ReshapingLong-Term Care

in Minnesota

State of MinnesotaLong-Term Care Task Force

Final Report

January 2001

This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp

This information is available in other forms to people with disabilities by contacting us at651-296-2062 (voice), or through the Minnesota Relay Service at 1-800-627-3529 (TTY)or 1-877-627-3848 (speech-to-speech relay service).

For additional information on this report, contact:larhae.knatterud@state.mn.usor visit the task force website at:http://www.dhs.state.mn.us/agingint/ltctaskforce

Table of ContentsLong-Term Care Task Force Membership ................................................ i

Introduction ............................................................................................... 1

Vision for Long-Term Care....................................................................... 2

Critical Long-Term Care Issues Facing the State .................................. 3Definition of Long-Term Care ........................................................................................ 3Increasing Need for Long-Term Care .......................................................................... 4Needs of Family Caregivers ............................................................................................ 4Current and Future Worker Shortages ....................................................................... 4Over-Reliance on Institutional Model ......................................................................... 5Need for More Community-based Options ............................................................ 6Need to Empower Consumers and Communities.................................................. 7Need for New Regulation and Reimbursement Systems ..................................... 8

Task Force Recommendations ................................................................. 9

Task Force Priorities for 2001 Legislative Session ............................. 10Rationale for Priority Strategies.................................................................................. 11Immediate Steps to be Taken...................................................................................... 13

Keeping the Vision .................................................................................. 14Next Steps ......................................................................................................................... 14Benchmarks ...................................................................................................................... 14

Appendix A .............................................................................................. 15Background on Task Force Work .............................................................................. 15Stakeholder Input Into Task Force............................................................................. 16

Appendix B ............................................................................................... 19Complete List of Strategies Recommended by Task Force .............................. 19

Long-Term Care Task ForceMembership

Senators:1. Linda Berglin (Minneapolis)2. John Hottinger (Mankato)3. Sheila Kiscaden (Rochester)4. Edward Oliver (Deephaven)5. Don Samuelson (Brainerd)6. Dan Stevens (Mora)

Representatives:1. Jim Abeler (Anoka)2. Fran Bradley (Rochester)3. Lee Greenfield (Minneapolis)4. Kevin Goodno (Moorhead)5. Luanne Koskinen (Coon Rapids)6. Mary Ellen Otremba (Long Prairie)

Commissioners:1. Kit Hadley (Minnesota Housing Finance Agency)2. Jan Malcolm (Minnesota Department of Health)3. Michael O’Keefe (Minnesota Department of Human Services)*

i*Commissioner O’Keefe served as chair of the task force.

IntroductionThis report is a summary of the work of a

long-term care task force composed ofMinnesota legislators and state agencycommissioners that met during the second half of2000 to address the state’s long-term care issuesand develop strategies for dealing with them.

This report includes: 1) the task force vision forlong-term care in the future; 2) a summary of thecritical long-term care issues facing Minnesota;and 3) the recommendations of the task force.The recommendations support the reshaping ofthe state’s long-term care system to addressimmediate issues, and help prepare the state forsignificant future long-term care pressures. Moreinformation on the task force is available on itswebsite, http://www.dhs.state.mn.us/agingint/ltctaskforce.

The task force recommendations included in thisreport represent general consensus among thetask force members. There was a great deal ofagreement among the task force members—cutting across party lines and governmentagencies—about the problems within the existingsystem and the general strategies that should bepursued. There was also a shared recognition thatthere were many more deserving strategies thanthere were resources to implement them (both interms of staff time and budgets). As a result, thetask force went through a priority-setting process,with input from stakeholders, to narrow the set ofstrategies to those presented in this report.

The task force acknowledges and is veryappreciative of the resource people who sharedtheir long-term care expertise with members.The task force also appreciates consumerrepresentatives, counties, providers, unions and

members of the general public who took thetime to attend focus groups, public meetings, orsend written comments. Without thesecontributions, the task force would not havehad as rich an understanding of how long-termcare affects the everyday lives of individuals andfamilies, nor as many ideas for improving thelong-term care system in Minnesota. The taskforce especially appreciates the activeparticipation of the many stakeholder groupsthat helped identify and analyze variousstrategies for change. If we all continue to worktogether on these issues, the task force believesthat Minnesota can accomplish the necessaryreshaping of its long-term care system, and canoffer the kind of long-term care each of uswants for ourselves, our families and ourcommunities.

The task force sees the implementation of therecommendations in this report as a multi-yeareffort of significant scope. Reshaping long-termcare, especially expanding the capacity ofcommunity care options and reducing capacityon the institutional side, is not quickly done, butthe effort must begin. Out of its final list of 48strategies for reshaping long-term care, the taskforce prioritized 15 strategies for action in theupcoming legislative session. The task force alsodirected staff to begin work immediately onrecommendations that do not require legislativeor budgetary authority. The remainingrecommendations can be implemented as futureopportunities present themselves. Over time,these incremental steps will achieve the taskforce vision.

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Vision for Long-Term Care

The task force developed an overall visionstatement for long-term care in Minnesota to

guide its discussion of issues and development ofrecommendations.

We envision a long-term care systemserving older Minnesotans that:Supports self-determination.Such a system:1. Empowers consumers and creates incentives for

them to make decisions about their long-termcare that balance cost, access and quality,when they are capable of doing so.

2. Provides consumers with useful informationabout long-term care options and providerperformance.

3. Is sensitive to consumer preferences and desires.4. Involves consumers in the planning, evaluation

and decision-making for long-term care, so thatservice design is driven at all levels by consumerneeds and preferences.

Provides services that meet consumer needs.Such a system:5. Makes multiple service options available in a

wide variety of settings for all consumers, andsupports older persons to live independently aslong as they desire and are able.

6. Supports development of culturally acceptable,alternative long-term care programs for elders inethnic, immigrant and tribal communities.

7. Responds to consumer desire for delivery oflong-term care in residential settings.

8. Supports innovation through new delivery andfinancing models, and through use of technology.

9. Supports social and physical wellness bykeeping people functional and connected withtheir communities.

Provides high quality care.Such a system:10. Ensures reasonable access, high quality and

affordable care.11. Rewards good outcomes, both in terms of

excellent performance and improvements inperformance.

12. Supports a motivated, stable work forcethrough adequate compensation, work forcetraining and career development opportunities.

13. Provides protections for the vulnerable,including those lacking in family and otherinformal supports, and those who are unable tomake decisions.

14. Ensures quality through objective performanceassessment, timely and appropriate response toconsumer complaints and care deficiencies,and protection of consumer rights.

Ensures efficiency and affordability.Such a system:15. Supports the informal care system, including

family, friends, volunteers, and existingcommunity resources, and takes no action thaterodes it.

16. Encourages efficiencies and productivity,including use of labor-saving technology,among both public and private long-term careproviders.

