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The Latest Wrinkle February 16, 2018
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A Look at LTC Financing for the Future


Late last week, the US Department of Health and Human Services released its funding proposal for the coming years. Although Congress is not likely to approve all of it, it does provide a map to the Administration’s priorities for the coming years. The 108-page document focuses on several critical issues, including the opioid crisis, drug prices, elimination of the ‘donut hole’ within Medicare Part D, and eliminates the expansion of Medicaid currently covered under the 2010 Affordable Care Act.

The proposal takes one step forward on the path to establishing Medicaid Block Grants or capping Medicaid payments to states, a plan that could have some impact on post-acute and long term care providers. Both the federal program requirements could restrict eligibility and increased financial pressure on states could impact optional expansions of eligibility in Michigan.

The plan for a new SNF reimbursement system that no longer is based on therapy but resident characteristics is still in the works within the next year or so; and there is still a plan to move to an episodic ‘unified’ payments system by 2024 that makes payments consistent between post-acute care settings.

Members should be pleased that the budget proposal also includes the idea of some regulatory relief by reducing the frequency of surveys for high performing providers.

While some of the changes may be challenging, none of these ideas are actually new and Congress has yet to approve. It is our strong belief that mission-driven members are the strength and backbone of quality care in Michigan, and we might just need to focus on what we are best at individually, improving our clinical care, and managing cost.


Advocacy

Governor Snyder’s Final Executive Budget


Governor Rick Snyder presented his final executive budget recommendation to the Michigan legislature on Wednesday, February 7, 2018 and offered a relatively flat budget for fiscal year 2019 that starts on October 1 of this year. At $56.8 billion (including both state and federal funds), the proposed budget is only 0.6 percent higher than the 2017-2018 budget. Governor Snyder highlighted certain elements of his budget, noting tax relief through the Homestead Property Tax Credit, funding for infrastructure including roads, increased per pupil funding for K-12 education, and making communities safer as important elements of the budget, among others.

The Michigan Department of Health and Human Services budget encompasses 44 percent of the total state budget, with the Medicaid program accounting for 60 percent of the department’s budget. A large proportion of the Medicaid budget is supported by federal funds through the Centers for Medicare and Medicaid Services.

The proposed Medicaid budget for healthcare services used by people who are aging or disabled includes increases in several categories. Notably, the largest proposed budget increases are in the nursing home, MI Choice waiver, and Program of All Inclusive Care for the Elderly (PACE) programs, with decreases in the Home Health and Hospice lines. The nursing home budget line is proposed to increase by approximately $19 million; the MI Choice line is proposed to increase by nearly $7 million; and the PACE line is proposed to increase by over $43 million for FY 2019. The large proposed increase for PACE is due primarily to new PACE sites that will open in FY 19. New PACE organizations starting in FY 19 include Grand Traverse and PACE of Central Michigan (Michigan Masonic Homes). In addition, PACE of Southeast Michigan is opening its fourth location in Dearborn next month.

LeadingAge Michigan will continue to advocate on behalf of its members as the state budget process evolves. Departments will offer presentations to legislative committees in the near future on their respective budgets. Updates will be provided as they emerge.

Quality Measure Initiative: The State Plan Amendment (SPA) that includes the Nursing Home Quality Measure Initiative (QMI) funded by the nursing home provider tax was submitted last year to CMS with a proposed start date of October 1, 2017. CMS has yet to approve the SPA, but the start date will be held and payments will be made retroactive to that date once approved. Providers with 2.5 stars or less have received notification from Medicaid for the need to submit action plans for improvement consistent with the QMI policy that was issued in August 2017. If members have questions about this process or the QMI Action Plan they may contact Medicaid Long Term Care Policy at MDHHS-NFQMI@michigan.gov for assistance.


Across the Continuum


Watch Your Mailbox


Year 2018 marks five decades of LeadingAge Michigan’s collaboration with more than 350 mission-driven members across the state. Because the true power of our association comes from the strength and support of the membership, we are creating numerous opportunities for member celebration in the coming year.

The celebration has begun with the mailing of an Anniversary Member Packet to each member provider and business partner. The packet included an invitation to participate in celebratory events throughout the year as featured in an events calendar. Also included was a LeadingAge Michigan membership decal we hope you will display proudly in a public place on your campus to help focus on the strength of our association and the importance of senior care as a mission.

