Visions for the Future
: Transforming NursingPrepared by the Illinois Council on Long Term Care
Introduction
Nursing homes in Illinois need to provide better service. Depending on whom you talk to, the nursing home profession is beset with many problems: poor image, media exposes, insufficient staff, inadequate funding, an enforcement system nobody likes, and lack of customer satisfaction. Regardless of what the problems are, dissatisfaction from both within and outside the profession is high. The public and consumers, residents and families, advocates and government, and the nursing home profession itself all recognize that there has to be a better way to provide health care services in Illinois, and that the current long term care system needs to change. Nursing home care needs to be more effectively integrated with and supportive of the continuum of home and community based care for seniors and the disabled. But how should this change take place?
The Immediate Crisis
It is sometimes difficult to talk about visions for the future when the needs of the moment are so critical. A 5.9% rate cut last year, no increases this year, skyrocketing staff and liability costs, and erratic and unpredictable payments from the state have all created a crisis atmosphere where some facilities will not survive. It is difficult to talk the future when survival is at stake.
In the short run, Illinois nursing homes need to stabilize Medicaid payments and restore the 5.9% Medicaid rate cut from July 2002, with future Medicaid reimbursement reflective of the continuing cost of caring for an increasingly fragile population. The recent increase in federal matching funds can restore the 5.9% cut without any cost to the state. In fact, by using federal matching funds to restore the 5.9% cut brings in even more federal matching funds to the state.
In the midst of an economic downtown and state budget crisis, we recognize that the most effective way of raising needed funds is through a provider tax, which brings in increased federal matching funds without any cost to the state general revenue funds. A provider tax is needed at this time to prevent a severe disruption to the continuum of the healthcare delivery system, help address some of the geographic discrepancies in nursing home rates around the state, and lay a foundation in long term changes for the future.
However, a one-time infusion will not address the issues of increasing resident need, greater technology in medical care, higher staffing needs, and the costs involved in the future. As with the federal government and many other states, Illinois should establish a rate review board for a continual review of costs and reimbursement. A review board establishes accountability, ensuring that the state gets value for its dollar. For providers a review board secures an equitable, professional, and even-handed approach to recognizing future medical and economic needs. A review board allows for a more predictable and rational approach to budget planning for both providers and the state.
The state’s current borrowing plan has gone a long way in reducing the existing backlog of Medicaid payments. However, the current borrowing provides no assurance that the payment cycles can be maintained in the near future. A way of stabilizing payments for providers, at no cost to the state, is authorizing a Medicaid receivable bond program through the Illinois Development Finance Authority. This would give providers a regular stabilized payment cycle, and provide some up-front cash so providers can pay the provider tax. The cost of the bond financing program is borne by the providers, although at an interest rate below commercial markets.
Visions for the Future
Illinois nursing homes have serious short-term needs. In the long run, however, the nursing home system in Illinois should be dramatically transformed and strengthened. The Illinois nursing home profession is looking for a partner committed to progressive reform of long term care services in Illinois. The following recommendations from the Illinois Council on Long Term Care outlines how nursing home care in Illinois can be transformed in the future. These innovations address three key areas for change: creating quality staff for quality care, developing smaller and more specialized facilities in a continuum of community based care, and refocusing on resident-centered care within the context of cost accountability.
Visions for the Future -- Caregivers
Professional caregiving is the heart of nursing home care. The quality of the services that residents receive at a nursing home directly reflects the caliber and training of the staff who are providing this care. Nursing home care is labor intensive; 74% of all nursing home expenses are labor related. And yet, this state and nation are in the midst of a very serious shortage of nurses and caregivers, with nursing school enrollments continuing to decline.
To improve nursing home care in the future, state government must be partners with the nursing home profession to encourage more and better paid and better trained staff. The state can create attractive employment opportunities and incentive for more Illinois citizens to enter the nursing field. Here are some short-term solutions for attracting and retaining quality staff that have been proven successful in other states:
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Career Ladder Programs -- Two years ago, the state legislature passed a law that required the Illinois Department of Public Health to develop a nurse assistant career ladder program. Once developed, this program would provide opportunities for nurse aides to receive advanced training, provide better resident care, and enable them to reach higher levels in their professions with increased pay and status. In addition, their training can be used as a bridge towards helping them become nurses. This type of career ladder program helps nurse aides see their jobs not as a "dead ends" but as catalysts towards advancement, respect and achievement, particularly for lower wage minority workers who might normally not have a chance for career advancement. Working with the universities, unions and providers, the state can establish the standards for advanced training. Once standards are agreed upon, the schools, unions and providers can work together to implement the career training that will open up doors of opportunity. Some of the provider tax money can be used to establish the training programs in pilot sites around the state.ü
Medication Technicians -- Another road for the advancement of the nurse aide is the development of a State Medication Technician Program. Through this program, nurse aides receive up to 100 hours of both classroom and clinical training on administering medications. Working under the direct supervision of a Licensed Nurse, the medication aides are then able to pass out routine medications to residents. This program would not reduce the number of nurses in nursing homes, but free up nurses for more direct bedside treatment. Currently, at least 13 states successfully use medication technicians in nursing homes, including Indiana, Iowa and Wisconsin. Earning a medication technician certification enables a nurse aide to earn higher wages, and have a stepping-stone into a career in licensed nursing.ü
Nursing Scholarships -- The nursing profession is facing a serious shortage of young people who are choosing nursing as their career. The average age of a nurse in long- term care is approaching 50 years old. The state can help by dedicating 20% of its existing nursing scholarship program for nurses who are willing to work in long term care. The state pays for these scholarships out of existing license fees and fines.