17. Offers incentives to consumers for privatefinancing of long-term care.

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Critical Long-Term Care IssuesFacing the State

Many experts feel that long-term care of theelderly will be one of the greatest challenges

of the 21st century. Fueled by the aging of the largebaby boom generation, increased life expectanciesand reduced fertility rates, a much larger proportionof the population than ever before will be over age85 and in need of long-term care beginning in2030. These demographic realities will cometogether to create an aging society with increasinglong-term care needs at a time when the necessaryfamily and work force resources will be in veryshort supply. These challenges will be particularlyacute for states because they are the major payersand regulators of long-term care.

To better understand these challenges, Minnesota’slong-term care task force undertook a number ofactivities. It heard presentations by noted long-termcare experts, spent time discussing the long-termcare system in Minnesota, and developed a visionstatement and gaps analysis based on thesediscussions. It also sponsored several consumerfocus groups and held eight public meetings toobtain input on the issues from citizens andorganizations throughout the state. Based upon allof this information, the task force identified severalcritical issues within long-term care and developedits recommendations. (See Appendix A foradditional information on the work of the taskforce.)

Definition of Long-Term CareFor purposes of its work, the task force used thefollowing definition of long-term care. Long-termcare is defined as the “assistance given over asustained period of time to people who are

experiencing long-term inabilities or difficulties infunctioning because of a disability.”1 Long-termcare can be provided in a variety of settings, notjust nursing homes, and most long-term care isprovided by family members in the home of theindividual who needs the assistance. People of allages have the physical and mental disabilities thatrequire long-term care, but the work of the taskforce focused only on the elderly who need long-term care.

What’s Included in Long-Term Care?Services

� Assistance with basic activities of dailyliving, e.g., bathing, dressing, eating,personal care.

� Assistance with instrumental activities ofdaily living, e.g., meal preparation, cleaning,shopping, money management,transportation.

� Assistive devices such as canes or walkers.� Technology such as computerized

medication reminders and emergencyresponse systems.

� Home modifications like ramps, grab barsor easy-to-use door handles.

Housing or Settings� Own home/apartment.� Adult day health centers.� Retirement housing.� Assisted living facilities.� Adult foster care, board and lodging, board

and care homes.� Nursing homes.

1Kane, Rosalie, Kane, Robert, and Ladd, Richard. (1998). The Heart of Long-Term Care. New York: Oxford University Press. p. 4.

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Increasing Need for Long-Term CareMinnesota faces unique challenges in long-termcare. Not only do we have the second longest lifeexpectancy in the United States (surpassed only byHawaii), we also have one of the highestproportions of persons age 85 and over in thecountry. Both of these facts signal a current andfuture high need for long-term care.

Figure 1

Minnesota’s 85+ Population2000-2050

Just as they have throughout their lives, babyboomers will demand options, flexibility and controlinto old age, and this will extend to how they wantlong-term care provided.

Needs of Family CaregiversAnother unique part of Minnesota’s long-term caresystem is the profile of our family caregivers.Minnesota has one of the highest labor forceparticipation rates for women in the country (67.7percent).2 Since women are the primary caregiversfor frail elderly, we have a high demand for thesupplemental assistance that working women needin order to provide care to frail relatives.

The task force heard from consumers, families andproviders that more options are needed to supportcaregivers, including better, more accessibleinformation about services; education and trainingso they can do a better job of caring for olderrelatives; and various forms of respite services in orderto supplement what they are able to do. Researchhas shown that family caregivers who receivetraining and respite services are able to provide careto frail relatives for longer periods of time, and delaynursing home placement.

Current and Future Worker ShortagesMinnesota is currently experiencing a severeshortage of workers in health and long-term care,especially nurses and “direct support” workers, suchas nursing assistants, personal care attendants andhome health aides. There are currently 4,000 directsupport job openings throughout the state,compared to 17,000 direct support positionsneeded.3 This shortage is expected to get worse inthe future.

Minnesota faces labor shortages across all industriesas a result of very low unemployment rates and highlabor force participation rates. Shortages in long-term care are made more acute by the intensecompetition for low-wage workers between long-term care and retail, restaurant and other low-wage

The need for long-term care will begin a steep rise in2030, as the first of the large baby boom generationreaches old age. Minnesota will have 1.6 millionpersons age 65 and over by 2030, representing oneout of every four Minnesotans, compared to oneout of every eight today. By 2050, about 250,000of these persons will be age 85 and over, about triplethe number in 2000.

Even assuming that future elderly will be healthier,Minnesota will have twice the number of elderlywith long-term care needs in 2030 (about 265,000persons) than it had in 2000.

2Available at www.des.state.mn.us3Available at www.des.state.mn.us

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sectors. In addition to low wages, the general lack ofbenefits is another barrier to the competitivenessof long-term care jobs. A recent study found thatMinnesota’s lower income workers were less likelythan higher income workers to be offered healthinsurance coverage.4 Another difficulty facing thelong-term care industry is the current perceptionthat “high tech” jobs are more attractive than “hightouch” jobs such as those in long-term care.

Figure 2Projection of FTE Home Health Aides

Needed in Long-Term Care (U.S.)2000-2040

remained longer in hospitals, waiting for nursinghomes to have staff and space available.

Shortages in home health care have also beengrowing. There are several counties in the statewhere clients are on waiting lists for personalcare attendants because no staff is available toprovide the service. Assisted living facilities in thestate face similar problems in recruiting andretaining workers.

Over-Reliance on Institutional ModelMinnesota has relied extensively on the institutionalmodel of long-term care since the 1960s when thepassage of Medicaid first made federal fundsavailable for nursing home care, and spurreddramatic growth in the nursing home industry.Because these dollars were intended to pay formedical care, federal and state officials envisionedthe emerging nursing homes as “miniaturehospitals” and thus the regulations put in placeemphasized life safety and nursing care. This meantthat nursing homes were required to provide a moremedical model of care than many elderly needed orwanted. However, these nursing homes often werethe only options available to the elderly whoneeded some assistance with day-to-day tasks.

By 1980, Minnesota’s nursing home utilization ratewas the highest in the nation, 8.8 percent ofpersons age 65 and over, and double-digit increasesin nursing home costs were straining the statebudget. Expenditures rose from $129 million to$441 million between 1976 and 1985. In 1983, inresponse to this situation, the state tightenednursing home reimbursement and placed amoratorium on the construction of new nursinghome beds. In addition, the state established severalprograms intended to divert elderly at risk ofinstitutionalization from nursing homes into morecost-effective home and community-basedservices whenever feasible.

4Minnesota Department of Health, Health Economics Program. (February 2000). Employer-based Health Insurance in Minnesota.St. Paul, MN: same.

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The task force heard many comments on theworker shortages at the focus groups and publicmeetings. In some regions, worker shortages havecaused nursing homes to close off admissions. This,in turn, has meant that some elderly patients have

Source: R. Suzman and K. Manton, “Forecasting Health and Functioningin Ageing Societies,” in chapter 5 of Aging, Health and Behavior, eds., M.Ory and R. Ables (Sage Publications, 1991).