Lastly, the packet included information about new and innovative opportunities to advertise in the anniversary edition of our membership directory. We encourage you to promote your community and your services while celebrating with us fifty years of shared mission.

Let’s the celebrations begin!


Communications Collaborative Listserv


LeadingAge in Washington has launched a new Communications Collaborative Listserv for LeadingAge members who work in communications, social media, and media relations. This listserv is a resource for connection, sharing and discussing approaches, best practices, opportunities and insights on message creation, management, and outreach. Visit My.LeadingAge.org to sign up.

Not in communications? Take a look at LeadingAge's complete list of listservs can join to connect with peers, get answers to questions, and share knowledge with colleagues. Listserv membership is open to all LeadingAge member staff.


Senior Citizen of the Year Award – Nominations Sought


Each year the Aging and Adult Services Agency awards one of Michigan’s unsung heroes who is an older adult and has selflessly given to his or her community. The winner receives, among other items, a $1,000 check courtesy of Consumers Energy.

Nominations are being accepted until April 5. For more information and a link to the nominations form click here.


Skilled Nursing


Medicaid Information and Updates


The Michigan Department of Health and Human Services Nursing Facility Workgroup meeting was held on February 7, 2018 with representatives of the three nursing home associations and Medicaid staff members in attendance.

Updates were provided by Medicaid staff on a number of topics starting with the state’s fiscal year 2019 budget currently under development. The FY2019 budget will be “lean” although the current services base will be maintained. The Medicaid program will see a decrease in the Federal Medical Assistance Percentage (the proportion of funding coming from the federal government in support of Medicaid) in the coming fiscal year. Although the state is facing several funding challenges, they anticipate no significant changes within the funding base. More information will become available as the state budget process develops during the next few months.

A summary of other topics covered in the meeting includes:

Managed Long Term Supports and Services (MLTSS) Boilerplate: Section 1857 of the FY2018 budget for MDHHS requires the department to produce a report to the legislature by July 1, 2018 on implementation of MLTSS. The Department has initiated a stakeholder process funded by the Michigan Health Endowment Fund that will include providers, provider groups, consumers and advocates. At this point, several focus group meetings have been conducted and the next phase of the process should begin soon.

Eligibility Long Term Care (LTC) Pilot Programs: During the last year the Department has engaged in establishing a pilot program for determining eligibility for persons in need of long term care services. The pilot program has now been expanded to ten counties across the state with the goal of making the eligibility process more efficient. The Department is eliciting feedback from providers about how the program is working. Please contact susan@leadingagemi.org if you would like to share feedback about your experiences with the pilot and they will be forwarded to the Department.

Level of Care Determination (LOCD): The Department’s internal LOCD design team is working to improve the medical/functional eligibility process. The Department has elicited input from stakeholders during the past month and Department representatives will discuss the new process at LeadingAge Michigan's Finance and Strategy Day on February 20 at the Radisson Hotel in Lansing. The Department plans to issue a ‘numbered letter’ outlining clarifications on the field definitions and applying the eligibility criteria. LeadingAge Michigan anticipates that several of the proposed changes should improve the process for members.

Implementation is targeted for early to mid-summer 2018 depending on when system changes can be made in CHAMPS. Members are reminded that the LOCD is now associated with the beneficiary in the system versus the provider. Members should continue to reference policy related to the Modernizing the Continuum of Care policy bulletins (Update letter, MSA 17-40, MSA 17-46) that were issue in late 2017 for information about Program Enrollment Codes and association with beneficiaries.

Modernizing the Continuum of Care (MCC): Patient Pay Amounts (PPA) have been found to be incorrectly calculated recently because of a file transfer problem between Bridges and CHAMPS. If no PPA is identified, providers are instructed to use the last known PPA until this issue is fixed.


Person-Centered Care Central to LTC Regulations


Improving resident quality of life and quality of care was a major focus in the recent revision of the Nursing Home regulations. The MegaRule made person-centered care a central theme, describing how each resident has choice and control over his or her individual care. There are specific mandates in multiple regulatory sections including resident rights, care planning, quality of life, quality of care, food and nutrition, and administration.

