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Care Providers of MinnesotaDecember 12, 2006

“Contracting with Private Nursing Homes to Assure

a Continuum of the Highest Quality of Care for Veterans”

Dan Goedken, MSSW, LICSWCoordinator, CNH Program

Minneapolis VA Medical Center612.567.4530

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A brief personal resume:A brief personal resume:

1968-1971, US Army1968-1971, US Army1971, started in the VA (Iowa City, Milwaukee)1971, started in the VA (Iowa City, Milwaukee)1976, BSW, U of Iowa1976, BSW, U of Iowa1979, MSSW, U of Louisville 1979, MSSW, U of Louisville 1988, joined staff at Minneapolis VAMC1988, joined staff at Minneapolis VAMC10 years as Coordinator, CNH Program 10 years as Coordinator, CNH Program 4 GAO, OIG federal inspections of CNH Program4 GAO, OIG federal inspections of CNH Program5 years as SW Supervisor5 years as SW SupervisorMarried to a Army Reservist Nurse Married to a Army Reservist Nurse

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An overview of the An overview of the

national VA system: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…………

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Nation-wide, there are over 1,300 VA care facilities, including….

163 hospitals, 850 community-based outpatient clinics, 206 veteran counseling centers, 137 VAMC nursing homes, and 43 domiciliary facilities

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Regardless of where the Regardless of where the veteran resides, veteran resides,

all veterans need to be enrolledall veterans need to be enrolled

in the VA to receive VA health in the VA to receive VA health carecare

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For veterans not enrolled, For veterans not enrolled, call the nearest VAMCcall the nearest VAMC

For Minneapolis VAMC area, For Minneapolis VAMC area, call VA Patient Access Centercall VA Patient Access Center

612-467-2071612-467-2071

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ONCE ENROLLED…..ONCE ENROLLED…..

(REGARDLESS OF LENGTH OF MILITARY SERVICE (REGARDLESS OF LENGTH OF MILITARY SERVICE OR COMBAT INVOLVEMENT)OR COMBAT INVOLVEMENT)

ALL VETERANS ALL VETERANS ARE RECOGNIZED IN ARE RECOGNIZED IN

ONE OF TWO ONE OF TWO VA ELIGIBILITY CATEGORIESVA ELIGIBILITY CATEGORIES

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Nonservice-connected (NSC)Nonservice-connected (NSC)

Veteran does not have injuries or illness that Veteran does not have injuries or illness that were determined (rated) by the VA to have were determined (rated) by the VA to have been incurred or aggravated by their military been incurred or aggravated by their military service. service.

Service-connected (SC)Service-connected (SC)

Veteran has been determined by VA to have a Veteran has been determined by VA to have a disability or illness incurred or aggravated by disability or illness incurred or aggravated by their military service. Rating will range from their military service. Rating will range from 0% SC (non-compensable) to 100% SC 0% SC (non-compensable) to 100% SC ($2,400+/month). SC veterans are potentially ($2,400+/month). SC veterans are potentially “Millennium Act” veterans.“Millennium Act” veterans.

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Although the NSC and SC rating is the over-Although the NSC and SC rating is the over-ridingriding

eligibility determination, there are other eligibility determination, there are other secondary secondary

eligibilities that might create access to eligibilities that might create access to particularparticular

VA clinics or specialized care:VA clinics or specialized care:

Agent Orange ExposureAgent Orange Exposure Ionizing Radiation ExposureIonizing Radiation Exposure Atomic Veterans Atomic Veterans Prisoners of WarPrisoners of War Military sexual traumaMilitary sexual trauma OIF/OEF Polytrauma CareOIF/OEF Polytrauma Care Purple HeartPurple Heart

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Some veterans will be Some veterans will be billedbilled for for services.services.

1. Service connected veterans1. Service connected veterans receive receive services almost entirely without co-services almost entirely without co-payments or charges.payments or charges.

