fear of losing independence is #1 • Fear of losing privacy • Fear of losing control • Food − When will I eat? − Where will I eat? − What will I eat? Resident Feelings • It is normal for the residents to feel: Angry Fearful Frustrated Hurt Sad Insecure Common New Resident Questions • • • • • • • What furniture can I bring? Who will give me my medicine? Will “they” tell me what to do? How will I get to the dining room? Will they have food like I cook at home? Who will I sit with? Is my family going to leave me? Admission • Recognizing liability triggers. • Identifying situations that create unrealistic expectations of care, service and outcome. • Establishing a protocol to involve nursing management and the physician when necessary. Recognizing Liability Triggers • What family members say about a resident • How family members ask questions about the facility • Their perception of assisted living • Their expected outcome Admission Protocol • Use the admission process to identify potential exposures. • Involve nursing and physician. • Identify needs of supporting family members. • Document all communication. Ask Yourself -Do the financial incentives for the marketing staff invite increased risk or decrease my profit potential? LITIGATION State Litigation • Medicaid Fraud Control Units Expanded authority with jurisdiction over nonMedicaid residential care settings Knowledgeable about LTC • Use consumer protection laws Deceptive trade practices False advertising Consumer fraud prevention State Litigation • Most states have similar consumer protection laws − Steep fines + damages + attorney’s fees − Additional liability if elderly or disabled − Allow for civil actions − Injunction authority • State attorneys general are close-knit, political and copy each other • Applies to all long term care facilities “An Ounce of Prevention…” Review materials Contracts/Admission Agreements Marketing Brochures Advertising Train staff Address problems and complaints ASAP Self-monitor Reasons Family Members Give For Suing Source: Tra Beicher, Risk Manager • • • • “I just couldn’t get them to listen to me.” “I knew something was wrong…” “I didn’t know this was going to happen.” “My [Mom/Dad/Aunt] just kept getting worse and worse.” • “They didn’t even apologize.” Key Factors That Drive Families to Sue Source: Tra Beicher, Risk Manager 1. Attitude of staff 2. Lack of communication 3. Unmet resident and family expectations Set Realistic Expectations for Residents and Families • Communicate reality: Families don’t see many conditions as terminal. • Talk openly about physical and mental decline. • Explain services that are not available. • Know and explain that the environment won’t fix all resident/family problems. • Provide clear information about how to complain. Three Things To Do Now • Teach staff to apologize • Give the family something tangible • Attach someone to the problem NCAL’s The Power of Ethical Marketing Disclosure Builds trust between the residence and the consumer Admission and Discharge Policies Contracts All Fee Schedules The Power of the Written Word • Opportunity to Showcase • Accuracy • Consistent with Spoken Word • Periodic Review and Comparison The Power of the Spoken Word Perception is Reality The Power of the Spoken Word The Tour Professionalism Balanced Presentation Effective Listening Personalized The Power of the Spoken Word • Staff Involvement • Resident Involvement • Consistent with Written Materials Disclosure and Dementia Care MetLife Mature Market Institute 2009 Findings • 59% of ALFs provide dementia care with 52% charging an additional average $1,304 per month. • 29% of nursing homes surveyed had separate dementia units and only 10% charge an additional fee. Those that did charged an average of $10 more per day. Customer Referral Form Tour Name: _____________________________________________________ Address: _____________________________________________________ City, State and Zip:_____________________________________________________ Telephone: _____________________________________________________ Referral Source: (circle one) Physician Family Member Clergy Social Worker Telephone Book Friend Drive-By Newspaper Ad Area Agency on Aging Hospital Licensing Other: ______________ Prospective Resident Information: Name: ____________________________________________________ Current Living Situation (circle one): Lives Alone Assisted Living Facility Nursing Home Other Needs Assistance With:_______________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Follow-Up Needed For: ______________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Staff Signature: _____________________________________________________ Date: ________________ Resident/Family Inquiry Form Name: _____________________________________________________________________________________________ Telephone: _____________________________________________________________________________________________ Nature of Inquiry: (circle one) Complaint Suggestion Feedback Other Comments:________________________________________________________________________________________________ __________________________________________________________________________________________________________ Action Taken:______________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Action Requested:__________________________________________________________________________________________ __________________________________________________________________________________________________________ Staff Signature:_____________________________________________________________________________________________ Date: ______________________________________________________________________________________________________ The Power of the Internet • User-Friendly Website • Current Information • Virtual Tours = In-person Tours • Privacy Issues • American Marketing Association’s Code of Ethics AMA’s Internet Code of Ethics • Support professional ethics to avoid harm by protecting the rights of privacy, ownership and access. • Adherence to applicable laws and regulations. • Awareness of changes in regulations related to Internet marketing. AMA’s Internet Code of Ethics cont. • Effective communication to organizational members on risks and policies related to internet marketing. • Organizational commitment to ethical internet practices communicated to employees, customers, and relevant stakeholders. The Power of the Community • Goodwill • Genuine Interest • Positive Impact • Sincerity The Power of Teamwork ALL STAFF COUNT ! • Education and Training • Staff Empowerment • Approval to say “I Don’t Know” • Follow up • Unified Customer Focus Teamwork Cont. Customer Service Telephone etiquette Listening skills Presentation skills Affect and expression Body language Fair Housing Act Prohibits discrimination based on: Race Religion Color Sex Disability Familial status National origin Americans with Disabilities Act • Prohibits discrimination based on physical or mental handicap in public accommodations operated by private entities. • 800/514-0301 (voice) or 800/514-0383 (TDD) Integrating FHA and ADA • Terminology • Photographs • Equal Housing Opportunity Logo • Fair Housing Policy Statement • Staff Training AMA’s Code of Ethics • Responsibility of the Marketer • Honesty and Fairness • Rights and Duties • Organizational Relationships Checklist for Staff _______ Does your written marketing material fully disclose in plain language your services and amenities? ______ Does your marketing material promise or allude to services that your residence is not able to provide? ______ Have you reviewed your written marketing material on a yearly basis and any time your state regulations change? ______ Have you incorporated customer-based marketing skills into your residence’s employee orientation program? Checklist Cont. ______ Have you trained your staff about the marketing materials? ______ Is your website current, functioning and userfriendly? ______ Do your advertisements contain the Equal Housing Opportunity logo? ______ Are the photographs in your printed advertisements representative of your community? NCAL’s Guiding Principles for Providing Information to Consumers • Main purpose: to articulate more fully NCAL’s commitment to ethical marketing practices and full disclosure of information to prospective and current assisted living resident sand their families or responsible parties. Consumer Disclosure Components • Contracts • Finances • Transfer and/or Move-out • Appeals Process • Special Care Provisions • Resources for Consumers Contracts • Primary tools to explain legal responsibilities of both the provider and the resident • Contract language should be consistent with all marketing materials and information conveyed verbally or through Web sites • Modifications may be made only with the agreement of all parties involved Contracts • Simple language is best • Review of contract by third party • Signature by responsible party or third party • Obtain rights, options, and limitations concerning the resident’s ability to obtain services outside of facility Finances • Fee increases • Refundable or non-refundable fees • Management of resident finances • Public financing options Transfer or Move Out • 30 days notice (minimum) • Effective date of transfer • Reasons (facts and circumstances) • Appeal process and time frame • LTC Ombudsman contact information • Right to representation Special Care • Special care provisions (Alzheimer’s care, etc) • Advance directives • End-of-life care Posting of State Contact Information • State or local long term care ombudsman program • State regulatory agency • Other advocacy bodies or government agencies mandated to be posted. Choosing an Assisted Living Residence • This guide helps future residents and their families learn about assisted living, determine whether it is an appropriate living option for their needs and preferences, and helps them make a wise selection. “The goal is to maintain maximum independence in a home-like setting.” Moving Into an Assisted Living Residence: Making A Successful Transition • This guide helps residents about to transition into an assisted living community. It covers: • Privacy Concerns • What to Bring to Your New Home • Moving Day Helpers • Making the Emotional Transition • Advice for Residents and their Families • Suggested Do’s and Don’ts Preparing Residents for Moving Out of Assisted Living Residences • This guide helps assisted living professionals prepare and support residents when they move-in or move-out to reduce stress and anxiety. “ALRs should find ways to facilitate an easy transition and one that makes the resident feel special and loved.” NCAL’s New Web site – www.ncal.org Assisted Living Research and Studies News Webinar and Event Info. NCAL Publications Quality Resource Labor, Workforce & OSHA Resources Consumer Resources Legislative Updates Practice Guidelines and Training Tools And more… National Assisted Living Week September 12 – 18, 2010 Contact Shane Osborne at [email protected] for an electronic version of this year’s logo. The Planning Guide and Product Catalog will be available in June! Visit www.nalw.org for more information.