Since the implementation of the Phase 2 of the MegaRule in November and the new survey process, we have noticed that the Care Planning tag (F656) and Care Plan timing/revision tag (F657) has been cited frequently here in Michigan. To assist member efforts toward meeting these requirements, The Compliance Store has developed a new training resource which will help staff understand the key concepts of person-centered care. This resource offers suggestions on establishing relationships, increasing resident participation in care plans, and improving communication. Because person-centered care permeates throughout the regulations, this training is applicable to all departments throughout your facility.

To learn more about how The Compliance Store can add value to your operations team, please contact Kasia@leadingagemi.org.


Payroll Based Journal (PBJ) coming to Five Star in April 2018


The Centers for Medicare and Medicaid Services (CMS) will use the 2017 Q4 PBJ data to replace the existing staffing measures posted on the Nursing Home Compare website. The 2017 Q4 submissions are due in mid-February 2018 and CMS is planning to introduce PBJ-based staffing measures in April. Initially, data from one quarter will be reported. It is anticipated that the 671 form will be discontinued around the same time. Overall, 95% of nursing homes in the country submitted data for 2017 Q3. CMS states the number of nursing homes submitting data has increased steadily from the initial submission period in 2016.


SNF ABN Update


The Centers for Medicare and Medicaid Services (CMS) has released a revised Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN) along with newly developed, concise and separate instructions to complete the form. The revised SNFABN includes required Denial Letter elements and looks very similar to the ABN. The five SNF Denial Letters and the Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (NEMB-SNF) will be discontinued. The revised SNFABN will be mandatory for use on May 7, 2018.

During the interim, SNFs may continue to use the old version of the SNFABN, the Denial Letters, or the NEMB-SNF, however, it is recommended that the revised SNFABN be used as soon as possible. The revised SNFABN and the form instructions may be located on the CMS website.


ASC 606: Implementation Guidance for CCRCs


Join Baker Tilly for a webinar focused on the recently released ASC 606 draft implementation guidance for continuing care retirement communities (CCRCs). Key learning objectives include improving an understanding of FASB ASC 606 as it pertains to CCRCs and the AICPAs implementation guidance for FASB ASC 606 specific to CCRCs, including:

  • Accounting for monthly/periodic fees, nonrefundable entrance fees and refundable entrance fees
  • Obligation to provide future services and facilities
  • Significant financing component considerations for CCRC contracts
This free webinar is intended for CCRCs and life care providers. Click here to register

Assisted Living


AFC Council


The Adult Foster Care (AFC) Council met on February 7. Director Calewarts briefly reviewed the member listing and announced the re-appointment of members to the Council. The term for LeadingAge Michigan’s Director of Regulatory Strategy remains active through December 31, 2019. As a reminder, the bylaws indicate there are no limits to the number of terms which Council members can serve, but it does define the term to be limited to three years.

In addition, Director Calewarts stated that initial work has been started to amend the AFC licensure rules. This would provide an additional category of care that would better fit residents with intensive behavioral issues which are not primarily caused due to dementia. Director Calewarts also gave a very brief account of other recently proposed bills (SB745, HB5505, HB5506, HB5452) that would amend the Adult Foster Care Facility licensing act such as allowances for certain exemptions from licensing requirements, redefining home capacity, licensure fees, and employment restrictions secondary to findings from background checks.

Please note that Director Calewarts will speak to these draft amendments at our HFA/AL Regulatory Day scheduled for February 27, 2018.

The AFC Advisory Council meeting dates for the remainder of 2018 are May 9, August 8, and November 7. These meetings are held at 611 W. Ottawa Street in Lansing and are open to the public. AFC Advisory Council meeting minutes can be viewed on the LARA webpage.


‘Medicaid’ Assisted Living Services


Earlier this month, the Government Accountability Office released a report on deficiencies of care and services provided to Medicaid beneficiaries in assisted living communities. State Medicaid agencies spent over $10 billion on services provided to over 330,000 in assisted living in 2014, according to the report. The GAO reported that states are not consistently monitoring critical issues as might be expected.

  • 26 state Medicaid agencies could not report the number of significant untoward incidents that have occurred in assisted living facilities
  • States varied in the type of incidents they did monitor
  • States varied in whether they made critical incident information available to the public

GAO recommended that CMS clarify state requirements for reporting program deficiencies and requiring annual reporting of critical events.


Housing


MSHDA


The Notice of Funding Round for April 2, 2018 along with a memo titled “LIHTC Program Updates” is now available on the “2018 Funding Round Information” page of the MSHDA website.


