Care Providers of Minnesota December 12 2006 Contracting

Care Providers of Minnesota December 12, 2006 “Contracting with Private Nursing Homes to Assure a Continuum of the Highest Quality of Care for Veterans” Dan Goedken, MSSW, LICSW Coordinator, CNH Program Minneapolis VA Medical Center 612. 567. 4530 1

A brief personal resume: 1968 -1971, US Army 1971, started in the VA (Iowa City, Milwaukee) 1976, BSW, U of Iowa 1979, MSSW, U of Louisville 1988, joined staff at Minneapolis VAMC 10 years as Coordinator, CNH Program 4 GAO, OIG federal inspections of CNH Program 5 years as SW Supervisor Married to a Army Reservist Nurse 2

An overview of the national VA system: VA medical system consists of integrated networks of care (VISNs) that are focused on pooling and aligning resources to better meet local health care needs and provide greater access to care………… 3

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Nation-wide, there are over 1, 300 VA care facilities, including…. 163 hospitals, n 850 community-based outpatient clinics, n 206 veteran counseling centers, n 137 VAMC nursing homes, and n 43 domiciliary facilities n 5

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Regardless of where the veteran resides, all veterans need to be enrolled in the VA to receive VA health care ~~~~~ For veterans not enrolled, call the nearest VAMC For Minneapolis VAMC area, call VA Patient Access Center 612 -467 -2071 7

ONCE ENROLLED…. . (REGARDLESS OF LENGTH OF MILITARY SERVICE OR COMBAT INVOLVEMENT) ALL VETERANS ARE RECOGNIZED IN ONE OF TWO VA ELIGIBILITY CATEGORIES 8

n Nonservice-connected (NSC) Veteran does not have injuries or illness that were determined (rated) by the VA to have been incurred or aggravated by their military service. n Service-connected (SC) Veteran has been determined by VA to have a disability or illness incurred or aggravated by their military service. Rating will range from 0% SC (non-compensable) to 100% SC ($2, 400+/month). SC veterans are potentially “Millennium Act” veterans. 9

Although the NSC and SC rating is the over-riding eligibility determination, there are other secondary eligibilities that might create access to particular VA clinics or specialized care: n n n n Agent Orange Exposure Ionizing Radiation Exposure Atomic Veterans Prisoners of War Military sexual trauma OIF/OEF Polytrauma Care Purple Heart 10

Some veterans will be billed for services. 1. Service connected veterans receive services almost entirely without co-payments or charges. 2. Non-service connected veterans, depending on a financial means test, may have charges: n n Medications ($8/month per prescription) Inpatient days, similar to Medicare Outpatient clinic charges ($15 -50) Contracted care in the community 11

Now a closer look at VA funding for enrolled veterans to receive care in the community through VA contracts. 12

VA coverage depends on enrollment and medical determination 1. Home Care n n n Skilled Care Homemaker Home Health Aide 2. Contract Adult Day Health Care 13

3. VA provides nursing home care in three different settings: VAMC Nursing Home Care Units n n In-house programs Minneapolis, St Cloud, Sioux Falls, Fargo State Veterans Homes n n Per diem payments Minneapolis, Fergus Falls, Laverne, Silver Bay, Hastings Contract Nursing Homes n n n Based either on MA or MC case mix formulary Each VA has it’s own CNH program A closer look at CNH……………. 14

The three current CNH patient funding priorities, based on nationally established requirements…. Respite (NTE 30 days a year) n Hospice Care n Long-term (Millennium Act) coverage for SC veterans n n Short-term contracts (discretionary, $) 15

…by the numbers, the Minneapolis VAMC CNH Program, as of 12/1/06……. . 51 Counties of jurisdiction in MN and WI 63 CNH facilities $9, 453, 256 Spent in FY 2005 491 Millennium Act veterans reviewed, 2000 232 Veterans on contract in FY 2005 155 Millennium Act veterans, 12/1/06 16

THREE YEAR CNH SUMMARY 2004 2005 2006 (YTD) Days of care 47, 573 49, 045 57, 276 Number of placed veterans 287 232 260 Mill Act veterans reviewed 78 77 117 17

