Copyright 2013 by Health Care Council of Illinois Phone: 217-544-4224 Past issues of THIS WEEK can be found at www.hccil.org

September 24, 2013 Number 1504 HCCI Testifies about Managed Care Problems at Legislative Hearing Last week the House Human Services Committee held a hearing to get feedback about the Integrated Care Program (ICP). Health Care Council of Illinois (HCCI) joined other providers and advocates to report the growing list of concerns about the Medicaid managed care program. With the help of Mary Glenn Richardson from Infinity Healthcare Management, HCCI prepared and presented testimony to the committee. “Managed Care is creating administrative chaos and jeopardizing the quality of care for the frail, vulnerable residents we serve,” HCCI Director of Communication Amanda Ginther said. “We fear the worst is yet to come as each day brings new problems.” Phase II of ICP, which began covering nursing home residents, has not been evaluated by researchers to determine its effectiveness. In fact, according to researchers presented by the University of Illinois-Chicago, it is too early to report the health and quality outcomes of any recipients the Medicaid Integrated Care Program (ICP), even the recipients researchers evaluated. Other states hammered out the details of managed care within the legislative process, but Illinois moved forward with no legislative input and created an unregulated managed care program. “We did not choose to be in a demonstration area, nor did our residents choose to participate,” Ginther told the committee. “Their elected officials did not choose the areas, set the parameters, design laws to govern the contracts, rates, billing, etc., or put in place restrictions to protect the rights of residents to receive medically necessary care.” Insurance executives from the two managed care companies in ICP, as well as HFS, conceded they need to do more to meet the needs of recipients and providers in managed care. However, Healthcare and Family Services (HFS) Director Julie Hamos did not think legislative intervention was necessary. Despite the concerns from providers and advocates, HFS plans to move forward with a large-scale, mandatory expansion of managed care, which will include nursing home residents who are dually eligible for both Medicare and Medicaid. Legislators asked for further evaluation of the managed care programs and for HFS to seek more input from stakeholders to improve outcomes for the individuals served by managed care. HCCI continues to work with HFS, managed care companies and legislators to remedy the plethora of problems caused by unregulated privatization of nursing home funding.

If you'd like to know what HCCI said at the hearing, check out the testimony.

Copyright 2013 by Health Care Council of Illinois Phone: 217-544-4224 Past issues of THIS WEEK can be found at www.hccil.org

HHS Releases Model Notices of Privacy Practices

HHS Office of Civil Rights (OCR) and Office of National Coordinator (ONC) for Health Information Technology published model privacy notices in response to requests for guidance. Notices are provided in four formats:

• Notice in the form of a booklet; • Text only • A layered notice that presents a summary of the information on the first page, followed

by the full content on the following pages; • A notice with the design elements found in the booklet, but formatted for full page

presentation.

Notices and instructions are available for both providers and health plans. Specific information for your facility can be entered into the model notice and then printed for distribution. Also refer to the This Week August 21 and August 28 for further information on recent HIPPA changes.

LTC Commissioners Report to Congress Highlights Dissention

The Commission on Long Term Care that was created in January released its recommendations to Congress last week. The report was transmitted to Congress with six commission members voting against the recommendations in the report and nine member voting in favor of it.

Overall the 114-page document, released by the 15-member bi-partisan commission, addressed a wide spectrum of long term care issues, including service delivery, workforce issues, and financing systems. It called for a working group to be formed to address unresolved issues.

At odds in the report are approaches to sustainable long term financing and addressing the needs of the non-elderly disabled. The report included not only recommendations for future action, but also highlights ideas already being debated in Congress. Notable among them was the three-day hospital stay rule, accelerating the commitment to LTC-specific health information technology and no wrong door policies.

You can view the whole report here.

New Five Star Data Posted to Nursing Home Compare

The new August Five Star data was posted to the Nursing Home Compare website on September 19. Questions about the data can be directed to BetterCare@cms.hhs.gov.

With increased numbers of consumers using the Nursing Home Compare website to choose nursing homes, it is important for providers to pay attention to these ratings and gain knowledge on how to raise their scores. The August 10, 2012 Clinical Capsule has an explanation of how these scores are determined and will help providers develop a proactive strategy.

Copyright 2013 by Health Care Council of Illinois Phone: 217-544-4224 Past issues of THIS WEEK can be found at www.hccil.org

NEW Alzheimer’s Report Looks at Long Term Care

Alzheimer’s Disease International reports quality of life is likely better for individuals with advanced dementia receiving facility-based care. It also found 80 percent of nursing home residents have some level of dementia currently. The report projects individuals in need of long term care will triple by 2050 with demand for dementia care rising.

