The Florida Legislature has been working hard on crafting proposals that would reform the health quality assurance system that provides regulatory oversight of quality and care that Floridians receive in state licensed assisted living facilities.
The current survey system now in use by the Agency for Health Care Administration has evolved over the last 30 yrs and was derived from the hospitals and nursing homes which are themselves medical models of care that require a citation driven deficiency model survey.
The major question for policy makers during the 2012 legislative session will be to answer one fundamental question; "If Florida were to purchase a new health quality assurance system today, would we buy the one we have today?"
It is my view that the current system is outdated and no longer serves the long term public policy interest of the state's need to have a cost effective system that provide regulatory oversight and contributes to the development of a robust system of ALF care that can meet the challenge of rising acuity.
Two major forces are underway that will create a need for substative change in how state's regulate assisted living facilities. As many states seek to manage their long term care costs many will seek to adopt policies that will place more people into managed care plans.
We know from Florida's experience with the nursing home diversion program that 50% of the placements in these long term care managed care plans are referred to assisted living facilities. It is a reality that the ALF can provide a comparable level of care due to a lower cost structure than the nursing home and managed care plans will increase their utilization of ALFs in Florida and should be expected to ask ALFs to do more and manage residents with higher levels of acuity.
The second major driving force that will affect assisted living facilities is the issue of rising acuity. It is expected that as the nation begins to age both the elderly and the adults with mental illnesses will begin to experience a rise in chronic medical conditions which impact on the rise in acuity that must be managed in the ALF.
The currentsystem now in use in Florida only focuses on the facility and not the system of care. The reality is the ALF only provides the residential function and some supportive services and DOES NOT provide medical care or clinical supervision. It is important how the clinical supervision is rendered and this is why any new system created should focus on the "system of care" that is in use as opposed to the narrow focus on the facility.
The basic elements that really matter most in my view to ALF residents and their families include the following;
1. Qualifications and involvement of the administrator.
2. The relationship between the frontline staff and the resident.
3. The presence of a well coordinated 'system of care" that promotes scheduled care over crisis care.
4. Collection of information on changes of condition and the speed with which information is linked to key decision makers in the system of care.
House Bill 397 by Representative Fresen is a real move towards a consultative model that includes a regulatory hammer for low performing facilities. It calls for higher standards for ALF administrators and creates a RFP for a statewide data collection system that can be useful in forecasting trends in resident care.
The need for real reform in how we consider or weigh the options for improvements to the oversight and regulatory system will play a critical role in how sucessful Florida will be in meeting the new challenges associated with an aging population and growing numbers of the mentally ill who need assistance in the next ten years.
Showing posts with label ALF. Show all posts
Showing posts with label ALF. Show all posts
Wednesday, November 2, 2011
Tuesday, July 14, 2009
Assisted Living Facilities and Federal Health Reform
Today the much anticipated Federal Health Reform proposal HR 3200 was released in the US House of Representatives. This massive 1016 page legislative proposal is wide ranging and filled with many changes to Federal Law that are intended to help reduce costs and improve access to care.
Health Care is a complicated issue and has many varied dynamics all at work. The Federal Plan will impose many new requirements for the health care providers and consumers and just like most of these other changes to our health care system people will respond to these changes and come up with new approaches that will allow for the provision of care.
The reality is that to reduce the cost of health care we must find ways to reduce the need for institutional care. The demand and dependence on instuitional care is expensive and in many instances not necessary.
While community based care COULD play a role in reducing the need for institutional care the reality is that it does not play a key role in reducing institutional costs because there is no incentive for community based care to delay, divert or otherwise avoid the need for institutional care. In many instances community based care improves consumer satisfaction and improves access to care but as it relates to reducing the need for institutional care there is no incentive for these care systems to play a central role in that goal or task.
For many years it has been well understood that licensed Assisted Living Facilities are frequently used by the Nursing Home Diversion Managed Care Program as a way of reducing long term care costs. In fact approximately 50% of the diversions in this program go to ALF care because it is effective in reducing the need for institutional care. For one monthly fee the ALF accepts the risk associated with acuity and care and provides a predictable, capitated environment that promotes healthy living routines and improves access to preventative care.
ALF care is a life style choice and in many instances the improvement of these routines and systems that surround a person whether they ben social, environmental or medical and dietary have a profound influence on what happens several years down the road. These congregate living arrnagements are vibrant communities with their own unique social structure and culture.