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IIn 1983, Minnesota began providing home andcommunity-based services (a wide range of long-term care services that can be provided in one’sown home to assist with day-to-day tasks, e.g., helpwith personal care, household chores) for Medicaid-eligible older persons at risk of institutionalizationthrough the Elderly Waiver program, a federallyapproved waiver from Medicaid financingrequirements. The state also established a parallelstate-funded Alternative Care program for olderpersons who were within the 180 days of eligibilityfor Medicaid and at risk of institutionalization.Another component put in place at this time wasthe Pre-Admission Screening program, a requiredscreening of anyone going to a nursing home, inorder to identify the level of care required.

Figure 3Nursing Home Beds per

1,000 Persons 85+

and apartments as long as possible, and saw nursinghomes as necessary only when the type or level ofcare they need can no longer be provided at home,e.g., when mental impairments became severe, formedically complex conditions, for end-of-life care.

Need for More Community-based OptionsProbably the most significant issue identified by thetask force is the dramatic change occurring inconsumer preferences in long-term care. Consumersno longer see nursing homes as the first or only long-term care option. New options are developing rapidlyand use of nursing homes is declining for the firsttime.

The average length of stay in Minnesota’s nursinghomes declined from 99 days in 1990 to 65.5 in1999. This decline accelerated in the mid-90s whenMedicare changes gave hospitals additional incentivesto discharge their elderly patients as quickly aspossible, very often to a nursing home for a shortrecuperative or rehabilitative stay before returninghome. The overall occupancy rate in Minnesota’snursing homes has also been steadily dropping for thepast five years, and now stands at 92 percent, downfrom 97 percent in 1992.6 Between 1993 and1998, the percent of the elderly using nursing homes(under Medicaid) declined from 7.6 percent to 6.1percent, and the percent using home andcommunity-based services increased from 1.5percent to 3.7 percent. In just over two years, thenumber of facilities registered with the MinnesotaDepartment of Health as “housing with serviceestablishments,” which includes assisted livingfacilities, increased from 400 to 628, and the numberof apartments/units within these facilities grew from13,000 in 1997 to 27,000 in 1999. (Statisticsavailable at http://www.health.state.mn.us)

Even with these efforts to provide community-basedcare, Minnesota’s high nursing home utilization ratescontinued. In 1996, Minnesota spent 92.6 percentof its Medicaid long-term care dollars on nursinghomes, ranking 7th out of 50 states in theproportion of Medicaid long-term dollars spent onnursing home care vs. community care, and 6th outof 50 in the number of nursing home beds per1,000 persons age 85 and over (587.0)5

At the focus groups and public meetings, consumerssaid they wanted help to stay in their own homes

5 Ladd, Richard, Kane, Robert, and Kane, Rosalie. (1999). State LTC Profiles 1996. Washington, D.C.: Administration on Aging. p. 123.6 Minnesota Department of Human Services and Minnesota Department of Health. (January 2000). The 1999 Distribution of Nursing Home Bedsin Minnesota. St. Paul, MN: same.

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These programs and services areessential, and Minnesota spends over$1 billion per year to provide long-termcare services to low-income frailelderly who need assistance.However, in order to meet sharpincreases in future needs, the statemust also support efforts that helppeople meet their own long-term careneeds and help communities supporttheir older residents.

Consumers are demanding morecontrol over how and where servicesare provided. They want a better fitbetween their needs and preferencesand services. For this to happen,individuals need better information

Figure 4Mean and Median Length of Stay in

Minnesota Nursing Homes1990-1999

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Even though the supply of home care and housingoptions has grown, there are still many countiesand regions of the state where an adequate array oflong-term care services and housing options doesnot exist. This is especially true in the rural areas ofMinnesota.

Many consumers, family members and providers atthe focus groups and public meetings described theneed for more choices and options in long-termcare. This need is particularly acute for ethnicelders. Many individuals described the need foradditional affordable supportive housing options,more options for people who want to stay in theirhomes, and the need for these options to beavailable on a sliding fee scale so that all elderly canaccess the services and pay for them based upontheir income.

Need to Empower Consumers andCommunitiesMuch of the emphasis in long-term care at the statelevel has been on developing and paying fortraditional formal services, whether nursing homecare or home and community-based programs.

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about long-term care, more information on howthey can use their personal financial resources, andinformation on the availability of other resourcesthat help them meet their own needs.

Communities are also taking more responsibility forbuilding the supports necessary to help olderresidents remain a part of their community.Examples of these efforts include Block Nurseprograms, volunteer driver and chore programs,availability of supportive and affordable housing,and businesses that are sensitive to the needs ofolder customers.

Consumers and others at the focus groups andpublic meetings talked about the need for moreapproaches that give the consumer control andchoice in how long-term care needs are met, andmore incentives, such as tax credits, to prepare forand meet their own needs. Many also described theongoing need for accurate, comprehensiveinformation about long-term care options and thequality and track record of specific providers. Inaddition, community representatives described theimportance of supporting local programs that helpthe elderly stay independent and integrated. They

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described the proven ability of communities toharness significant volunteer unpaid resources tomeet many of the day-to-day needs of olderresidents, often at much lower costs than formalprograms.

Need for New Regulation andReimbursement SystemsThe types of changes needed in Minnesota’s long-term care system have many regulatory and fundingimplications.

As long-term care moves away from a medicalmodel of care to a nonmedical, supportive model,the current highly prescribed regulatory approachthat focuses on clinical standards will not work. Thisnew model requires more flexibility in meeting theoutcomes important to individual consumers asopposed to a “one-size-fits-all” approach. As morelong-term care is provided in the home and inresidential settings, the way that quality is definedand measured needs to change.

It was clear at the focus groups and public meetingsthat there is a high level of dissatisfaction with theway that long-term care is now regulated andreimbursed. Consumers, families and providersdescribed levels of paperwork and documentationrequired by regulators and funders in both nursinghomes and home care programs that areoverwhelming and ineffective, from their point ofview. Many stated that too much paperworkimpedes the provision of direct care, and reducesthe productivity of staff already stretched becauseof worker shortages.

On the other hand, consumer advocates indicatedthat the current regulatory system is not alwaysenforced effectively enough to protect vulnerableelderly. This issue will become even more critical asincreasing levels of care are provided in home andcommunity settings.

Since most if not all regulations in this area arefederal, any change will require change in, orwaivers from, current federal rules. Thus, the taskforce believes that the state must approach thefederal government regarding any needed changes.

In addition to new regulatory approaches, areshaped long-term care system needs areimbursement system that effectively supports thenew array of services and programs. As the state’snursing home capacity is rebalanced, adequatereimbursement is a key ingredient to strengtheningthe remaining nursing home industry so it canprovide services in the new system. Reimbursementrates for nursing homes have relied on outdatedcost data, include inequities and disparities that areworsening, and have made it difficult for facilities tocomplete necessary maintenance and facilityimprovements.