The Minneapolis CNH Staff Primary Team 1 Coordinator 1 Contracting Officer 5 Clinical Social Workers 4 Nurse Coordinators 1 Dietician 3 Life Safety Inspectors 1 RN/Quality Improvement Consultative Team 1 Geriatrician 1 Physiatrist 1 HBPC Director 1 Clinical Pharmacist 1 Physical Therapist 1 Occupational Therapist 1 Speech Pathologist 18

Contracted veterans residing in a CNH regularly receive outreach visits from the VA. Social Work or Nurse Limited other follow-up by mental health or other disciplines Telephone or visit Chart review, assessment visit with patient, speak with staff Ensures continuity of care/coordination between the CNH and VA Quality oversight of the plan of care Troubleshooting issues Review for appropriate discharge planning Life safety inspector every 3 years 19

So why would a nursing home wanta VA contract? n n n n Broadens the pool of available funding Higher daily funding than MA provides Increased opportunities to serve America’s veterans Increases the gender mix/more male referrals May contribute to Culture Transformation Unique geographic offering Access to increased VA clinics for support VA RN and SW visits to veterans on contract 20

And there are certainly reasons why a nursing home may not wanta VA contract…. n n n n Paperwork Accountability Perceived too few referrals for the effort NH is too small to offer unique options to the VA NH occupancy is generally already 100% NH is not 100% fire sprinkled Therapy VA pre-authorization 21

On average, the Minneapolis VAMC maintains 60+ nursing homes on contract. In any given year, we non-renew/loose 4 -6 facilities. And we add a similar number, based on, among other reasons……. . 22

VA needs assessment for a new CNH: n current availability of VA funding, n implications for growth/decline in the current contract facilities, n density/proximity of existing contract facilities, n tendency for openings within the existing pool of contracted facilities, n unique facilities that serve specialized needs, n the desire to providing ample business to existing contract facilities to warrant their continued affiliation. 23

A primer on the MVAMC VA contract…… n Medicare PPS case mix formulary (53 levels); VA follows CMS for MDS timetable: admission, 14, 30 day, quarterly, annually, significant change. n An all-inclusive contract. Per diem rates include a semi-private room, meals, nursing care, rehabilitation, respiratory, oxygen therapy, medical/nursing supplies. n Most oral medications are included up to 8. 5% of the per diem, as well as most durable medical equipment items, X-rays, and routine lab tests. Medication costs that exceed 8. 5% of the per diem, are billed to the VA at the AWP. High costs meds may be better dispensed by VA. n Specialized equipment (i. e. air fluidized bed) can be pre-authorized. n VA-paid travel to VA appointments. n VA will reimburse the CNH for incurred MD costs. VA follows CMS standards for physician visits (i. e. frequency, documentation, and 24/7 coverage). 24

Contractual stipulations when a veteran is on a VA contract in a CNH…. . Coverage planning: always verify that patient will be covered by the VA. PC: The NH MD needs to solely provide the PC for the CNH veteran. No other payment source for same day coverage. It is fraud to bill two different federal payer sources for services provided within the CNH for the same day of coverage. For example, billing the VA for per diem, and MC for the MD, therapy, medications. (Exception is when a veteran is on hospice: VA will pay R&B, MC will pay for hospice agency to provide end of life meds, hospice staffing, consultation) Medications: VA does not supply routine medications for the CNH patient CNH acquires medications AWP from their own pharmacy source. PT, OT, or SLP: needs to be pre-authorized by the VA. 25

Expectation of timeliness ~ of submitting invoices ~of VA payment Invoices (per diem, medications, pre-approved ancillaries) to the VA should be current (within 15 days following the month of when services when were provided) From the date VA receives the invoice, VA is required to make electronic payment to the CNH account within 30 days If the VA electronic payment is delayed in excessive of 30 days beyond the invoice reception date, VA automatically pays a interest penalty for each day beyond 30: invoice amount x. 55750 daily interest 26

VA CONTRACT “To be considered for a VA contract, or to annually renew an existing contract, VA takes the approach that a broad review of all available data is essential” 27