2. Non-service connected veterans, 2. Non-service connected veterans, depending on a financial means test, may depending on a financial means test, may have charges:have charges:

Medications ($8/month per prescription)Medications ($8/month per prescription)

Inpatient days, similar to MedicareInpatient days, similar to Medicare

Outpatient clinic charges ($15-50)Outpatient clinic charges ($15-50)

Contracted care in the communityContracted care in the community

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

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VA coverage depends on VA coverage depends on

enrollmentenrollment and and medical medical determinationdetermination

1. Home Care1. Home Care Skilled CareSkilled Care

HomemakerHomemaker

Home Health AideHome Health Aide

2. Contract Adult Day Health Care 2. Contract Adult Day Health Care

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3. 3. VA provides VA provides nursing home carenursing home care in three different settings:in three different settings:

VAMC Nursing Home Care UnitsVAMC Nursing Home Care Units In-house programsIn-house programs Minneapolis, St Cloud, Sioux Falls, FargoMinneapolis, St Cloud, Sioux Falls, Fargo

State Veterans HomesState Veterans Homes Per diem payments Per diem payments Minneapolis, Fergus Falls, Laverne, Silver Bay, HastingsMinneapolis, Fergus Falls, Laverne, Silver Bay, Hastings

Contract Nursing HomesContract Nursing Homes Based either on MA or MC case mix formularyBased either on MA or MC case mix formulary Each VA has it’s own CNH programEach VA has it’s own CNH program A closer look at CNH…………….A closer look at CNH…………….

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The three current CNH patient The three current CNH patient funding priorities, based on funding priorities, based on nationally established nationally established requirements….requirements….

Respite (NTE 30 days a year)Respite (NTE 30 days a year) Hospice CareHospice Care Long-term (Millennium Act) coverage Long-term (Millennium Act) coverage

for SC veteransfor SC veterans

Short-term contracts (discretionary, $)Short-term contracts (discretionary, $)

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……by the numbers, the Minneapolis VAMC by the numbers, the Minneapolis VAMC CNH Program, as of 12/1/06……..CNH Program, as of 12/1/06……..

5151 Counties of jurisdiction in MN and WI Counties of jurisdiction in MN and WI

6363 CNH facilities CNH facilities

$9,453,256$9,453,256 Spent in FY 2005 Spent in FY 2005

491 491 Millennium Act veterans reviewed, Millennium Act veterans reviewed, 2000 2000

232 232 Veterans on contract in FY 2005 Veterans on contract in FY 2005

155 155 Millennium Act veterans, 12/1/06 Millennium Act veterans, 12/1/06

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THREE YEAR CNH SUMMARYTHREE YEAR CNH SUMMARY

20042004 200520052006 (YTD)2006 (YTD)

Days of careDays of care 47,57347,573 49,04549,04557,27657,276

Number of Number of placed veteransplaced veterans 287287 232232 260260

Mill Act Mill Act veterans reviewedveterans reviewed7878 7777 117117

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The Minneapolis CNH StaffThe Minneapolis CNH Staff

Primary TeamPrimary Team1 Coordinator1 Coordinator1 Contracting Officer 1 Contracting Officer 5 Clinical Social Workers5 Clinical Social Workers4 Nurse Coordinators 4 Nurse Coordinators 1 Dietician1 Dietician3 Life Safety Inspectors3 Life Safety Inspectors1 RN/Quality Improvement 1 RN/Quality Improvement

Consultative TeamConsultative Team1 Geriatrician1 Geriatrician1 Physiatrist1 Physiatrist1 HBPC Director1 HBPC Director1 Clinical Pharmacist1 Clinical Pharmacist1 Physical Therapist1 Physical Therapist1 Occupational Therapist1 Occupational Therapist1 Speech Pathologist1 Speech Pathologist

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Contracted veterans residing in a CNH Contracted veterans residing in a CNH regularly receive outreach visits from regularly receive outreach visits from

the VA.the VA.

Social Work or NurseSocial Work or NurseLimited other follow-up by mental health or other disciplinesLimited other follow-up by mental health or other disciplinesTelephone or visitTelephone or visitChart review, assessment visit with patient, speak with staffChart review, assessment visit with patient, speak with staffEnsures continuity of care/coordination between the CNH and Ensures continuity of care/coordination between the CNH and VAVAQuality oversight of the plan of care Quality oversight of the plan of care Troubleshooting issuesTroubleshooting issuesReview for appropriate discharge planningReview for appropriate discharge planning

Life safety inspector every 3 yearsLife safety inspector every 3 years

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So why would a nursing home So why would a nursing home

want want a VA contract?a VA contract?Broadens the pool of available funding Broadens the pool of available funding

Higher daily funding than MA providesHigher daily funding than MA provides

Increased opportunities to serve America’s veteransIncreased opportunities to serve America’s veterans

Increases the gender mix/more male referralsIncreases the gender mix/more male referrals

May contribute to Culture TransformationMay contribute to Culture Transformation

Unique geographic offeringUnique geographic offering

Access to increased VA clinics for supportAccess to increased VA clinics for support

VA RN and SW visits to veterans on contractVA RN and SW visits to veterans on contract

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And there are certainly reasons why a And there are certainly reasons why a nursing home nursing home may not wantmay not want a VA a VA contract….contract….

