Phil Manz Director of Assisted Living, Housing and Home Care Pmanz@careproviders 952 851 2484

1. Update on 2009 Legislative Agenda of theLong-Term Care ImperativeandElderly Waiver Customized LivingRate Setting Toolkit and Process Phil Manz Director of Assisted Living, Housing and Home Care Pmanz@careproviders.org 952 851 2484 Care Providers of Minnesota January 2009 Regional Meetings

2. 2009 Long-Term Care ImperativeLegislative Agenda Care Providers of Minnesota January 2009 Regional Meetings Developed in 2008 with member input $426 Million Deficit Thru June 30, 2009 November 08 Forecast of $4.8 Billion Deficit for July 1, 2009 thru June 30, 2011 February 09 Forecast Deficit Will Be Growing Governor Unalloted to Cover Thru 6/30/09 Governor releases plan for July 1, 2009 thru June 30, 2011 on January 27, 2009

3. Elderly Waiver Customized Living Rate Setting Toolkit and ProcessAgenda EWCL Rate Setting Process 2007 – 2008 EWCL Rate Setting 2009 Timeline Goal – Understanding of the critical issues that current draft of tools presents Goal – Catalyze and capture feedback of stakeholders who have used the tools Care Providers of Minnesota January 2009 Regional Meetings

4. EWCL Rate-setting Process – 2007 Providers met separately 5 times with DHS – Advocated for Joint meetings with lead agencies User’s manual with definitions and instructions Test all parts of rate tools together DHS Attendance at regional meetings Care Providers of Minnesota January 2009 Regional Meetings

5. EWCL Rate Setting Process - 2008 January 8 – DHS Video Conference March Regional Meetings – DHS Discusses/Gets Feedback on EWCL Contract Planning Worksheet, Part 1 June 19 – DHS Video Conference Fall Regional Meetings – Discuss county understanding of documents proposed at June 19 DHS video conference Care Providers of Minnesota January 2009 Regional Meetings

6. EWCL Rate Setting Process - 2008 • Fall – DHS negotiates renewal of Elderly Waiver Program with federal officials (CMS) • November 13 – EWCL Stakeholder Group Meets – DHS Announces Agreement with federal officials (CMS) and New Timetable • Dec 1 and 3 – Provider Stakeholders Meet for 5 to 6 hours to begin understanding the tools • December 11 – DHS Video Conference • December 16 – 1 Hour of EWCL Stakeholder Group Discussion Care Providers of Minnesota January 2009 Regional Meetings

7. EWCL Rate Setting 2009 Timeline DHS to Issue Bulletin with Rate Setting Tool Kit by January 1, 2009 Care Providers of Minnesota Regional Meetings: January 6 - 16 EWCL Stakeholder Group Training – Jan 15, Jan 29, Feb 26, March 26 DHS will use “SNAP” Surveys thru 3/31 Care Providers of Minnesota Regional Meetings – March 3 - 13 “Final” Bulletin to be Issued June 30, 2009 Care Providers of Minnesota January 2009 Regional Meetings

8. Objectives: Critical Issue #1 Understand how most of your home care services operation for all clients, public and private pay, is allocated among five hourly service categories that are divided into scheduled and unscheduled (supervision) sections, for the purposes of negotiating your service rates. Care Providers of Minnesota January 2009 Regional Meetings

9. Objectives: Critical Issue #2 Understand the implications of having most of your home care services operation allocated in the manner proposed. For example, will “staffing ratios” for clients become available on the Internet? Care Providers of Minnesota January 2009 Regional Meetings

10. Objectives: Critical Issue #3 Understand if and how the separation of scheduled and unscheduled (supervision) hours is accounted for in the delivery of services to a client. Care Providers of Minnesota January 2009 Regional Meetings

11. Objectives: Critical Issue #4 Care Providers of Minnesota January 2009 Regional Meetings Enhance your nursing practice by understanding how supervision as defined in the Nurse Practice Act is distinguished from the definition of supervision used in the service definitions in the EWCL rate setting tools.