Visions for the Future -- Smaller and More Specialized Facilities within a Community Context
The state should maintain its commitment to enabling elderly citizens to live at home and receive community-based health care whenever possible. Nursing homes should strengthen their focus in providing higher-level skilled nursing and rehab services in the state's continuum of health care. In each local area, there should be a single source referral center that coordinates the most appropriate, cost-effective placement within the continuum of home and community-based services. Progressive public policy should decrease the competition between home-based services and nursing homes for clients and more effectively assess the services clients need and where they need it. The transition between home care and day care and home health and assisted living and nursing and rehabilitation centers should be more smoothly integrated and case managed, so clients receive the most cost effective care in the least restrictive setting.
When people think of nursing homes, they tend to envision large, self-contained, institutional-looking environments that resemble smaller versions of hospitals, and seem very little like a real "home" setting. To improve living environments in the future, nursing homes should be smaller, with residents living in private rooms whenever possible. These environments need to be more "home-like" and stimulating in nature, filled with plants, animals, and children for emotional health; fitness areas for physical health; safe outside parks for persons with dementia; and internet areas and entertainment sections for mental stimulation and family communication. In addition, these facilities should provide ample transportation opportunities so that the residents can spend more enjoyable hours in the community.
Additionally, it is far more cost effective to revitalize existing nursing homes than construct new ones from scratch. Effective financing and bonding approaches can aid existing facilities to upgrade for modern technology, resident centered equipment, and solar panels and other heating efficiencies.
The following are some practical short-term solutions that the state should consider:
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Single source case management referral system - The current system of determining what services and where a person receives those services is a chaotic hodgepodge of competing and conflicting interests. There is very little oversight in assessing the most cost effective and appropriate care for an individual, whether at home or in a supportive living environment, a nursing facility or a specialized rehabilitation center. Referrals are individually made, some by hospitals, some by community agencies, some by doctors, some by individuals themselves looking in the phone book. There should be a consistent, impartial area case management referral agency – without any ties to a particular provider agency – to assess an individuals needs and serve as a resource to clients and families to assemble the best array of services in the community to meet a client’s needs.ü
A Moratorium on the Number of Nursing Home Beds - With the appropriate increase in home and community alternatives to nursing homes, there are nearly 15,000 unused nursing home beds in Illinois. Excess beds equals inefficiency; more beds than people drive up costs, and creates an insecurity in the healthcare delivery system. Too many nursing home beds in the system causes an unnecessary competition for clients with home and community-based services. Those empty bedrooms are a waste of health care resources and could be converted to more modern, quality living space for residents. The first step in that process is to stop any new beds being crowded into the system. The state legislature should either freeze the number of nursing home beds in Illinois, or have the new health facility planning process issue with a moratorium on nursing home beds.ü
Create a Bond Program for Downsizing Facilities - The second step is to reduce the number of beds. To reduce beds, Illinois could support a bond program for nursing home modernization, and establish an equity capital rate for those homes converting unused beds to quality living space and private bedrooms. Similar "buy back" or conversion programs exist in Minnesota, Iowa, Nebraska, Ohio, and Wisconsin. This program would go a long way in creating more comfortable and home-like environments for Illinois nursing home residents, as well as increasing facility efficiency, and making the entire home and community based system more balanced.ü
Modernization - The most efficient use of healthcare dollars is to modernize existing facilities, creating more livable environments through renovation; upgrading efficiency in heating, cooling, and long term maintenance; and increasing resident and worker safety through new technology and equipment. Low-interest renovation loan through the Health Finance Authority can help transform last century’s infrastructure into modern, efficient, people-friendly living environments.
Visions for the Future -- Resident-Centered Care
Nursing homes promote resident-centered care, meeting the specific needs of each individual resident. This theme is the hallmark of the Pioneer Movement: designing programs to give residents more day-to-day choices in their life routines, and empower front-line staff to make more care decisions for the residents they serve. Across the nation, nursing home providers are looking beyond the traditional nursing home model to develop new and innovative ways to meet each resident's individual care needs. The kind of management and staffing changes these programs require, however, are often beyond the means of Medicaid nursing homes. The state should sponsor an incentive program to those progressive Medicaid facilities willing to invest in innovative, non-traditional approaches to care.
Besides promoting innovation, the state can better meet residents' specific health care needs by certifying nursing facilities based on their specialties. Categories for certification include Alzheimer's disease, stroke, cardiac care, diabetes, skin care and many others. These certifications would help consumers make better nursing home choices, selecting nursing facilities that have the most expertise in the treatment of specific medical conditions.