PaperworkPaperwork

AccountabilityAccountability

Perceived too few referrals for the effortPerceived too few referrals for the effort

NH is too small to offer unique options to the NH is too small to offer unique options to the VAVA

NH occupancy is generally already 100%NH occupancy is generally already 100%

NH is not 100% fire sprinkledNH is not 100% fire sprinkled

Therapy VA pre-authorizationTherapy VA pre-authorization

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On average, the Minneapolis VAMC On average, the Minneapolis VAMC maintains maintains

60+ nursing homes on contract. 60+ nursing homes on contract.

In any given year, we non-renew/loose In any given year, we non-renew/loose 4-6 facilities.4-6 facilities.

And we add a similar number, And we add a similar number,

based on, among other reasons……..based on, among other reasons……..

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VA VA needs assessmentneeds assessment for a new CNH: for a new CNH:

current availability of VA funding, current availability of VA funding,

implications for growth/decline in the current implications for growth/decline in the current contract facilities,contract facilities,

density/proximity of existing contract facilities,density/proximity of existing contract facilities,

tendency for openings within the existing pool of tendency for openings within the existing pool of contracted facilities,contracted facilities,

unique facilities that serve specialized needs,unique facilities that serve specialized needs,

the desire to providing ample business to existing the desire to providing ample business to existing contract facilities to warrant their continued contract facilities to warrant their continued affiliation.affiliation.

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A primer on the MVAMC VA A primer on the MVAMC VA contract……contract……

Medicare PPS case mixMedicare PPS case mix formulary (53 levels); VA follows CMS for formulary (53 levels); VA follows CMS for MDS timetable: admission, 14, 30 day, quarterly, annually, MDS timetable: admission, 14, 30 day, quarterly, annually, significant change. significant change.

An all-inclusive contractAn all-inclusive contract. Per diem rates include a semi-private . Per diem rates include a semi-private room, meals, nursing care, rehabilitation, respiratory, oxygen room, meals, nursing care, rehabilitation, respiratory, oxygen therapy, medical/nursing supplies. therapy, medical/nursing supplies.

Most oral medications Most oral medications are included up to 8.5% of the per diem, as are included up to 8.5% of the per diem, as well as most durable medical equipment items, X-rays, and routine well as most durable medical equipment items, X-rays, and routine lab tests. Medication costs that exceed 8.5% of the per diem, are 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 billed to the VA at the AWP. High costs meds may be better dispensed by VA.dispensed by VA.

Specialized equipmentSpecialized equipment (i.e. air fluidized bed) can be pre-authorized. (i.e. air fluidized bed) can be pre-authorized.

VA-paid travelVA-paid travel to VA appointments. to VA appointments.

VA will reimburse the CNH for incurred VA will reimburse the CNH for incurred MD costsMD costs. VA follows CMS . VA follows CMS standards for physician visits (i.e. frequency, documentation, and standards for physician visits (i.e. frequency, documentation, and 24/7 coverage). 24/7 coverage).

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Contractual stipulations when a veteran is on a Contractual stipulations when a veteran is on a VA contract in a CNH…..VA contract in a CNH…..

Coverage planning:Coverage planning: always verify that patient will be covered by always verify that patient will be covered by the VA.the VA.

PC: PC: The NH MD needs to solely provide the PC for the CNH The NH MD needs to solely provide the PC for the CNH veteran.veteran.

No other payment source for same day coverage.No other payment source for same day coverage. It is fraud to bill It is fraud to bill two different federal payer sources for services provided within two different federal payer sources for services provided within the CNH for the same day of coverage. For example, billing the VA the CNH for the same day of coverage. For example, billing the VA for per diem, and MC for the MD, therapy, medications. for per diem, and MC for the MD, therapy, medications. (Exception is when a veteran is on hospice: VA will pay R&B, MC (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 will pay for hospice agency to provide end of life meds, hospice staffing, consultation)staffing, consultation)

Medications:Medications: VA does not supply routine medications for the CNH VA does not supply routine medications for the CNH patient - CNH acquires medications AWP from their own patient - CNH acquires medications AWP from their own pharmacy source.pharmacy source.

PT, OT, or SLP:PT, OT, or SLP: needs to be pre-authorized by the VA. needs to be pre-authorized by the VA.

