AHCA/NCAL 58th Annual Convention and Exposition October 7-10, 2007 Boston, MA Effective Packaging of Personal Care Servi

1. AHCA/NCAL 58th Annual Convention and Exposition October 7-10, 2007 Boston, MA Effective Packaging of Personal Care Services in Assisted Living NCAL Day – October 7, 2007 2:15-4:15 pm

2. Presenters • Tom Melchior, Manager, LarsonAllen Minneapolis, MN • Rosemary Brandt, RN, Assisted Living Nurse Consultant, Tealwood Care Centers Bloomington, MN • Dennis Acrea, Senior Vice President, Benedictine Health System Cambridge, MN • Susan Taylor, Vice President, Health Service Innovations St. Paul, MN

3. Learning Outcomes • Understand the various approaches to service delivery and the pros and cons of each. • Learn how diverse organizations custom designed service packages to meet residents’ needs. • Recognize the revenue implications of flexible approaches to service delivery.

4. Introduction and Background Assisted Living and the Senior Care Continuum

5. Types of Senior Housing • Few/no services • Age-restricted townhomes & single-family homes, for sale or rental; may be part of a campus • Senior ownership, usually very limited services • “Active adult” single or multi-family, own or rent • Housing with services • Independent/congregate housing – some services (i.e., meals, housekeeping) may be included in the rent or all services may be optional • Assisted living – basic services (meals, housekeeping) usually included in the rent; some also include personal care services in the rent (often the case with memory care); others have all personal care as an option

6. Assisted Living – Services and Housing • Variety of definitions of “Assisted Living” • “Assisted Living” refers to housing AND care • The care can be delivered in a variety of settings • Key is that supportive services are provided: • Meals, housekeeping, laundry, supervision • Assistance with ADL’s • Possibly activities/socialization, transportation

7. Growth in Demand for Assisted Living • Persons Age 85+ • 2.2 million in 1980 • 4.3 million in 2000 • 9.6 million in 2030 • 15.4 million in 2040 • In 2004: • 36,000 assisted living residences • Serving 900,000 persons

8. Types of Services • Real Estate (the “Room” of “Room and board”) • Housing unit (includes management, building maintenance, etc.) • Basic Services • Meals • Housekeeping • Laundry (may be provided as part of a personal care package) • Linen service (may be provided as part of a personal care package)

9. Types of Services - Continued • Personal care - assistance with ADL’s/IADL’s • ADL’s include: assistance with bathing, dressing, toileting, etc. • IADL’s include: assistance with housekeeping, shopping, medication • Persons with dementia (memory loss) may have additional needs such as redirection or special needs related to behavior

10. 3 Methods of Service Delivery • All-inclusive • A la carte • Packaged plans • Fixed-service packages • Flexible-service packages • Time-specific packages • Packages offered for services other than “room and board” (room and board includes housing, meals, housekeeping, activities, and transportation)

11. All-Inclusive • All personal care services, including escorts, medication management, etc. is included along with “room and board” (housing unit, meals, utilities) for one fixed monthly fee • Tends to attract very frail seniors, due to level of services provided • Usually applies to smaller units, typically studios and often in shared units • Costs typically $3,500 and up, typically $4,000+

12. A la Carte • All personal care services provided on an individual basis, “pay as you go,” billed monthly to the resident • Housing and meal costs (two to three meals per day) usually bundled, including utility costs • May provide the highest level of revenue, since “full price” attained for each service, but billing can be cumbersome • Services may be provided and charged 1) for each use (i.e., each medication reminder or per bathing assist) or 2) by time only (i.e., per 15-minute increment)

13. Packaged Plans • Most housing with services buildings provide services in packages; easier for residents/families to comprehend; easier for billing purposes • Packaged plans are a compromise between all-inclusive service plans and totally a la carte services • There are many ways service packages are organized. The categories of packages are: • Fixed-service packages • Flexible-service packages • Time-specific packages

14. Fixed-Service Packages • Packages include specific services: • package A consists of bathing assistance 2 times per week and one med reminder per day; • package B consists of package A plus morning and evening cares (dressing and grooming assistance) and 2 med reminders per day, etc. • Residents take the package that best meets their needs based on the services included • 2 to 5 levels are usually offered (possibly more), 3 to 4 are typical • Often a resident can fit into one package with a limited a la carte service added to satisfy a specific need

15. Flexible-Service Packages • Resident’s care plan based on a staff evaluation; services are based on resident’s individual needs • A point system is used to determine fees • This method provides the most individualized plan for residents and relates costs to specific needs • Billing is easy, since the cost falls into a specific service level based on the point total • 3 to 5 levels are typical, but some organizations have 8 or more • The greater number of levels often relate to a higher level of service provided (i.e., incontinence care) as well as more refined package distinctions

16. Time-Specific Packages • Services provided within specific blocks of time, i.e., one-half hour per day, one hour per day, etc. or perhaps by the amount of time per week required • Residents provided with whatever specific services needed within the time frame of the package… bathing assistance, dressing assistance, escorts, etc. • Medication reminders often provided separately • Costs determined based on time

17. PRE-ADMISSION ASSESSMENTThe Stepping Stone to Services

18. Why Do A Pre-Admission Assessment? Services Needed/Wanted Services Available Facility Criteria Alternative Sources of Care