Reimbursement rates for home and community-based services are also problematic. Geographicdisparities exist as do disparities between similarservices within different programs. Another issue isthe degree to which the current reimbursementsystem encourages consumer directed care options.Many counties and home health agencies testifiedat the public meetings that low or inflexiblereimbursement rates have forced some agencies toclose their doors. Disparities in rates between theElderly Waiver and Alternative Care programs andacross counties have caused access and equityproblems in many areas.

Reimbursement issues in housing revolve around thedegree to which the state pays for housingseparately from long-term care services, how thatpayment is made and what type of funding is used.These issues will grow as more and more consumerschoose home and residential settings for theprovision of their long-term care, but need financialassistance, or affordable housing options, in order toremain in these settings.

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Task Force Recommendations

To respond to immediate concerns, prepare forfuture pressures on the state’s long-term care

system, and achieve its vision, the task forceconcluded that a major reshaping of Minnesota’slong-term care system is necessary. The frameworkfor this reshaping includes six major policydirections, each of which addresses a theme fromthe vision statement. To move forward on thesepolicy directions, the task force is recommending48 strategies. A complete list of these policydirections and strategies is included in Appendix B.

Policy Direction #1

Maximize peoples’ ability to meet their ownlong-term care needs.Any redesign of long-term care needs to putprimary emphasis on empowering individuals tomeet their own long-term care needs to the extentpossible. Consumer control over decision-makingmust be a key feature of new long-term careapproaches.

Policy Direction #2

Expand capacity of community long-termcare system.In order to expand the home and community-based options that consumers prefer, much work isneeded to develop these services and housingoptions in all parts of the state so they are trulyavailable to all elderly. In addition, communities needassistance to further develop their capacity tosupport older residents.

Policy Direction #3

Reduce Minnesota’s reliance on theinstitutional model of long-term care.In order to provide services that are more responsive

to consumer needs, we must reduce our reliance onnursing homes, and transform and strengthen theremaining nursing homes to serve those consumerswho will need the services best provided in the typeof protected setting that nursing homes can provide.

Policy Direction #4

Align systems to support high quality andgood outcomes.The current emphasis on paperwork anddocumentation must be refocused to ensureachievement of good outcomes for the consumer.More quality data needs to be collected and madeaccessible to consumers and providers.

Policy Direction #5

Support the informal network of families,friends and neighbors.Because of smaller families and increasing laborforce participation rates among women, familycaregivers need more support than they havereceived in the past to manage continuedprovision of large amounts of assistance to older,frail relatives.

Policy Direction #6

Recruit and retain a stable long-term carework force.Because future increases in the numbers of elderlyneeding long-term care will occur at the same timethat the pool of entry level workers is shrinking, it isessential that steps are taken to support amotivated and stable work force in long-term care.While there is no one single strategy that achieves asolution, a number of actions can be taken to moreadequately compensate workers and improverecruitment, retention and training of workers.

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Task Force Priorities for 2001Legislative Session

The task force identif ied 15 strategies aspriorit ies for action in the 2001 legislative

session. (The wording included here may becondensed. See Appendix B for complete wordingfor all strategies.)

1. Expand consumer information and assistanceservices; redesign case management servicesinto a broker model; develop a single point ofaccess for all elderly in a local area; makeinformation more accessible to elders in ethnic,immigrant and tribal communities, and to familycaregivers.

2. Encourage development of the long-term careinsurance market, through continuing thecurrent state tax credit for long-term careinsurance, promoting long-term care insurancewith employers, and beefing up consumerprotection measures for long-term careinsurance products.

3. Ensure adequate funding for the Elderly Waiverand Alternative Care programs to serve elderlydiverted from nursing homes, and equalize therate limits between these programs and acrossall Minnesota counties.

4. Create an inter-agency competitive capital fundto develop new or retrofit existing buildings toprovide assisted living, supportive housing, andto help nursing homes improve their physicalplants.

5 . Develop a process for the voluntary closureof nursing homes, that includes incentivesfor nursing homes to close, a method for

determining excess capacity and gaps, aregional planning process, a state level RFPprocess, and a nursing home planning andtransition grant program for rural nursinghomes.

6. Explore different standards for subacute andlong-term care.

7. Study and identify a new method for settingrates for nursing homes in the context of thechanges in their customers and services, andother changes in the long-term care system.

8. Identify and apply valid measures of quality oflife across long-term care settings, anddisseminate these and other data to consumers,providers and the general public.

9. Develop a cohesive strategy for approachingthe Health Care Financing Administration(HCFA) to obtain more state flexibility in theregulation of long-term care.

10. Provide a greater menu of respite services tocaregivers in all parts of the state, and makeservices more affordable to caregivers using asliding fee scale.

11. Add a Cost-of-Living-Adjustment (COLA) tothe rates of all long-term care providers, anddesign mechanisms for long-term care employerbuy-in to group health insurance for workersand their families.

12. Require state registration of pool agencies,criminal background checks for all pool staff,and set a maximum rate paid to pool agencies.

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13. Create strong intergenerational programs withinschools, and encourage middle and high schoolstudents to work and volunteer in health andlong-term care settings.

14. Expand tuition credits and loan forgivenessoptions, and develop a “GI bill” for health andlong-term care workers.

15. Require the Minnesota State Colleges andUniversities (MNSCU) and the HigherEducation Industry Partnership (HEIP) workforce partnerships to improve recruitment,training, retraining, on-the-job-training,certification process, and develop careerladders for direct support workers in health andlong-term care. In these efforts, specialemphasis should be placed on: a) the needs ofimmigrant workers; and b) development ofInternet-based curricula and other technology-based learning tools.

Rationale for Priority StrategiesListed below are the rationales for the task forceselection of these 15 strategies as priorities for the2001 legislative session. The estimated overall costof these strategies is approximately $113 million.Major expenditures include the provision of aCOLA for long-term care providers, ensuringadequate funding for the Elderly Waiver andAlternative Care programs and creation of a capitalhousing fund (which may be more appropriatelyconsidered in the 2002 session bonding bill). Majorsavings result from the closure of excess capacityin the nursing home system. Several of the otherindividual strategies have minimal costs. In addition,staff work on some strategies can beginimmediately without legislative or budgetaryaction.

1. Expand and improve consumer information andassistance, and improve case managementservices.

� Older consumers and their families want tofind and obtain their own long-term carebut need accurate, timely information andtrained professionals to assist them inmaking these critical decisions.

� Case management services need to take amore comprehensive approach to long-term care assessment, and refer elderly to abroad range of services, not just publicly-funded services.

2. Encourage development of the long-term careinsurance market.

� There are many middle-income individualswho now pay out-of-pocket for long-termcare services.