Sadly access to ALF care for the low income and state funded individuals is on the decline and is fast disappearing from the shores of Florida. Last year the Florida legislator reduced the optional state supplementation program from $25 million to $15 million. The lawmakers also reduced the Medicaid assistive care services program which pays for services in these settings from $32 million to $25 million, no other social service program sufferred cuts in theior budgets similar to these twin pillars that provide access to care. So why the cuts? The answer is simple, many of the beds for care of the low income are fading away as the mounting prolems with the economy encompass many of the samll facilities.
The reality is that many of the ALFs that care for the state funded residents have closed and gone away quietly. The state has lost olver 2100 beds for low income ALF residents since 2001, in the last four years it has 980 beds for the low income adults with mental illness. The chronic substandard rate of reimbursement for care at $9.28/day coupled with the increasing costs associated with meeting the current regulatory standards has all but made the business model for continuation of this important housing link all but unsustainable.
The cost saving role of the ALF has been significant over the years in providing stable housing for persons with mental illness. On frequent instances the courts, homeless shelters, hospitals, crisis stabilization units and others will look for a good ALF to care for a complex person with mental illness, often with emerging medical needs and in many instances problems with substance abuse. The loss of these beds is now beginning to show up in the data, over the last few years in Florida the numbers of mentally ill headed to forensic mental health treatment facilities has shot up creating a crisis. In Florida that number has gone from 1200 to 1500 today and is costing taxpayers $140,000 per year for each bed.
In Florida we see that 125,000 citizens each year are arrested and charged with a crime who also have a mental illness. There are 17,000 residing in state prison beds, 14,000 in county detention facilities and another 40,000 under supervision of probation and parole. The Department of Corrections spends $68 million each year on the mental health needs of its inmates and this number continues to grow. The large percentage of crimes committed by these people were committed while the person was not taking their medications and is in part due to their mental illness.
The data shows that 12 months after discharge from a state mental health treatment facility of 1300 people discharged annually in Florida 782 end up on a correctional facility, hospital, nursing home, homeless shelter or unknown. These are not the desired outcomes that people would expect and this is the reality that feeds the revolving door because of the lack of stable housing and services.
When you look at how effective the limited mental health ALF setting is in reducing the need for forensic mental health treatment beds, the data in Florida shows that over the last four years only 26 mentally ill residents of the ALFs are sent for care in an forensic mental health institution. By contrast when you compare to the FACT team, the assertive community treatrment teams, over 200 on average are sent to a state mental health treatment facility. In many instances the provision of FACT services is not enough to avoid the need for instutional care, what is needed is a combination of stable housing and stable services.
So what can fgederal lawmakers do to help reverse the slide toward rising costs and greater use of jails to care for the mentally ill in Florida and nationally. The development of proper incentives to care for the most functionally impaired is of broad puyblic interest, people would like to ensure the mentally ill are cared for in an appropriate way at the lowest cost possible.
Clearly as the Nursing Home Diversion Program has learned the proper use of an ALF can help divert risk, reduce the need for expensive institutional care and improve customer satisfaction. The federal lawmkers would be well served to consider using the savings from the continuing disability review program that is funded through the social security administration to create a federal subsidy for those individuals with a serious and persistient mental illness who meet certain criteria relative to functional impairment to fund access to care in a state licensed limited mental health assisted living facility, personal care homes or other state regulated residential care facility. The federal subsidy would be expected to be from $150/month to $320/month and would be based upon the income of the resident.
The use of the savings from the SSA continuing disability review program would create an incentive for licensed residential facilities to offer care for the more functionally impaired and would help reduce the need for jails, prisons and ER visits that would otherwise arise when these individuals do not have access to stable housing and supervision. This approach would be based on the availability of funds and would be a federal subsidy that would be based on the allocation of slots for care and would include a process for recertification of eligibility and recoupment when funds are paid for persons determined to be ineligible.
The development of a federal plan to expand the access to state licensed limited mental health assisted living facilities would help reduce the cost of health care for the low income chronically mentally ill. The need for immediate attention in viortually every state is a growing crisis. The unintended consequences associated with decisions made on a federeal level too many times leaves the most functionally impaired left out and struggle to find a new way just to survive the change that imposes new burdens and new struggles. The plan for federal health reform should consider changes that would offer the right incentives and work to fully utilize the care settings that help control costs and reduce the need for institutions, these are the investments and changes in federal policy that should be pursued.
Todays decisions will impact on the results we see 30 years from now. How will the mentally ill be treated in our society in the future? The absence of changes that will offer adults with mental illness the stable housing and services they need will result in the further collapse of the limited resources now available and result in new costs for institutional care. Now is the time for change in how America provides for the chronic adults with mental illness and their need for stable housing. This one change will produce a significant change in the need for crisis care and will allow these important Americans to join the community in building a prosperous future for everyone.