The report, Journey of Caring: An Analysis of Long-term Care for Dementia, calls on government to begin the process of developing a national strategy around long term care services and supports for those with all degrees of dementia. Acknowledging the cost factor, it stresses the urgency of the problem and need to involve all stakeholders in a national debate.

National Spending for Medicare Expected to Rise

According to a new Health Affairs analysis of spending trends, Medicare is expected to dramatically rise between 2015 and 2022 as more baby boomers qualify for benefits with the most dramatic increases post 2019. Specifically, the report projects that nursing home and continuing retirement community expenditures will climb by nearly 70 percent during the next nine years. The authors of the report have national expenditures growing from $157 billion in 2013 to $264 billion by 2022. Reference the report for more information.

Another Look at Rehospitalizations

A recent report released by the Commonwealth Fund looked at 30 individual factors in attempting to gauge how well state health systems are serving low-income residents. Rehospitalizations of nursing residents was one of the factors. Specifically, it examined the percent of nursing home residents hospitalized within a 30-day period and percentage of short-stay residents rehospitalized within 30 days of discharge to a nursing home. Overall, Illinois was ranked 36th in providing health care for low income residents. Reference the full report for more information.

Medicaid Payment Update The associations received the following confirmation of payment schedules from the Department of Healthcare and Family Services on September 18, 2013.

• Nursing Facilities (NFs): 5/13 services paid. 6/13 services vouchered. 7/13 services vouchered into group 8.

• Expedited Nursing Facilities (ENFs): 07/13 services paid. • Institutions for Mental Disease (IMDs): 06/13 services paid. 07/13 services

vouchered. • Expedited Institutions for Mental Disease (EIMDs): 07/13 services paid. • Facilities for the Developmentally Disabled (DDs): 06/13 services paid. 07/13

services vouchered and paid into group 6. 08/13 services vouchered into group 3. • Supportive Living Facilities (SLFs): 05/13 services paid. Part of 06/13 services paid.

07/13 services vouchered. • Expedited Supportive Living Facilities (ESLFs): 7/13 services paid.

September 24, 2013 Volume 18 Number 38

Antibiotic Resistance

The Centers for Disease Control and Prevention (CDC) recently published Antibiotic Resistance Threats in the United States, 2013. The 112-page paper gives a snapshot look at the problem of antimicrobial resistance today and what needs to be done in the future to curb this threat. When first and second line antibiotics do not work due to resistant bacteria, health care providers are forced to use more expensive and more toxic antibiotics that are often less effective. The CDC study is broken down into three parts. The first part gives an overview of the problem of antibiotic resistance in the United States. Data from the CDC shows more than two million people are infected by antibiotic-resistant infections with 23,000 dying yearly as a result. 250,000 people each year are infected with Clostridium difficile (C. difficile) alone, with 14,000 dying. These antibiotic-resistant infections are not only devastating to the victims, but cost the United States healthcare system billions of dollars. Estimates of the health care costs are as high as $20 billion, with an additional $35 billion in lost productivity. The CDC divided the resistant bacteria into three categories: urgent, serious and concerning. Many of the resistant bacteria are already being seen in long term care facilities. Frail, elderly patients with these infections are at a much greater risk for complications and death. The categories are: Urgent Threats Clostridium difficile Carbapenem-resistant Enterobacteriaceae (CRE) – IDPH recently required the reporting of CRE on a special website Drug-resistant Neisseria gonorrhoeae Serious Threats Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida (a fungus) Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs) Vancomycin-resistant Enterococcus (VRE) Multidrug-resistant Pseudomonas aeruginosa Drug-resistant Non-typhoidal Salmonella Drug-resistant Salmonella Typhi Drug-resistant Shigella Methicillin-resistant Staphylococcus aureus (MRSA) Drug-resistant Streptococcus pneumoniae Drug-resistant tuberculosis Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus

The second section of the report summarizes what can be done by health care providers to fight this threat and what CDC initiatives are currently in place. The CDC supports four core actions to combat antimicrobial resistance. They are: “1) preventing infections from occurring and preventing resistant bacteria from spreading, 2) tracking resistant bacteria, 3) improving the use of antibiotics, and 4) promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.” The report goes into great detail on each of the core elements that the CDC feels are needed to fight this threat. Charts included in the report have estimates of morbidity and mortality for 13 of these resistant bacteria. Antibiotic resistance was first identified in 1940 when staphylococcus became resistant to penicillin and tetracycline and erythromycin were developed within the next ten years. The fact that antibiotics were introduced into the food chain through treatment of cattle with antibiotics adds another layer of concern to the resistant problem. Resistance is developed by the bacteria in the cattle and then the bacteria are transferred to humans when they consume the meat. Antibiotics are not without adverse drug events. They can cause an allergic reaction, drug interactions and side effects, as well as, C. difficile. As the antibiotics kill off the problem bacteria, they also destroy many of the good bacteria in the intestine. This leaves an environment where C. difficile, normally present in the intestine, can multiply and cause infection. The CDC report stated that one in five emergency room visits is for adverse drug events from antibiotics. The third part of the report summaries the specific microorganisms in each of the three threat levels. Each separate report covers the resistance of concern; the public health threat; what the CDC is doing; what health care providers can do; and what patients can do. The report is written in a way that not only health care providers can understand, but also the public. The report can be used to educate the public on this serious threat. It contains online resources for each of the resistant bacteria. All providers should download this excellent study and utilize the resources and training to educate the staff. It is essential that all staff be aware of these resistant bacteria, how to prevent their spread and what we can all do to stop the continued threat in the future. This report is the most comprehensive report on antimicrobial resistance published in a long time, and will guide facilities with established standard of care procedures. To download the report, click here.