12. Objectives: Critical Issue # 5 Understand how a case manager will develop an individualized EW Customized Living Plan that takes into account the allocations of hourly service rates. Care Providers of Minnesota January 2009 Regional Meetings

13. The EWCL Tool Kit 1) EW Customized Living Contract Planning Worksheet, Part I 2) Purchasing Customized Living Services in the EW Program 3) EW Customized Living Excel Workbook Contract Negotiation and Management as of 11 21 08 A) EW Customized Living Component Input Worksheet, (AKA: Component Rates Input Form) B) EW Customized Living Negotiated Component Rates (AKA: Negotiated CL Rates) C) Individualized EW Customized Living Plan - One page 11 x 17 inches - Seven pages 8.5 x 11 inches Care Providers of Minnesota January 2009 Regional Meetings

14. The EWCL Tool Kit 3) (Continued) Reference Worksheets D) CL Component Rate Limits E) Customized Living Rate Limit F) County Geographical Groups G) Information from Individual’s Screening Document H) EW Community Support Plan 4) Instructions for Workgroup Review and Testing of EW CustomizedLiving Tools (17 legal pages) Care Providers of Minnesota January 2009 Regional Meetings

15. The EWCL Tool Kit 5) Instructions for Completing the Elderly Waiver Customized Living/24 Hour Customized Living Component Input Worksheet(8 pages) Corrected 07-25-01C Comprehensive Policy on Elderly Waiver (EW) Customized (Formerly Assisted) Living Appendix A, B, C not included in handouts Deconstructing Definitions of Supervision for January 2009 Region Meetings Class A and Class F Definitions of Home Management, Care Aide, and Health Aide Tasks for January 2009 Regional Meeting We anticipate that some or all of the first 5 sets of handouts will be in the bulletin scheduled to be delivered by January 1, 2009. Care Providers of Minnesota January 2009 Regional Meetings

16. The EWCL Tool Kit Training Utilizes “Excel” Spreadsheets Benefits from 5 and 6 hour meetings of multiple members from multiple organizations in early December 2008 Will defer to Bulletin that was scheduled to be sent January 1, 2009 Has led to extended discussions of terms used Will benefit from extended discussions between providers and lead agencies Care Providers of Minnesota January 2009 Regional Meetings

17. The EWCL Tool Kit Training Represents a significant amount of work that doesn’t necessarily answer the question about what could change a provider’s reimbursement Information not listed on the tools can be as critical as information listed on the tools Focus on numbers/math because they are objective measurements and could be used to establish ratios that will be used for years to come Daunting task to develop these EWCL tools and then provide training and instructions Care Providers of Minnesota January 2009 Regional Meetings

18. EWCL Tool Kit - 1) EW Customized Living Contract Planning Worksheet Vetted at State wide Regional Meetings in 2008 Colors of Services Have Meaning Green – Home Mgt/Making/Support Service Red – Home Care Aide Service Orange – Home Health Aide Service Purple – Licensed Nurse Service Confusion of Class A and Class F language on page 12 – “Like Tasks” Care Providers of Minnesota January 2009 Regional Meetings

19. EWCL Kit – 5) Instructions for Completing the EWCL/24HrCL Component Input Worksheet Lines 15 – 19) “Setting” – Does this mean HwS registration? Lines 21 – 24) “Level of service” – How is this determined? Memory Care, Case Mix A - K Lines 26 – 29) Lead agency may request verification of staffing and average number of residents served Line 53-54) HwS Provider Location – Physical site registered with MDH, How will campus names be included in “establishment name/provider location” Lines 109 – 126) Hourly Rate Limits – “Legislature grants increases or requires decreases in comparative rates” Care Providers of Minnesota January 2009 Regional Meetings

20. EWCL Kit – 5) Instructions for Completing the EWCL/24HrCL Component Input Worksheet Lines 140 – 141) Staff time spent on congregate meal preparation should be included in the total home management staff hours reported. Lines 154 – 155) Level of service defined by different staff schedules and staff competencies Lines 155 – 157) Worksheet for each staffing model (Schedule) Lines 196 – 198) Medication set-ups must be purchased based on time Line 263) Service Delivery Planning Tool(AKA: Individualized EW Customized Living Plan) Care Providers of Minnesota January 2009 Regional Meetings