Health Care is a complicated issue and has many varied dynamics all at work. The Federal Plan will impose many new requirements for the health care providers and consumers and just like most of these other changes to our health care system people will respond to these changes and come up with new approaches that will allow for the provision of care.
The reality is that to reduce the cost of health care we must find ways to reduce the need for institutional care. The demand and dependence on instuitional care is expensive and in many instances not necessary.
While community based care COULD play a role in reducing the need for institutional care the reality is that it does not play a key role in reducing institutional costs because there is no incentive for community based care to delay, divert or otherwise avoid the need for institutional care. In many instances community based care improves consumer satisfaction and improves access to care but as it relates to reducing the need for institutional care there is no incentive for these care systems to play a central role in that goal or task.
For many years it has been well understood that licensed Assisted Living Facilities are frequently used by the Nursing Home Diversion Managed Care Program as a way of reducing long term care costs. In fact approximately 50% of the diversions in this program go to ALF care because it is effective in reducing the need for institutional care. For one monthly fee the ALF accepts the risk associated with acuity and care and provides a predictable, capitated environment that promotes healthy living routines and improves access to preventative care.
ALF care is a life style choice and in many instances the improvement of these routines and systems that surround a person whether they ben social, environmental or medical and dietary have a profound influence on what happens several years down the road. These congregate living arrnagements are vibrant communities with their own unique social structure and culture.
Sadly access to ALF care for the low income and state funded individuals is on the decline and is fast disappearing from the shores of Florida. Last year the Florida legislator reduced the optional state supplementation program from $25 million to $15 million. The lawmakers also reduced the Medicaid assistive care services program which pays for services in these settings from $32 million to $25 million, no other social service program sufferred cuts in theior budgets similar to these twin pillars that provide access to care. So why the cuts? The answer is simple, many of the beds for care of the low income are fading away as the mounting prolems with the economy encompass many of the samll facilities.
The reality is that many of the ALFs that care for the state funded residents have closed and gone away quietly. The state has lost olver 2100 beds for low income ALF residents since 2001, in the last four years it has 980 beds for the low income adults with mental illness. The chronic substandard rate of reimbursement for care at $9.28/day coupled with the increasing costs associated with meeting the current regulatory standards has all but made the business model for continuation of this important housing link all but unsustainable.
The cost saving role of the ALF has been significant over the years in providing stable housing for persons with mental illness. On frequent instances the courts, homeless shelters, hospitals, crisis stabilization units and others will look for a good ALF to care for a complex person with mental illness, often with emerging medical needs and in many instances problems with substance abuse. The loss of these beds is now beginning to show up in the data, over the last few years in Florida the numbers of mentally ill headed to forensic mental health treatment facilities has shot up creating a crisis. In Florida that number has gone from 1200 to 1500 today and is costing taxpayers $140,000 per year for each bed.
In Florida we see that 125,000 citizens each year are arrested and charged with a crime who also have a mental illness. There are 17,000 residing in state prison beds, 14,000 in county detention facilities and another 40,000 under supervision of probation and parole. The Department of Corrections spends $68 million each year on the mental health needs of its inmates and this number continues to grow. The large percentage of crimes committed by these people were committed while the person was not taking their medications and is in part due to their mental illness.
The data shows that 12 months after discharge from a state mental health treatment facility of 1300 people discharged annually in Florida 782 end up on a correctional facility, hospital, nursing home, homeless shelter or unknown. These are not the desired outcomes that people would expect and this is the reality that feeds the revolving door because of the lack of stable housing and services.
When you look at how effective the limited mental health ALF setting is in reducing the need for forensic mental health treatment beds, the data in Florida shows that over the last four years only 26 mentally ill residents of the ALFs are sent for care in an forensic mental health institution. By contrast when you compare to the FACT team, the assertive community treatrment teams, over 200 on average are sent to a state mental health treatment facility. In many instances the provision of FACT services is not enough to avoid the need for instutional care, what is needed is a combination of stable housing and stable services.
So what can fgederal lawmakers do to help reverse the slide toward rising costs and greater use of jails to care for the mentally ill in Florida and nationally. The development of proper incentives to care for the most functionally impaired is of broad puyblic interest, people would like to ensure the mentally ill are cared for in an appropriate way at the lowest cost possible.