Questions about this month’s Clinical Capsule can be addressed to Susan Gardiner at (773) 478-6613. Past issues of the Clinical Capsule can be referenced at the HCCI website www.hccil.org.

Copyright Health Care Council of Illinois and Illinois Council on Long Term Care Volume 18 Number 38, September 24, 2013

Copyright 2013 by the Illinois Council on Long Term Care and Health Care Council of Illinois 1

September 24, 2013 Number 727

Connecting the Generations – Part II This week we conclude the articles about beginning or revamping your current intergenerational program. A good program has to have structure and be evaluated on a regular basis. We will explore these elements in detail to help you have a successful intergenerational program for your residents.

Policies and Procedures It is very important to have formal guidelines when introducing and implementing a new activity for the residents. Make sure when you are setting the guidelines for your program that you involve the educators or group leaders with whom you’ll be working. Ask the educator for information regarding policies and procedures of which you may need to be aware, before launching the intergenerational program.

For instance, when working with an organization involved in government-funded programs, such as Head Start, you have to be in compliance with the Department of Child and Family Services (DCFS). DCFS requires a medical record for any adult volunteering or working in a child care facility, day care center, group home, Head Start classroom, etc. DCFS also requires an acknowledgement that the volunteer understands, and subscribes to, the prohibition of corporal punishment and signs a document stating this fact before working with the children. This document also requires a witness’ signature. (Determine what laws need to be followed in your state.)

At first, this may seem like a lot of trouble to go through to establish an intergenerational program, but actually, most residents in health care communities have had a physical within the timeframe specified by the government requirements. Be sure to check the resident’s record before asking him or her to have a physical. As for the corporal punishment form, keep in mind this is not only for the protection of the child, but the residents as well. Gather the residents that will be involved in the program and explain the reason for the agreement. Be sure to define “corporal punishment” and what it entails, because most elders believed in spanking their children and do not see anything wrong with this action. Remember, this is not required for all intergenerational programs, but it is a good idea to execute this form and have this discussion anyway.

Once you have reviewed the policies and procedures of the school or organization with which you’ll be working, make sure you share the policies and procedures regarding your facility and such programs.

Program Guidelines Remember that it is important to be consistent when offering an intergenerational

Copyright 2013 by the Illinois Council on Long Term Care and Health Care Council of Illinois 2

program. Things that need to be consistent when setting up your program include, but are not limited to:

• Size of the Group – Do you want the program to be one-on-one or do you want the same number of children involved with an equal number of residents?

• Environment – Is the room big enough to accommodate residents in wheelchairs? How is the lighting in the room? Are there enough tables and chairs for everyone and are they at the correct height to accommodate everyone?

• Length of Time – How long are the attention spans of the children and residents? You don’t want to lose their attention before getting started.

• Scheduled Days – Usually the same day of the week is always best.

• Frequency – How often do you want to meet?

• Accessibility – When visiting the children, is the area wheelchair assessable? Tour the classroom with the educator before bringing the residents to the classroom. Make sure there are true handicapped accessible restrooms, with room for a CNA to transfer a resident to the toilet.

• Transportation – How are the children getting to the facility and how are the residents getting to the school? What about insurance?

• Activities – Once the children and residents get together, will the activities be structured or unstructured?

How will the children be oriented to the elderly? This is a vital part of the program. Ask the educator about their knowledge regarding the aging process. Children need to be oriented to the handicaps and disabilities of the elderly. Discuss what a nursing home is and why people live there or in other retirement settings. Even if you don’t work in a nursing home, talk about your setting and why people live there.

Offer your expertise in the field of gerontology by visiting the children in their setting, and presenting an overview of the residents. Bring adaptive equipment such as walkers, canes, wheelchairs, etc. into the classroom setting and allow the children to experience the use of these. If possible, leave them in the classroom until their first visit to the facility. When you visit the children, explain to them that you are conducting the orientation a few weeks in advance, so they can become comfortable with visiting the facility. Give the educator a copy of the Intergenerational Bibliography attached to this newsletter. Encourage them to use the library and internet as a resource for information on the aging process and intergenerational programming.