� If these individuals were covered byinsurance, their chances of becomingimpoverished and qualifying for Medicaidwould be greatly reduced.

3. Ensure Elderly Waiver and Alternative Careprogram adequacy.

� As nursing homes close or downsize, theremust be adequate community-basedservices to meet the demand for long-termcare.

� In order to maintain client access toservices, historic rate disparities betweenthese programs and differences in ratesacross counties must be eliminated.

4. Create an inter-agency competitive housingfund.

� Stable, affordable and appropriate housingis vital for the provision of services to frailelderly.

� As nursing home capacity is reduced,additional affordable housing options will beneeded in many communities.

� Physical plants of remaining nursing homesmay need upgrading.

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5. Develop a process for the voluntary closure ofnursing homes.

� Minnesota has growing excess nursinghome capacity because older people whoneed long-term care prefer to stay in theirhomes and other housing options,supported by families and communities, andhome and community-based services.

� A voluntary process for closure of nursinghomes provides incentives to homes toclose, and involves relevant communityinterests in determining how long-term careneeds should be met in local areas.

6. Explore different standards for subacute andlong-term care.

� Current regulations for long-term carefollow a medical model for staffing andservices.

� As long-term care changes, currentregulations may not fit the changing natureof the elderly served in the programs.

7. Study and identify a new method for settingnursing home rates.

� Nursing home rates should be sufficient toprovide for the needs of a quality facilityoperated in an economic manner.

� Providers report that current rates do notcover actual costs and many areexperiencing losses.

� A study needs to be completed andrecommendations developed for ratesetting options.

8. Identify and apply valid measures of quality oflife, and disseminate the resulting information.

� Quality of life measures, including thosecontained in consumer satisfaction surveys,are essential to assess the performance ofproviders in delivering satisfactory servicesto consumers.

� This information would empower

consumers and their families to makeinformed decisions when selecting long-term care providers, and would providecomparison data to providers so they canassess the results of their efforts.

9. Develop a cohesive strategy for approachingthe Health Care Financing Administration(HCFA) to obtain more state flexibility inregulation of long-term care.

� There is growing concern among statesabout the regulatory burden placed onthem and providers by federal long-termcare regulations.

� Methods must be found to reduce theamount of paperwork, so that more stafftime can be focused on direct care andachieving better outcomes.

10. Improve respite services for caregivers in allparts of the state.

� Respite services are a key ingredient ingreater support of caregivers. Respite is themost frequently mentioned service whencaregivers are asked what they need tokeep providing services.

� Many Minnesota communities do not yethave a full range of respite services to meetthe needs of their caregivers.

11. Add a COLA to rates of all long-term careproviders, and design mechanisms for long-termcare employer buy-in to group health insurancefor workers and their families.

� It is increasingly difficult for long-term careproviders to attract and retain directsupport workers, in part because of lowwages and lack of benefits.

� Provision of better wages and benefits isessential for long-term care jobs to havesome degree of competitiveness in thecurrent labor market.

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12. Require state registration of pool agencies,criminal background checks for all pool staff,and set a maximum rate paid to pool agencies.

� The use of staff from pool agencies hasrisen in the past few years as a result ofworker shortages and the need to coverstaffing requirements.

� In order to ensure a more level playing field,there needs to be some additionalregulation of how pool agencies providingstaff to long-term care providers operate inthe state.

13. Encourage middle and high school students tovolunteer and work in health and long-termcare settings.

� In order to overcome the negative publicimage of work in long-term care, effortsare needed to introduce young people tothe positive aspects of long-term care.

� Internship programs for students in healthcare settings have experienced 50 percentretention rates after five years. It appearsthat early exposure to these jobs is aneffective method of recruiting andretaining workers.

14. Expand tuition credits and loan forgivenessoptions, and develop a “GI bill” for health andlong-term care workers.

� The costs of obtaining the required trainingfor long-term care jobs can be a barrier tosome potential workers.

� Finding ways to remove these barriers andmaking training accessible are importantparts of a larger work force strategy.

15. Require MNSCU and HEIP work forcepartnerships to focus on the needs of directsupport workers.

� It is essential that the state’s highereducation and work force systems addressthe urgent need for direct support workersin health and long-term care.

� Even though these jobs are not “highwage” jobs, the functions they perform incaring for children, disabled and elderlyindividuals (many of whom are clients ofpublicly funded programs) are functionsessential to the state.

Immediate Steps to be TakenThe task force asked staff to identify any of therecommended strategies where work could bebegin immediately without legislative or budgetaryauthority.

The staff identified the following strategies wherework can begin immediately.

1. Promote greater use of Elderly Waiver andAlternative Care programs to obtain and pay forassistive devices and home modifications.

2. Implement the Bush Foundation demonstrationto create affordable assisted living.

3. Identify and collect data on actual costs oflong-term care across all settings.

4. Provide more and better information on assistedliving for consumers and families.

5. Promote greater use of existing hardship waiversto pay family caregivers.

6. Explore ways to make better use of staff, e.g.,more flexible hours and more use of theuniversal worker concept.

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Keeping the Vision

Next StepsThe work of the task force has engendered a greatdeal of enthusiasm and optimism that long overduereforms in the long-term care system will begin.Consumers, providers and policymakers supportthese changes. Many stakeholders are hopeful thatthey can continue to be involved in the changes,and to build on the momentum generated by thework of the task force.

The first step in this reform, will be to enact thetask force’s high priority strategies in the 2001legislative session. The task force intends toreconvene after the 2001 legislative session andtake stock of what was accomplished, hearprogress reports on the strategies that staff hasbeen working on, and discuss what next stepsmight be necessary.

Another step the task force has taken is to setbenchmarks to measure the state’s progress inrebalancing the long-term care system, improvinginformation and quality, supporting familycaregivers, helping people take care of their ownneeds as much as possible, and making jobs in long-term care more competitive.

BenchmarksListed below are several benchmarks that will beused to measure change in Minnesota’s long-termcare system over time.

1. Nursing home beds per 1,000 persons age 85and older.

2. Percent of Medicaid long-term care dollarsspent on community-based services.

3. Proportion of Medicaid long-term care dollarsspent on consumer-directed care.

4. Percent of providers having and using consumersatisfaction surveys.

5. Reduction in disability rates in the elderlypopulation.

6. Reduced use of nursing homes for less disabledelderly.

7. Improved satisfaction with long-term care byboth providers and consumers.

8. Reduced use of pool staff in long-term care.

9. Lower staff turnover rates in long-term caresettings.

10. Increased availability of quality profiles for alllong-term care settings.

11. Proportion of frail elderly receiving assistancefrom family caregivers.

12. Increased proportion of the population havingprivate long-term care insurance coverage.

The work of the task force hasengendered a great deal ofenthusiasm and optimism thatlong overdue reforms in the long-term care system will begin.