21. EWCL Kit – 3A) EWCL Customized Living Component Input Worksheet Services Offered – Customized Living/24 Hour Customized Living Program Offered – How to summarize 12 page document into one line? Programs (Worksheet) vs. Setting, Level of Service (Directions) Minimum Direct Care = Unlicensed staff hours available on average per day (24 hour period) in HwS setting, regardless of payor Hourly Service Rate – Is for a service not an employee, although they can frequently be confused Scheduled Hours with Assigned Tasks vs. “Supervision Only” Care Providers of Minnesota January 2009 Regional Meetings

22. EWCL Kit – 3A) Component Worksheet Minimum Direct Care = Unlicensed staff hours available on average per day (24 hour period) in HwS setting, regardless of payor 1, 1, 1, 1, 1.3, 1.64, 1.95, 2.27, 2.29, 2.56, 3.07 Average = 1.73 Mode = 1.0 Median = 1.64 Regardless of payor = All your clients Care Providers of Minnesota January 2009 Regional Meetings

23. EWCL Kit – 3A) Component Worksheet Hourly Service Rate – Is for a service not an employee, although they can frequently be confused. Note: provider may receive higher “hourly rate” for private pay than public pay. To determine the cost of your service, use all costs necessary to deliver that service that are not being allocated to another service, for example rent. Care Providers of Minnesota January 2009 Regional Meetings

24. EWCL Kit – 3A) Component Worksheet Outstanding issues: Distinguishing home management, home care aide and home health aide tasks for employees is challenging. (Handout #8) Home care aides are not permitted to provide “assistance with self-administration of medicine” Home care aide rate is artificially created: Average of Home Management and Home Health Aide Home health care aide rate is 90% of Fee for Service Equivalent Care Providers of Minnesota January 2009 Regional Meetings

25. EWCL Kit – 3A) Component Worksheet One example with 123 residents receiving services, 98 receiving supervision Average daily payment for assigned hours: $6,239.96/123 = $50.76 for supervision hours: $2,229.38/98 = $22.85 Care Providers of Minnesota January 2009 Regional Meetings

26. EWCL Kit – 3A) Component Worksheet Average monthly supervision = $22.85 x 30.4 days/month = $694.64 Case Mix C 24 CL Monthly Limit $3,064.00 – Average monthly supervision $ 694.64 = Available for assigned tasks $2,369.36 If client’s total assigned tasks > $2,369.36, multi-tasking factor (Cell R94 on Individualized EW Customized Living plan) equation takes $ from supervision allocation. Care Providers of Minnesota January 2009 Regional Meetings

27. EWCL Kit – C) Individualized EW Customized Living Plan and 4) Instructions for Workgroup Review and Testing of EW Customized Living Tools EW Customized Living Plan starts with smaller dollar items that, in general, increase in size, ending with supervision. How will this work practically with case workers and clients? How will all stakeholders react if and when we can’t afford what we want to provide? How will all these choices be shown to participants? One page 11 x 17 inches or Seven pages 8.5 x 11 inches Care Providers of Minnesota January 2009 Regional Meetings

28. EWCL Kit – 3A) Component Worksheet 1) Negotiated Rate vs. Service Rate Limit 2) Type of service rates – Slide 23 Example Home Health to Home Care Assigned Hours 154/16.67 ~ 10:1 Home Health to Home Care Supervision Hrs 76/8 ~ 9:1 3) Hours deployed Assigned vs. Supervision Home Care Assigned vs. Supervision Hours 16.67/8.21 ~ 2:1 Home Health Assigned vs. Supervision 154/76 ~ 2:1 Care Providers of Minnesota January 2009 Regional Meetings

29. EWCL Kit - Discussion of “Supervision” Compare 6) Comprehensive Policy on EWCL page 11 compared to Handout 3C) Individualized EW Customized Living Plan Care Providers of Minnesota January 2009 Regional Meetings

30. EWCL Kit – Discussion of Supervision Do the supervision plan requirements and definitions change one’s understanding of how they deploy staff? EWCL Kit implies all tasks are scheduled vs. unscheduled; what is your experience? Does it make sense to deconstruct supervision? Handout 7) Deconstructing Definitions of Supervision for January 2009 Region Meetings Care Providers of Minnesota January 2009 Regional Meetings

31. EWCL Kit – In Conclusion Raised more questions than answers? Evaluation Sheets Are Really Important How to keep stakeholders invested in the validation of the tools? Care Providers of Minnesota January 2009 Regional Meetings