Intergenerational Program Ideas When planning an activity, keep in mind the senior population with which you’ll be working and the age of the children. Remember to adapt each activity appropriately to meet their needs. Here are a few ideas for intergenerational programs:

Copyright 2013 by the Illinois Council on Long Term Care and Health Care Council of Illinois 3

• Writing and Reading Activities: Child reading to a resident; resident reading to a child; creative writing projects; group discussions; pen pals; personal life review; storytelling; tutoring

• Games: bingo; bowling; tabletop bowling; cards; dice; horseshoes; parachute; crossword puzzles; jigsaw puzzles; scrabble; checkers; board games

• Cooking and Baking: bake sale; edible crafts; no-bake cookies; fruit salad; making butter; planning a meal; cookout; sharing favorite recipes; pudding painting

• Gardening: flower arranging; pressing flowers; planting flowers and vegetables; caring for houseplants; dried flower crafts

• Field Trips: bowling; Christmas light tour; dances; farm; flower garden; library; museums; parade; picnic; pumpkin patch; zoo; television or radio station

• Holidays: decorate bulletin boards; decorate Christmas trees; decorate Easter eggs; ice cream socials; make decorations; make Halloween masks; make holiday cards; make table favors; Valentine’s Day Tea; organize and staff a haunted house

• Celebrations: Grandparents’ Day (September); National Nursing Home Week (May); Older American’s Month (May); Friendship Day (December); Earth Day (April); or any holiday

• Miscellaneous: Sing-along; make/play musical instruments; infants visiting with moms; become “book buddies” with an elementary school; exchange lifestyle information with high school students; do manicures; write biographies of the residents

Evaluating the Program Evaluation of the program is the key to measuring its success and effectiveness. Begin by meeting with the intergenerational staff to discuss the positive aspects as well as any problems that may exist. Discuss ways to develop alternative solutions.

A simple summary written after each visit will enhance this process. After reviewing the notes, the staff will be able to identify problem areas and address them immediately. Be careful not to discuss concerns in front of the children or residents. After a solution has been reached, the program participants can be informed of the changes that will occur in the program.

• Periodically review your objectives and goals to determine whether you are meeting them. If not, why?

• Document the residents’ reaction to the children and the children’s reaction to the residents.

• Periodically interview the children and the residents for their perspectives.

• Do a written survey of the program; include the parents and all staff involved with the program.

• Rotate the staff when needed; this will prevent burnout.

Copyright 2013 by the Illinois Council on Long Term Care and Health Care Council of Illinois 4

• Evaluate the staff involved in the program and solicit their opinions.

Program Maintenance In order to have a well-rounded Intergenerational Program, incorporate the following ideas:

• Schedule Regular Meetings with all the staff involved. Keep written minutes and file them in a notebook for easy reference.

• Be Prepared when the children come to visit the residents. Have supplies, the room, and the residents ready to participate.

• Be Consistent: by establishing a specific day and time when the residents and children will meet. Once established, it should not be changed or cancelled (if at all possible)

• Schedule in Advance and plan an agenda with the educator or group leader. If possible, develop an agenda for the entire year’s program. (Refer to Program Guidelines)

• Ongoing and Open Communication is the key to a successful program. Keep the lines of communication open by establishing a contact person for both entities. Share pertinent information regarding changes in the residents and children, program changes, schedule changes, etc.

• Both Entities MUST Take Responsibility for planning and executing the activities of the intergenerational program – it cannot be one-sided, with the activity professional shouldering all the responsibility for the program. Planning and executing the program must be shared equally.

Promoting Your Program When working with public schools or neighborhood officials, emphasize the importance of intergenerational programming.

• Garner publicity by contacting your Public Relations Department, if you have one, or the local press.

• Prepare public service announcements for cable television and radio stations.

• Write a newsletter.

• Videotape your program and use it as an orientation when developing new intergenerational programs.

• Offer seminars and workshops

• Have an open house for parents, family, staff and the general public.

• Provide presentations for churches, PTA meetings and other local groups.

• Take plenty of pictures while visiting the classroom, Senior Center, or on field trips. Put these together on a poster or bulletin board, or create several scrapbooks to share.

Copyright 2013 by the Illinois Council on Long Term Care and Health Care Council of Illinois 5

• Join committees and community organizations.

• Remember to “toot your own horn,” because no one else will do this.

Summary Remember, the simplest action can develop into an event that shapes lives. Be part of the adventure by initiating or revitalizing an intergenerational program in your facility.

For an intergenerational reading list for educators, parents and family members, click here.