Clearly as the Nursing Home Diversion Program has learned the proper use of an ALF can help divert risk, reduce the need for expensive institutional care and improve customer satisfaction. The federal lawmkers would be well served to consider using the savings from the continuing disability review program that is funded through the social security administration to create a federal subsidy for those individuals with a serious and persistient mental illness who meet certain criteria relative to functional impairment to fund access to care in a state licensed limited mental health assisted living facility, personal care homes or other state regulated residential care facility. The federal subsidy would be expected to be from $150/month to $320/month and would be based upon the income of the resident.
The use of the savings from the SSA continuing disability review program would create an incentive for licensed residential facilities to offer care for the more functionally impaired and would help reduce the need for jails, prisons and ER visits that would otherwise arise when these individuals do not have access to stable housing and supervision. This approach would be based on the availability of funds and would be a federal subsidy that would be based on the allocation of slots for care and would include a process for recertification of eligibility and recoupment when funds are paid for persons determined to be ineligible.
The development of a federal plan to expand the access to state licensed limited mental health assisted living facilities would help reduce the cost of health care for the low income chronically mentally ill. The need for immediate attention in viortually every state is a growing crisis. The unintended consequences associated with decisions made on a federeal level too many times leaves the most functionally impaired left out and struggle to find a new way just to survive the change that imposes new burdens and new struggles. The plan for federal health reform should consider changes that would offer the right incentives and work to fully utilize the care settings that help control costs and reduce the need for institutions, these are the investments and changes in federal policy that should be pursued.
Todays decisions will impact on the results we see 30 years from now. How will the mentally ill be treated in our society in the future? The absence of changes that will offer adults with mental illness the stable housing and services they need will result in the further collapse of the limited resources now available and result in new costs for institutional care. Now is the time for change in how America provides for the chronic adults with mental illness and their need for stable housing. This one change will produce a significant change in the need for crisis care and will allow these important Americans to join the community in building a prosperous future for everyone.
Friday, May 1, 2009
cig taxes and schizophrenia a formula for new state budget woes
With any change in state policy there is always unintended consequences. Jacksonville is home to a large population of persons who have a serious and persistent mental illness. Some of these people with the greatest needs are persons with schizophrenia.
It is estimated by researchers that 44% of all cigarettes sold in the United States are sold to people with mental illness. Studies show that persons with mental illness spend 27% of their income seeking tobacco products. It is well known there is a strong connection between schizophrenia and how nicotine works in the brain. The nicotine provides brief alleviation of psychotic symptoms or voices and can help improve memory for persons with this disabling condition.
In Florida there are 5379 individuals with a mental illness who are reported to live in a state licensed limited mental health assisted living facility. Many of these residents have a primary diagnosis of schizophrenia and 90% are addicted to smoking or nicotine products.
For most of these people the terrible consequences of nicotine addiction include cardiac problems, COPD, bladder cancer and a host of other complications. It seems to make sense, just raise the price and they will quit. This is a case of easily said than done.
Even though residents will seek to quit smoking and we get them started on the nicotine patch, because of the diminished insight that accompanies schizophrenia many will keep on smoking cigarettes in addition to using the nicotine patch, a very dangerous combination. Often once the physician knows they are doing both they will discontinue the patch out of caution.
For many of the state funded residents who reside in Florida's licensed limited mental health assisted living facilities they received $9.28/day from Medicaid to help pay for their care and services they need and they received $54/month in a personal needs allowance that is to pay for dental care, vision, clothing, shoes and personal care products.
At our facility we have a tobacco resale license which allows us to purchase cigarettes from a wholesaler. We will purchase the cigarettes each month on behalf of the residents, for what we consider to be a month's supply would generally be $38/month at wholesale prices. This provides enough tobacco for 4 cigs per time four times per day.
The new federal cigarette tax will pay for children's health insurance will exact a significant toll on persons with mental illness. According to our sources the average cost of cigarettes will increase by $6/carton and so what use to cost $38/month will now be around $56/month just for cigarettes. The next proposed wave of taxes from the state will drive up costs another $10/carton for a total of $86/month.
Recent DCF data demonstrates clearly that stable housing and stable services are keys to keeping people with schizophrenia, for instances of 5329 mentally ill residents who were reported living in an ALF only 26 per year get charged with a crime and sent to an expensive ( $140,000/bed) forensic mental health treatment facility.
By contrast if you are enrolled in one of Florida Assertive Community Treatment Teams which serve 3200 adults you have 200 per year headed to forensic care costing taxpayers $28 million.