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Expectation of timelinessExpectation of timeliness ~ of submitting invoices ~ of submitting invoices ~of VA payment~of VA payment

InvoicesInvoices (per diem, medications, pre-approved (per diem, medications, pre-approved ancillaries)ancillaries)

to the VA should be current (within 15 days to the VA should be current (within 15 days following the month of when services when were following the month of when services when were provided)provided)

From the From the date VA receivesdate VA receives the invoice, VA is the invoice, VA is required to make electronic payment to the CNH required to make electronic payment to the CNH account within 30 daysaccount within 30 days

If the VA electronic payment is delayed in excessive If the VA electronic payment is delayed in excessive of 30 days beyond the invoice reception date, VA of 30 days beyond the invoice reception date, VA automatically pays a automatically pays a interest penaltyinterest penalty for each day for each day beyond 30: beyond 30:

invoice amount x .55750 daily interestinvoice amount x .55750 daily interest

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VA CONTRACT VA CONTRACT

““To be considered for a VA contract, To be considered for a VA contract,

or to annually renew an existing contract, or to annually renew an existing contract,

VA takes the approach that VA takes the approach that

a broad review of all available data is essential”a broad review of all available data is essential”

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To assess for a new VA contract, andTo assess for a new VA contract, andto annually renew an existing VA contract, to annually renew an existing VA contract, we review the following formal we review the following formal

documents……documents……

1. Copy of State License.1. Copy of State License.

2. 2567 state survey, including noted corrections and 2. 2567 state survey, including noted corrections and revisitrevisit    

3. CNH Continuous Improvement Plan3. CNH Continuous Improvement Plan    

4. Current CNH annual staff training/competency 4. Current CNH annual staff training/competency summarysummary

5. Fire Marshal inspection5. Fire Marshal inspection  

7. Indemnification liability insurance certification7. Indemnification liability insurance certification

8. CNH Emergency Preparedness Plan8. CNH Emergency Preparedness Plan

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We also assemble the We also assemble the available web-based information:available web-based information:

NH Compare NH Compare quality measures quality measures staffing reportsstaffing reports

Minnesota Health Facilities Complaint Minnesota Health Facilities Complaint OfficeOfficeMinnesota Nursing Home Report Card Minnesota Nursing Home Report Card OSCAR 3 and 4.OSCAR 3 and 4.NH watch list NH watch list

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And initiate regular telephone And initiate regular telephone contact with …….contact with …….

Veterans Benefit AdministrationVeterans Benefit Administration Guardians, conservators, fiduciariesGuardians, conservators, fiduciaries

Nursing Home OmbudsmanNursing Home OmbudsmanHx of complaints, trendsHx of complaints, trendsAmenableness to complaint resolutionAmenableness to complaint resolutionEvidence of consultation efforts by the NHEvidence of consultation efforts by the NHStaffing/turnover issuesStaffing/turnover issuesIntegration of resident/family council processIntegration of resident/family council processSupport of cultural transformationSupport of cultural transformationGeneral view of care providedGeneral view of care provided

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Acquire comparative data from the Acquire comparative data from the

Department of Health…Department of Health…

Average # of state survey deficienciesAverage # of state survey deficiencies

Deficiency free inspectionsDeficiency free inspections

(If this state’s percentage of deficiency-free (If this state’s percentage of deficiency-free inspections are above the VA acceptable 20% inspections are above the VA acceptable 20% threshold, VA is required to report to CMS.)threshold, VA is required to report to CMS.)

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When a VA contract is up for annual renewal, When a VA contract is up for annual renewal,

we also review our own VA electronic we also review our own VA electronic medical medical

records (from the monthly SW and RN visits records (from the monthly SW and RN visits

to the CNH) of the veterans served on to the CNH) of the veterans served on contract contract

during the last year…..during the last year…..

Clinical observationsClinical observations

Quality improvement effortsQuality improvement efforts

Patient/family satisfaction or complaintsPatient/family satisfaction or complaints

General observations of CNH General observations of CNH

Observations of staffing issues/turnoverObservations of staffing issues/turnover

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So….the CNH Team routinely….. So….the CNH Team routinely….. and at the time of annual and at the time of annual

renewal….renewal….