The state could also help consumers make sound health care decisions by developing resident and family customer satisfaction surveys, sharing these results with the public through the Internet or by publishing an IDPH consumer guide on choosing a nursing home. These materials should emphasize three key areas: the restorative and rehabilitation services that each nursing home provides; the medical specialties of each facility; and the customer satisfaction levels of the individuals served by each home.
This emphasis on care delivery and outcomes should carry over to the state's survey enforcement system as well. The state should focus its system on the results of the care residents receive, with less emphasis on the hundreds of current survey items that have no impact on resident well-being.
Here are the short-term solutions that the state should consider in promoting resident- centered care for Illinois nursing homes:
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Quality of Care Commission Providing Incentive and Innovation Grants - Exceptional performance deserves exceptional recognition. It makes common sense and is good public policy to provide incentives to be the best. The state should develop a Quality of Care Commission to review grant applications and provide incentive payments to nursing homes that develop new and innovative practices. Incentive payments would be tied to specific program improvement and deliverables that increase residents' quality of life and empower front-line caregiving staff.ü
Certification Programs for Specialty Care - The state can develop certification programs for specialty areas of care, such as Alzheimer's, stroke and skin care. This formalized certification program would ensure that each facility has the proper staffing, policies, training and programming in place to meet the health care needs of these specialized populations. Families and referral sources such as hospitals and physicians can use these state certifications to help patients choose the best facility in meeting their specific medical needs.ü
Statewide Resident and Family Satisfaction Surveys - IDPH should work with the provider associations, universities and consumer research experts to develop resident and family satisfaction surveys. Other states, including Michigan, have successfully developed this type of program. The state could share the results from these surveys with consumers, in order to help them make sound decisions on the choice of a health care setting. The surveys would also help to positively focus quality improvement efforts within facilities, as each facility strives to have the highest customer satisfaction ratings in its market area.ü
IDPH Consumer Guide Website Based on Services, Specialties and Satisfaction - Currently, the Illinois Department of Public Health website offers consumers very little helpful information other than reports on survey violations. At best, this tells consumers which nursing home to avoid; it does nothing to help find a good nursing home. Consumers looking for a nursing home want to know which nursing homes can improve a resident’s independence and functioning. Consumers want to know which nursing homes specialize in the problems their family member currently has. Consumers want to know how current residents and families feel about the nursing home. Consumers need more comprehensive and detailed information to make better placement decisions. We strongly recommend that IDPH develop a consumer guide website that reports the restorative services, medical specialties and satisfaction levels for each nursing home in Illinois. This information could also be printed and made available to consumers in a book format.ü
Enforcement Program Based on Sentinel Resident-Centered Events - The current nursing home enforcement program emphasizes a "gottcha" approach to finding deficiencies. There are over 700 regulations that facilities are currently cited for, including the cleanliness of the janitor closet and whether there are dust balls under the bed. In a more sophisticated and technological healthcare delivery system of the 21st century, we are still saddled with a microscopic, paper-intensive enforcement system developed with investigative attitudes and techniques from the 60’s and 70’s. A more progressive enforcement system should emphasize actual resident care outcomes rather than the thousands of minor technical mistakes that can happen in every health care setting. The federal government's 30 "sentinel care" outcomes – based on extensive computerized resident assessment data - provide an effective springboard for evaluating the overall quality of care provided in each Illinois nursing home, allowing enforcement agencies to target areas that warrant more intensive investigation, without bogging themselves and the nursing home community down in a Dick Tracy approach to resident care.
Conclusion
As tightly as resources are stretched, there are some things some nursing homes do poorly – and we all hear about it on the front page of the newspaper. There are many things nursing homes do well which never make the news. And there are some things nursing homes do better than anybody else. Illinois nursing homes are among the top ten states in the national Nursing Home Quality Measures. Illinois nursing homes lead the nation in restoring resident independence. Illinois nursing homes lead the nation in restraint reduction and infection control. Illinois nursing homes take the lead in reducing falls. According to OSHA, Illinois nursing homes are some of the safest in the nation.
While the Illinois nursing home profession faces a variety of challenges, the state has a multitude of opportunities to make a very positive impact on the health care services provided to our state's frail and elderly citizens.
The state can partner with the nursing home profession to employ more, better paid and better trained staff through such effective measures as career ladders and nursing scholarships.
The state’s public policy should be to integrate the disparate home and community- based services into a well-managed continuum of care, from home-care all the way to sub-acute care and rehabilitation services. Nursing homes should evolve from hospital-looking environments to more home-like settings that offer specialty services and private rooms. Resident-centered care should be the underlying theme of care in the future, with incentive grants offered to facilities that develop new and innovative practices. The state can help consumers by publishing the kind of services, specialties and satisfaction levels for each Illinois nursing home on the Internet. In addition, the state enforcement system should help consumers find good facilities by focusing on care outcomes rather than hundreds of minor technical mistakes that have no real impact on resident well-being.
All of these recommendations would pave the way for Illinois truly offering progressive and quality nursing home care to our state's 85,000 citizens who need it most.
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