To assess for a new VA contract, and to annually renew an existing VA contract, we review the following formal documents…… 1. Copy of State License. 2. 2567 state survey, including noted corrections and revisit 3. CNH Continuous Improvement Plan 4. Current CNH annual staff training/competency summary 5. Fire Marshal inspection 7. Indemnification liability insurance certification 8. CNH Emergency Preparedness Plan 28

We also assemble the available web-based information: NH Compare quality measures staffing reports Minnesota Health Facilities Complaint Office Minnesota Nursing Home Report Card OSCAR 3 and 4. NH watch list 29

And initiate regular telephone contact with ……. Veterans Benefit Administration Guardians, conservators, fiduciaries Nursing Home Ombudsman Hx of complaints, trends Amenableness to complaint resolution Evidence of consultation efforts by the NH Staffing/turnover issues Integration of resident/family council process Support of cultural transformation General view of care provided 30

Acquire comparative data from the Department of Health… Average # of state survey deficiencies Deficiency free inspections (If this state’s percentage of deficiency-free inspections are above the VA acceptable 20% threshold, VA is required to report to CMS. ) 31

When a VA contract is up for annual renewal, we also review our own VA electronic medical records (from the monthly SW and RN visits to the CNH) of the veterans served on contract during the last year…. . n n n Clinical observations Quality improvement efforts Patient/family satisfaction or complaints General observations of CNH Observations of staffing issues/turnover 32

So…. the CNH Team routinely…. . and at the time of annual renewal…. Assembles a portfolio of primary and secondary data Applies stringent application of VA standards, and RN and SW complete regular follow-up visits to contracted veterans, and Team reviews the medical records (both VA and CNH records, and Has regular communication with Ombudsman, VBA, and QI/Continuous Improvement initiatives And when warranted, actively communicates with the state survey team to examine particular performance issues. 33

We then annually assemble this assortment of data and apply seven national VA standards…. 34

SEVEN VA CNH STANDARDS 1) Are there three level ‘G’ or higher deficiencies in the current survey? 2) In the current survey, are the total number of health requirement deficiencies twice the state average? 35

3) In the current survey, is there a level ‘E’ or higher deficiency in any of the following areas: Restraints (F 221 or F 222) Abuse (F 223) Staff treatment of patients (F 225 or F 226) Dignity (F 241) Licensure (F 491) 36

4) In the NH Compare review are the RN hours per resident day below the state average? 5) In the NH Compare review are the total nursing staff hours per resident below the state average? 37

6) Are six or more of the MDS quality measures from NH Compare above the state average? 7) In the current survey is there a level “E” or higher deficiency in any of the following areas: a. b. c. d. e. Nursing services (F 353) Nursing aide training (F 494, F 495, or F 496) Regular in-service training (F 497) Proficiency of nursing aides (F 498) Staff qualifications (F 499) 38

To consider the contract, we apply the 7 VA standards…. and review all other relevant performance information… in the determination process. . …. . If a newly proposed contract, proceed or decline Renewal of existing contract (most common) Renewal with added clinical oversight Renewal with additional stipulations Suspension of placements Suspension/termination of contract 39

In summary, through the contract program, VA believes that enhancing the NH care for veterans within the CNH further enhances the care for all residents. 40

For the current CNH programs affiliated with the VA, we thank you for your genuine commitment, your business relationship, and enduring care provided to veterans and their families!! 41

Even if your nursing home does not have a VA contract, the facility can still partner to provide limited services to the veteran…… (based on the veteran’s unique VA eligibility (SC/NSC, etc), some planning & pre-authorization) VA hospitalization: 612 -467 -2019 Brief VA payment for emergency private hospitalization: 612 -467 -2003 VA-paid transportation to VA appointment: 612 -467 -4290 42

Other services: n Outpatient care (specialty or primary care/medications: 612 -467 -2019 n Prosthetics equipment (specialized wheelchairs, etc): 612467 -2001 n Review for discharge planning & home care services: 612567 -1994 43

in the end…. . …. ”the willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive the veterans of earlier wars were treated and appreciated by their nation. ” -George Washington 44