Assembles a portfolio of primary and secondary dataAssembles a portfolio of primary and secondary data

Applies stringent application of VA standards, andApplies stringent application of VA standards, and

RN and SW complete regular follow-up visits to contracted veterans, RN and SW complete regular follow-up visits to contracted veterans, andand

Team reviews the medical records (both VA and CNH records, andTeam reviews the medical records (both VA and CNH records, and

Has regular communication with Ombudsman, VBA, and Has regular communication with Ombudsman, VBA, and QI/Continuous Improvement initiativesQI/Continuous Improvement initiatives

And when warranted, actively communicates with the state survey And when warranted, actively communicates with the state survey team to examine particular performance issues.team to examine particular performance issues.

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We then annually assemble this We then annually assemble this

assortment of data and apply assortment of data and apply

seven national VAseven national VA

standards….standards….

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SEVEN VA CNH STANDARDSSEVEN VA CNH STANDARDS

1)1) Are there three level ‘G’ or higher Are there three level ‘G’ or higher deficiencies in the current survey?deficiencies in the current survey?

2)2) In the current survey, are the total In the current survey, are the total number of health requirement number of health requirement deficiencies twice the state deficiencies twice the state average?average?

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3)3) In the current survey, is there In the current survey, is there a level ‘E’ or higher deficiency a level ‘E’ or higher deficiency in any of the following areas:in any of the following areas:

Restraints (F221 or F222) Restraints (F221 or F222) Abuse (F223) Abuse (F223) Staff treatment of patients (F225 Staff treatment of patients (F225

or F226)or F226)Dignity (F241) Dignity (F241) Licensure (F491)Licensure (F491)

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4)4) In the NH Compare review are In the NH Compare review are the RN hours per resident day the RN hours per resident day below the state average?below the state average?

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

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6)6) Are six or more of the MDS quality Are six or more of the MDS quality measures from NH Compare above measures from NH Compare above the state average?the state average?

7)7) In the current survey is there a In the current survey is there a level “E” or higher deficiency in level “E” or higher deficiency in any of the following areas:any of the following areas:

a.a. Nursing services (F353) Nursing services (F353) b.b. Nursing aide training (F494, F495, or Nursing aide training (F494, F495, or

F496) F496) c.c. Regular in-service training (F497) Regular in-service training (F497) d.d. Proficiency of nursing aides (F498) Proficiency of nursing aides (F498) e.e. Staff qualifications (F499)Staff qualifications (F499)

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To consider the contract, we apply the 7 VA To consider the contract, we apply the 7 VA standards….standards….

and review all other relevant performance and review all other relevant performance information…information…

in the determination process..…..in the determination process..…..

If a newly proposed contract, proceed or declineIf a newly proposed contract, proceed or decline

Renewal of existing contract (most common)Renewal of existing contract (most common)Renewal with added clinical oversightRenewal with added clinical oversightRenewal with additional stipulationsRenewal with additional stipulationsSuspension of placementsSuspension of placementsSuspension/termination of contractSuspension/termination of contract

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In summary, through the contractIn summary, through the contract

program, VA believes thatprogram, VA believes that

enhancing the NH care enhancing the NH care

for for veterans veterans within within

the CNH further the CNH further

enhances the enhances the

care for care for allall

residents.residents.

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

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Even if your nursing home does not have a VAEven if your nursing home does not have a VAcontract, the facility can still partner to contract, the facility can still partner to

provide limitedprovide limitedservices to the veteran……services to the veteran……

(based on the veteran’s unique VA eligibility (SC/NSC, etc), (based on the veteran’s unique VA eligibility (SC/NSC, etc), some planning & pre-authorization)some planning & pre-authorization)

VA hospitalization:VA hospitalization: 612-467-2019612-467-2019

Brief VA payment for emergency private Brief VA payment for emergency private hospitalization:hospitalization:

612-467-2003612-467-2003

VA-paid VA-paid transportationtransportation to VA appointment: to VA appointment: 612-612-467-4290467-4290

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Other services:Other services:

Outpatient careOutpatient care (specialty or primary (specialty or primary care/medications: care/medications: 612-467-2019612-467-2019

ProstheticsProsthetics equipment (specialized equipment (specialized wheelchairs, etc): wheelchairs, etc): 612-467-2001612-467-2001

Review for discharge planning & Review for discharge planning & home carehome care services: services: 612-567-1994612-567-1994

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in the end…..in the end…..

……..”the willingness with which our young people are likely ”the willingness with which our young people are likely to to

serve in any war, no matter how justified, shall be serve in any war, no matter how justified, shall be directly directly

proportional to how they perceive the veterans of earlier proportional to how they perceive the veterans of earlier wars wars

were treated and appreciated by their nation.”were treated and appreciated by their nation.”

-George -George WashingtonWashington