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Appendix ABackground on Task Force WorkWhat Led to the Task Force?The changing market forces in long-term care,increasing financial instability within the state’snursing home industry, and a severe labor shortagein long-term care came to a head during the 2000legislative session. Many nursing homes faced thepossibility of closure. Labor shortages wereexacerbating the occupancy problems for nursinghomes, and also posed a problem for home careproviders. There was also a great deal of concernabout the actual effectiveness of the regulationsand paperwork required by the federal governmentin both nursing homes and home health programs.

Leadership from the legislative and executivebranch of state government agreed that thesecritical issues should be dealt with outside thehectic schedule of the legislative session, at a timewhen members could focus on these complexissues, and develop solutions for specific long-termcare problems in the context of all long-term care.

Work of the Task ForceIn May 2000, the task force convened to addressthe emerging issues in long-term care in Minnesota.The task force members included 12 legislators, sixsenators and six representatives, named by theleadership in the Senate and House, with bipartisanrepresentation. Members also included the threecommissioners of state agencies most involved inlong-term care issues: the Minnesota Departmentof Human Services, Minnesota Department ofHealth and the Minnesota Housing FinanceAgency. The Commissioner of Human Servicesconvened the task force and chaired the meetings.

The goal of the task force was to develop acommon understanding of needs and issues in long-term care for older citizens of Minnesota, andreach as much agreement as possible on the beststrategies for addressing these issues. Based uponthis work, the task force members developedproposals for the 2001 legislative session.

The task force retained a consultant, Bailit HealthPurchasing of Boston, Massachusetts, to providesupport to the staff of the task force, participate inpublic meetings, facilitate consumer focus groups,and maintain ongoing communication with anextensive list of “stakeholders” in long-term care,including consumer organizations, unions, providers,local government representatives, and providerassociations.

The task force met 12 times between May andDecember 2000. At the first three meetings in Mayand June, the task force reviewed currentinformation about the long-term care system andthe issues facing the state, developed a workingdraft of a vision statement, and heard responses tothe draft vision statement from stakeholders.During July, the task force consultant held a seriesof consumer focus groups around the state, andthe task force discussed gaps between its visionand the current system. In August, the task forceheld a series of eight public meetings to obtain inputfrom citizens and stakeholders around the state onlong-term care issues. It then formed five workgroups made up of task force members, counties,stakeholders and agency and legislative staff toreview all of the input received, and to identify andanalyze a broad range of strategies for achievingthe vision.

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Following this intensive process, the task forceidentified six major policy directions necessary toachieve its vision, and reviewed over 90 strategiesfor implementing these policy directions. Afterfurther discussion and analysis, the task forcedirected staff to prepare more detailed proposals fora subset of these strategies. At its last threemeetings, the task force reviewed these proposalsalong with the associated costs of implementation,agreed on a set of 48 strategies and relatedbudgetary estimates for both short- and long-termlegislative and administrative action. It then chose15 strategies as priorities for action during the 2001legislative session. The task force alsorecommended that staff continue work alreadybegun or begin work immediately on strategieswhere legislative or budgetary action is notimmediately required.

Stakeholder Input Into Task ForceThe task force placed great emphasis on hearingfrom “stakeholders, ”including individuals andorganizations with a particular stake in the long-term care system, such as consumers, their families,providers, local government, advocacyorganizations, and general citizens, about thechanges underway in long-term care. To do this, thetask force sponsored several consumer focusgroups and a series of public meetings throughoutthe state.

Consumer Focus GroupsThe task force particularly wanted to hear fromconsumers and their families about their needs andpreferences in long-term care. The task forceconsultant held seven focus groups with a broadrange of consumers and family members. AreaAgencies on Aging and advocacy organizationsprovided assistance with the arrangements for thefocus groups. The focus groups were held in July,and the consultant facilitated the discussion using acommon instrument for all groups.

In addition to these consumer focus groups, thetask force also requested additional meetings withelders from the minority and immigrantcommunities who have special difficulties findingand using available long-term care services. Staffprovided the task force with summaries of anumber of other recent focus groups held withelders in minority and immigrant communities. Inaddition, staff from the Department of HumanServices held five focus groups with elders from theCambodian, Hmong, and Korean communitiesduring August.

The most common themes that emerged fromthese focus groups are summarized below. Asummary of each focus group is available on thetask force web site at http://www.dhs.state.mn.us/agingint/ltctaskforce.

Service Gaps in Community

� There is a lack of affordable services formoderate-income seniors.

� The elderly, especially immigrant elders, havedifficulty finding and coordinating services.

� There is a great need for additional support andrespite for family caregivers.

Nursing Homes

� Staffing problems are increasing in nursinghomes.

� Homes need to do a better job ofcommunicating with family members.

� Staff training, especially how to deal withdementia patients, must be improved.

� More funding is needed for state ombudsmanservices for older Minnesotans.

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Special Problems for Ethnic and ImmigrantElders

� There are not enough interpreter services andbrochures and applications in non-Englishlanguages.

� Staff at county and home health agenciesoften do not speak the language of the elders,and may not be sensitive to cultural differences.

� Families of elders carry heavy responsibilities forproviding assistance to older relatives who needlong-term care.

� Elders face high levels of depression, isolationand sense of loss due to their immigration.

� There are some community agencies that havetailored services to meet the needs of ethnicelders.

Public MeetingsIn order to hear from citizens across the state onthe current situation in long-term care, the taskforce sponsored a series of eight public meetingsduring August. The purpose of the meetings was toask Minnesotans for their input on the followingquestions:

1. In what way does the current long-term caresystem meet your needs and the needs of yourfamily?

2. In what ways does it not?

3. Does the vision of a long-term care system asstated by the task force make sense to you?

4. How can policymakers improve long-term careright now and for the future?

Meetings were held in St. Paul, Rochester,Minneapolis, Mankato, Moorhead, Willmar, Duluth,and Brainerd. Approximately 800 persons attendedthe meetings, and 150 provided testimony. Taskforce members chaired six of the meetings, andlocal legislators chaired two of the meetings. In

addition, legislators who were members of thehealth and human services committees and whosedistrict included the community where the publicmeetings were held were invited to attend, andmany did so, giving them an opportunity to hearfirst hand about the long-term care issues in theirareas. The meetings also received substantial mediacoverage. The public was encouraged to follow-upwith written comments through use of the taskforce web site and related e-mail. Over 75additional comments were received through theweb site.

Several themes emerged at the public meetings, andsome of the most commonly voiced concerns arelisted below. A summary of each meeting is availableon the task force web site.

Information and Consumer Support

� The elderly and their families need more andbetter information about services.

� The need for timely, useful information and helpwith decision-making is particularly acute whenthe elderly are discharged from the hospital,and available information and assistance iscurrently inadequate.

� The elderly and their families want one-stopshopping for information and services.

Nursing Homes and Community Services

� Nursing facilities should be downsized, andemphasis placed on helping the elderly stay athome as long as possible.

� Affordable housing options, including housingthat provides supportive services, and home-based and community services, need to bemore available, especially in rural areas.