It is well established fact that when persons with schizophrenia re psychotic and aggressive having available a small supply of cigarettes can help everyone stay in control and avoid someone getting hurt. When you think about the problem this can create, Florida spends $250 million each year caring for the mentally ill who have committed a crime, 48% of the people charged in FS 916 are charged with battery on a law enforcement officer.
Absent doing nothing here is a description of the unintended consequences, as the price of cigarettes go up, residents will only be able to purchase a smaller quantity, residents who have higher demand for cigarettes will start to engaged in "panhandling" behaviors, they will commit petty crimes that include stealing cigarettes from local stores or friends. The utilization rates of hospital emergency rooms, already "psychosis" is the number three diagnosis seen in Florida's hospital emergency rooms.
You will likely have people decide they would prefer to get their nicotine needs met and will elect to live at a homeless shelter, take up housing in an unlicensed assisted living facility where there is no supervision or will seek housing in settings that could be best described as unstable. This all creates a tsunami for state budget planners and new dangers for patients and families.
Douglas D. AdkinsExecutive DirectorDayspring Village, Inc.PO Box 1080Hilliard, Florida 32046
It is estimated by researchers that 44% of all cigarettes sold in the United States are sold to people with mental illness. Studies show that persons with mental illness spend 27% of their income seeking tobacco products. It is well known there is a strong connection between schizophrenia and how nicotine works in the brain. The nicotine provides brief alleviation of psychotic symptoms or voices and can help improve memory for persons with this disabling condition.
In Florida there are 5379 individuals with a mental illness who are reported to live in a state licensed limited mental health assisted living facility. Many of these residents have a primary diagnosis of schizophrenia and 90% are addicted to smoking or nicotine products.
For most of these people the terrible consequences of nicotine addiction include cardiac problems, COPD, bladder cancer and a host of other complications. It seems to make sense, just raise the price and they will quit. This is a case of easily said than done.
Even though residents will seek to quit smoking and we get them started on the nicotine patch, because of the diminished insight that accompanies schizophrenia many will keep on smoking cigarettes in addition to using the nicotine patch, a very dangerous combination. Often once the physician knows they are doing both they will discontinue the patch out of caution.
For many of the state funded residents who reside in Florida's licensed limited mental health assisted living facilities they received $9.28/day from Medicaid to help pay for their care and services they need and they received $54/month in a personal needs allowance that is to pay for dental care, vision, clothing, shoes and personal care products.
At our facility we have a tobacco resale license which allows us to purchase cigarettes from a wholesaler. We will purchase the cigarettes each month on behalf of the residents, for what we consider to be a month's supply would generally be $38/month at wholesale prices. This provides enough tobacco for 4 cigs per time four times per day.
The new federal cigarette tax will pay for children's health insurance will exact a significant toll on persons with mental illness. According to our sources the average cost of cigarettes will increase by $6/carton and so what use to cost $38/month will now be around $56/month just for cigarettes. The next proposed wave of taxes from the state will drive up costs another $10/carton for a total of $86/month.
Recent DCF data demonstrates clearly that stable housing and stable services are keys to keeping people with schizophrenia, for instances of 5329 mentally ill residents who were reported living in an ALF only 26 per year get charged with a crime and sent to an expensive ( $140,000/bed) forensic mental health treatment facility.
By contrast if you are enrolled in one of Florida Assertive Community Treatment Teams which serve 3200 adults you have 200 per year headed to forensic care costing taxpayers $28 million.
It is well established fact that when persons with schizophrenia re psychotic and aggressive having available a small supply of cigarettes can help everyone stay in control and avoid someone getting hurt. When you think about the problem this can create, Florida spends $250 million each year caring for the mentally ill who have committed a crime, 48% of the people charged in FS 916 are charged with battery on a law enforcement officer.
Absent doing nothing here is a description of the unintended consequences, as the price of cigarettes go up, residents will only be able to purchase a smaller quantity, residents who have higher demand for cigarettes will start to engaged in "panhandling" behaviors, they will commit petty crimes that include stealing cigarettes from local stores or friends. The utilization rates of hospital emergency rooms, already "psychosis" is the number three diagnosis seen in Florida's hospital emergency rooms.
You will likely have people decide they would prefer to get their nicotine needs met and will elect to live at a homeless shelter, take up housing in an unlicensed assisted living facility where there is no supervision or will seek housing in settings that could be best described as unstable. This all creates a tsunami for state budget planners and new dangers for patients and families.
Douglas D. AdkinsExecutive DirectorDayspring Village, Inc.PO Box 1080Hilliard, Florida 32046
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