19. When Is The Assessment Done? Prior to Admission Prior to Initiation of Services How Is The Assessment Done? ____________________________ Communication Observation

20. What Is Assessed? Physical Status Functional Status Cognitive Status Where Does the Assessment Take Place? ______________________________________ Home Hospital Long Term Care Facility Other Senior Living Facility

21. Who Contributes To The Assessment? Potential Tenant Family Members Facility Staff (if in another facility) Medical Personnel

22. What Tools Are Used In The Assessment? • Pre-Screening Questionnaire • Mental Status Questionnaire • Assessment for Self-Administration of Medications

23. The Assessment Home Environment Communication Personal Hygiene Needs Nutrition/Diet Needs Mobility Needs Elimination Needs Mental Needs

24. The Assessment - continued Physical Needs Social Support Needs Medications Vulnerability

25. Service Charges Based on Assessment Ala Carte Pay only for services needed/wanted Determination ofcost Based on region Time needed to complete task

26. Packaged Services Memory Care Three Levels All-inclusive

27. Incidental Charges Based on time involved Non-scheduled services Tenant requested

28. Case Study 83 year old gentleman Recently widowed Lives at home Daughter lives in area Very supportive family

29. Case Study - continued House in disarray Urine odor Wheelchair folded up in corner Difficulty hearing Cat

30. Case Study - continued Incontinent care Bathing assist Medication assist Assistance with hearing aid

31. Assisted Living Service Packages – Alternative Plans AHCA Annual Convention and Exposition - 2007

32. Key Elements of Success • Management is up to the task • Ability to project revenues and expenses • Know operating efficiencies • Clear value for monthly service fee(s) • Careful monitoring of Aging in Place • Active monitoring of resident profile • Tracking Local Occupancies of Assisted Living • Up-to-date data regarding service delivery models Integration with referral sources/spectrum providers

33. Physical Location of the Facility • Attached to an existing SNF • Stand alone facility, on-site of SNF • Stand alone facility, off-site 6.03

34. CASE STUDY - Metro 29 Independent Living Units 30 Assisted Living Units

35. Assessment Methodology

36. Assessment Methodology – continued

37. Assessment Methodology – continued

38. Assessment Methodology – continued

39. Assessment Methodology – continued

40. Package Plan Methodology • Heavily dependent on relationship with clients and families • Easy to Explain • No surprise bill • Consumer friendly • Assessment tracks increased services • Allows negotiated risk • Staff has flexibility

41. Personal Care Package A • Our Monthly Service Fee provides you with a base of support which includes our Personal Care Package A: • Noon Meal • 24-Hour onsite staff • 24-Hour emergency response system • Weekly light housekeeping • Activities and Spiritual programs • Scheduled shopping transportation

42. Personal Care Package B • Daily Continental Breakfast & Supper • Weekly Bed and Bath Laundry Service • 24-hour emergency call system response – up to 3 times per month – ($5.00/additional call) • Daily Wellness Check

43. Personal Care Package C • All the services in Personal Care Packages A, B and…. • Personal Laundry Service–pickup, wash, dry, fold and deliver up to 3 loads per week (does not include dry cleaning). • 24-hour emergency call system response - up to 5 times per month -($5.00/additional call) • Personalized service plan with staff assistance in the areas indicated in our assessment.

44. Personal Care Package D • All the services in Personal Care Packages A, B, C and … • 24-hour emergency system response - up to 10 times per month – ($5.00/additional call) • Medication Assistance - up to 3 reminders per day • Personalized service plan with staff assistance in the areas indicated in our assessment.

45. Personal Care Package E • All the services in Personal Care Packages above and… • 24-hour emergency call system response - up to 15 times per month –($5.00/additional call) • Weekly Medication Set up • Medication Assistance – up to 6 reminders per day • Personalized service plan with staff assistance in the areas indicated in our assessment.

46. Personal Care Package G • All the services in packages above as needed and… • 24 – Hour Emergency Call System Response as needed • Daily Confusion Management – providing escorts, cueing and reminders for those who require regular daily assistance and oversight • Daily Incontinence Management (tenant must provide any needed incontinence products) • Personalized service plan with staff assistance in the areas indicated in our assessment

47. Triggers to Higher Levels of Service Plans • ADL Assessment • Non-scheduled ADL Assist • Medication Management • Medical Monitoring • Escorts and cueing due to cognitive needs • Wander Alert Door Monitoring

48. Continued Stay Criteria • Able to function safely and appropriately • Performs ADL with available assistance • Feeds self or needs minimal assistance • Mobility with devices or available assistance • Manages continence w/ available assistance • Does not endanger self or others • Behaviors managed w/ available assistance

49. 1998 Staffing 8.00 FTE P C A 1.00 FTE RN 1.00 FTE LPN 0.50 FTE Housekeeping 0.50 FTE Maintenance 1.00 FTE Manager 12.00 FTE Total 2007 Staffing 8.88 FTE 1.40 FTE 0 1.43 FTE .50 FTE 1.00 FTE 13.21 FTE Total Staffing Assumptions

50. Key Elements of Success • Management is up to the task • Ability to project revenues and expenses • Know operating efficiencies • Clear value for monthly service fee(s) • Careful monitoring of Aging in Place • Active monitoring of resident profile • Tracking Local Occupancies of Assisted Living • Up-to-date data regarding service delivery models Integration with referral sources/spectrum providers