� Rates paid to nursing homes, and in the ElderlyWaiver and Alternative Care programs from onecounty or region to the next are insufficientand unequal.

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� The savings from nursing home closuresneed to be reinvested into communityservices.

� Community services need to be expandedand strengthened in order to supportadditional individuals diverted from nursinghomes.

� There is a lack of services, including nursinghomes, on Indian reservations.

Administrative Requirements/Quality� Too much paperwork detracts from time

available to provide direct care.� Staff turnover and the use of pool staff

means less attention to and inadequatecare for nursing home residents.

� Staffing problems in assisted living facilitiesare growing.

� Regulations should not be eliminated—theyare needed to ensure that resident andconsumer safety is protected.

Informal Caregiving� Families need much better access to a full

menu of respite services.� It should be possible to pay caregivers or

give them vouchers.� Tax breaks or similar incentives should be

available to caregivers.� Families of elders from ethnic, immigrant

and tribal communities carry heavyresponsibilities for meeting long-term careneeds of older relatives.

Work Force Issues� There is an insufficient supply of nursing

aides and personal care attendants.� Non-competitive wages and benefits in

long-term care make these jobs lessattractive to workers.

� Staff training is needed on how to workwith those with dementia and to preparestaff for “reality” on the job.

� Long-term care workers need non-monetary rewards and incentives, e.g., childcare, recognition ceremonies, awards forexcellence.

� Increasing use of immigrant workers in long-term care presents special challenges, e.g.,provision of responsive education andtraining, acceptance by consumers andtheir families.

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Appendix B

Complete List of StrategiesRecommended by Task Force

1. Maximize peoples’ ability to meet theirown long-term care needs.

Strategies

A. Provide consumers with objective,accessible and useful information on long-term care and preparation for retirement andold age.

1. Greatly expand and strengthen informationabout long-term care options for consumersand family caregivers.

� Expand Senior Linkage Line services in waysthat make it more accessible to familycaregivers.

� Provide basic information on all long-termcare resources, and trained professionals toassist consumers and families in makingdecisions.

� Redesign county-level case management tobecome a “service broker” model thatprovides universal access to long-term careservices.

� Develop a single point of access for allelderly in a given geographic area.

� Encourage special efforts to makeinformation about long-term care servicesand housing options accessible and usefulto ethnic, immigrant and tribal elders andtheir families.

B. Expand the availability and use ofmechanisms for private financing of long-term care.

1. Encourage the development of the long-termcare insurance market in Minnesota.

� Continue the current state tax credit forlong-term care insurance.

� Work with employers to promote theoffering of long-term care insuranceproducts to their employees.

� Beef up consumer protection safeguardsfor long-term care insurance purchase.

C. Expand the use of assistive devices andhome modifications that enable consumersto meet their own long-term care needs.

1. Simplify and expand information about, andfunding for, home modifications, energymodifications, general repairs and personaladaptive equipment for older persons wantingto stay in their homes.

2. Promote greater use of available reimbursementfor assistive devices and home modificationsthrough the Elderly Waiver and Alternative Careprograms.

D. Retool the long-term care system andredesign key components.

1. Expand efforts to test the applicability ofconsumer-budgeted and directed care, e.g.,vouchers.

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2. Set up a pilot to test a redesign of the systemthat incorporates a single point of access for allelderly within a given geographic area,combines multiple public funding streams, andestablishes a sliding fee scale for private payconsumers.

3. Implement a process to track long-term careinvestments across state agencies to allow moreintegrated long-term care budgeting andspending, and the potential of reinvestingsavings from one part of the system to another.

4. Explore separating payment for housing frompayment for services, to allow consumers to“buy” housing they desire with their incomeand assets, and receive services regardless oflocation.

2. Expand capacity of the community long-term care system.

Strategies

A. Expand capacity of Elderly Waiver (EW)and Alternative Care (AC) programs, throughreinvestment of savings from nursing homedownsizing

1. Strengthen the Elderly Waiver and AlternativeCare programs.

� Ensure adequate funding in these programsto meet increased demand due to elderlybeing diverted from nursing homes.

� Equalize the rate limits between theseprograms.

� Equalize these programs’ rate limits acrossall Minnesota counties.

B. Expand the availability of affordableassisted living and other supportive housingoptions.

1. Create an inter-agency competitive capital fundto develop new, or retrofit existing, buildingsinto affordable assisted living or othersupportive housing, and to help nursing facilitiesimprove their physical plants.

2. Implement the Bush Foundation demonstrationproject recently funded at the Department ofHuman Services to create affordable assistedliving, using existing affordable senior housinglinked to Elderly Waiver, Alternative Care, andOlder Americans Act services.

C. Make communities more “age-sensitive,”with more supports for older residents.

1. Expand Seniors’ Agenda for Independent Living(SAIL) statewide to bring communities andproviders together to shape long-term careservices and housing options that meetcommunity needs, and facilitate the planningprocess for voluntary nursing home closures.

D. Provide long-term care that is responsiveto the special needs of elders in ethnic,immigrant and tribal communities.7

1. Ensure that the strategies described in thisreport are responsive to the needs of elders inethnic, immigrant and tribal communities asthey are implemented.

2. Develop long-term care services and housingoptions that address the special needs of eldersin ethnic, immigrant and tribal communities andtheir families, as part of the strategies in thisreport.

7These communities include African American, Asian American, American Indian, Hispanic, and a variety of immigrant and other ethnic communities.

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3. Reduce Minnesota’s reliance on theinstitutional model of long-term care.

Strategies

A. Reduce the size and capacity ofMinnesota’s nursing home system.

1. Develop a process for voluntary closure ofnursing homes that provides incentives tohomes that close. Savings should be reinvestedinto capital funding for renovations, increasedrates, and expansion of community serviceoptions.

This process needs to include:� A method for determining the current and

future need for nursing home beds, assistedliving and home care services at the stateand regional/local level.

� A regional/local planning process thatconsiders the community’s long-term careneeds and resources now and in the future,so that adequate supplies of long-term careservices and housing options (includingnursing homes) are available. The stateshould provide any available data on locallong-term care needs and resources toregional/local entities completing theplanning process.

� A state level RFP process for soliciting andapproving closure proposals. The RFPshould encourage nursing homes in areas ofexcess supply to close some or all of theircapacity and retrofit for other uses thatmeet local long-term care or communityneeds.

� A nursing home planning and transitiongrants program that would provide planningsupport to nursing homes in rural areas toassess their situations and theirenvironments, and plan appropriatechanges in services, including developmentof facility renovation plans.

B. Transform remaining nursing homes toaddress specialized long-term care needs.

1. Explore the possibility of different standards forsubacute and long-term care facilities, with amore medical model required in subacutefacilities serving rehab clients, and a moreresidential model in programs serving longer stayresidents with specialized needs, e.g., end-of-lifecare, mental impairments, medically complexneeds.

� The inter-agency capital fund included insection 2B above would be available to helpnursing homes retrofit or improve theirphysical plants to serve more specializedneeds.

� The nursing home planning and transitiongrants program in section 3A above wouldprovide planning support to nursing homesin rural areas to assess their situations andplan appropriate changes in services.

C. Provide adequate and competitive ratesfor nursing home providers.

1. Implement targeted rate increases for nursinghomes, especially to diminish existinggeographic rate disparities.

2. Study and identify a new method for settingrates for nursing homes in the context ofongoing changes in the customers and services,and other changes in the long-term caresystem.

3. Identify and collect accurate data on the actualcosts of providing long-term care in all settings,including nursing homes. These data includewages, case mix of clients served, labor marketcompetitiveness, geographic disparities, etc.

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4. Align systems to support quality andgood outcomes.

Strategies

A. Collect consumer-focused quality dataacross all long-term care settings, and utilizethis data (together with other approaches) toimprove quality.

1. Identify and apply valid measures for “qualityof life” across all long-term care settings, withstakeholder participation, and phase them inover time.

� Clinical measures should be developed afterquality of life measures are in place.

� Develop separate quality measures forsubacute care and long-term care.

� Publish consumer reports that include thisqualify information.

� Disseminate information to consumers,providers and the public, using hard copyand the Internet, and through the media,consumer advocacy and otherorganizations.

B. Improve the efficiency and effectivenessof the state’s regulatory process.

1. Revise the current survey process for nursinghomes to incorporate more consultation andtechnical assistance. Develop and fund atechnical assistance team within theDepartment of Health to consult with andprovide training to nursing homes.

2. Establish an ongoing mechanism to explorealternative regulatory strategies and regulatoryrelief, in order to decrease or make regulationsmore flexible, and to reduce paperwork acrossall long-term care settings.

3. Explore the creation of a standardizedassessment instrument to use across all caresettings.

4. Implement the case mix revisions now beingdeveloped to eliminate duplicate assessmentsystems in nursing homes.

5. Provide more and better information toconsumers and their families about assistedliving options, and identify methods to helpconsumers compare service packages acrossdifferent assisted living providers.

6. Foster greater community involvement inquality oversight through community councilsthat can monitor quality across care settingswithin a geographic area. To begin, develop apilot project using the Region 10 qualityassurance model and apply that approach tolong-term care for the elderly. Apply for waiversif necessary to implement the project.

7. Develop a cohesive strategy for approachingthe Health Care Financing Administration(HCFA) to obtain more state flexibility in theregulation of long-term care in the state, and inhow high quality is achieved and monitored.Work in collaboration with the Council of StateGovernments and the National Council of StateLegislatures on this strategy.

C. Ensure that consumer protectionmechanisms are adequate to address theneeds of vulnerable elders across all long-term care settings.

1. Assure that the ombudsman program for olderMinnesotans has adequate program capacity tomeet current mandates.

2. Assure that state and county agencies have theresources they need to fulfill the mandates ofthe Vulnerable Adults Act.

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5. Support the informal network of families,friends and neighbors.

Strategies

A. Provide training, education andinformation about long-term care resourcesto caregivers.

1. Develop a cohesive program for training andeducation of caregivers to help them in theircaregiving role. This should include writtenformats, videos, classes, and use of the Internetto make the information as accessible aspossible.

2. Encourage families to include children in thecare and support of older relatives.

B. Strengthen and expand workplacesupport of eldercare.

1. Work with employers and groups such as theChambers of Commerce, Minnesota BusinessPartnership, and the Minnesota EmployersAssociation to promote eldercare benefits andpolicies.

C. Pay targeted family caregivers to providecare.

1. Promote greater use of existing hardship waiversand other exceptions in public programs to payfamily caregivers in specific cases:

� if the family provides Personal CareAttendant (PCA) services.

� if the family is the provider chosen underthe cash option within the Alternative Careprogram.

� in cases where culturally competent staff isnot available to care for an elder in anethnic, immigrant or tribal community.

D. Provide a wide variety of respite servicesfor caregivers.

1. Provide a greater menu of respite services tofamily caregivers in all parts of the state,including such services as adult day health, in-home respite (either volunteer or paid), out-of-home respite (either foster care or nursinghome care), and other types of assistance thatcan serve as respite.

2. Allow reimbursement for transportation costsin state-reimbursed adult day health services.

3. Make respite services more accessible andaffordable to all caregivers, including the use ofsliding fee scales.

6. Recruit and retain a stable long-term carework force.

Strategies

A. Provide competitive wages and benefitsfor all workers in long-term care.

1. Add a cost-of-living adjustment (COLA) to thereimbursement rates for all long-term careproviders, and design a mechanism to facilitatelong-term care employer buy-in to group healthinsurance for workers and their families.

2. Require state registration of pool agencies,require criminal background checks ofemployees of registered pool agencies, and havethe state set a maximum rate for payments topool agencies.

B. Change the way that work is done in alllong-term care settings to optimize laborresources.

1. Reduce the amount of paperwork in all long-term care settings by:

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� Reducing paperwork requirements.� Fostering innovation and improved

efficiencies through application oftechnology, including a capital fund topromote technology improvements, andgreater use of telemedicine.

2. Explore ways to make better use of staff, e.g.,more flexible hours, more use of the universalworker concept.

C. Cultivate creative recruitment of directsupport workers.

1. Create strong intergenerational programs withinschools in order to provide interaction betweenall generations, and encourage middle and highschool students to volunteer and work in long-term care settings.

2. Develop non-monetary rewards for long-termcare workers, e.g., a well-publicized and regularrecognition or award to workers who exemplifyexcellence and commitment to the elderlythey serve.

D. Make training more responsive to theneeds of long-term care workers.

1. Expand tuition credits and loan forgivenessprograms, and develop a “GI bill” for long-termcare workers.

2. Require the Minnesota State Colleges andUniversities (MNSCU) and the Higher EducationIndustry Partnership (HEIP) work force

partnerships to improve recruitment, training,retraining, on-the-job training, certificationprocess, and develop career ladders for directsupport workers in health and long-term care. Inthis effort, special emphasis should be placedon: a) the needs of immigrant workers; and b)development of Internet-based curricula, andother technology-based learning tools.

3. Provide resources to regions of the state thatneed help (or require existing higher educationor work force resources to be used) to addressregional health and long-term care work forceissues and develop concrete strategies.

E. Prepare health and long-term careworkers to meet the changing needs of theircustomers.

1. Increase the competence of all health and long-term care workers in the areas of disability andaging.

2. Develop a cultural training and awarenessmodule for current long-term care workers andincorporate it into the required certified nursingassistant (CNA) curriculum and in-servicetraining.

3. Incorporate training on dementia care into therequired curriculum and in-service training forcurrent long-term care workers in all long-termcare settings who provide care to those withdementia.

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