Website Updates


The following documents have been updated for the April 2018 funding round:

  • Scoring Summary for 2017-2018
  • Addendum III Application and Checklist
  • Tab P Affirmative Fair Housing Marketing Plan

These documents can be found on the “Combined Application for Rental Housing Programs” page of the MSHDA web site.


HUD Addresses Homelessness


HUD’s Office of Multifamily Housing encourages assisted housing owners and property management companies to make their subsidized apartments available to individuals and families experiencing homelessness or who are transitioning out of permanent supportive housing designated for formerly homeless households. HUD-funded Continuums of Care (CoCs), state housing finance agencies, and state housing departments can be key partners in implementing a preference. HUD issued a Program Notice and Toolkit that provide step-by-step guidance to implement a homeless preference, allowing eligible, currently homeless households to move to the top of a property’s waiting list.

Individualized technical assistance (TA) will be available through this Request for Interest (RFI). CoCs and housing providers (both privately owned and State agencies) may receive individualized TA coaching, education, and concrete support from an assigned expert in implementing the Multifamily Homeless and Move On preferences. This TA will help housing providers streamline their internal processes and improve rates of success in admitting households who are experiencing homelessness or who were formerly homeless. TA will also include assistance in outreach to and relationship-building with local housing providers and homeless service agencies. TA will begin in April and continue through the end of October 2018.

The RFI application is due by March 5, 2018 and can be found here.

You can view the RHIIP Tips Archives, under "Listserv-Multifamily RHIIP Tips" at the HUD website.


Member Update


EHM Senior Solutions Reaches Out To Local High School Students


Senior residents of EHM Senior Solutions and area high school students recently completed a unique project to bring greater understanding to the emotional and intellectual dimensions of memory loss.

Using tablet technology from It’s Never 2 Late (iN2L), students worked with EHM residents living with memory loss to create visual and audio stories based on seniors’ personal recollections surfaced during student-led interviews. To read the full press release, click here


Member Value


“Mega Rule” Requires Nursing Facilities to Evaluate Pharmacy Services During Emergency Situations


In response to recent changes to the State Operations Manual Omnicare has provided an outline of the steps it will take in emergency situations to provide continuous and seamless provision of medications. Please click here for the entire statement.


Education Center


   
 

Join us for our 50th anniversary celebration!

Click Here for more information
 

Finance & Strategy Day
February 20 ~ Lansing

There are many issues relative to how members meet their missions in different business models but how do we strategically plan and improve financial operations. This in-depth program will explore:

  • New LOCD Process, Eligibility & Medicaid Updates
  • Changes to the Federal Tax Act & PA448
  • Tax exempt bond, tax reform and balancing tax risk factors
  • The benefits and challenges of operating low income housing property
  • Current funding environment changes behind low income housing
  • The managed care market in Michigan
  • Future strategies in the face of managed care
  • Recent acquisitions and the NFPs
  • Best practices for current and alternative payment models
  • Variable cost limit impact
  • Provider Tax Bulletin updates

This session will deepen your understanding of operational assessments and improvements, capital project planning and strategic initiatives to support overall organizational health.

Click Here for more information and to register.


HFA/AL Day
February 27 ~ Okemos

Plan to join us for a full-day program where our expert presenters will review the new legislation under Public Act No. 167 and the State of Michigan's Home for the Aged Licensure Exemption requirements and request form. Other topics to be addressed include Life Safety Code requirements, a CCRC update from the State of Michigan and HCBS Rule & Appeal Process. We are assembling an all-star faculty for this event including: Phyllis Adams, Dykema Gossett; Jay Calewarts, LARA; Heather Hill, MDHHS; and Brian Williams, Bureau of Fire Services.

Click Here for more information and to register.


MDS RAC Certification Workshops 2018
March 13-15 ~ Novi
September 18-20 ~ Mt. Pleasant
November 6-8 ~ Grand Rapids

Did you know you can become RAC Certified in just three days?

LeadingAge Michigan, in partnership with the American Association of Nurse Assessment Coordination (AANAC), is pleased to offer the highly esteemed Resident Assessment Coordinator-Certified (RAC-CT) a certification program for long-term care professionals. This workshop is designed to increase knowledge of clinical assessment and care planning, completion of the MDS, and the regulations surrounding the RAI/MDS process. Earning the RAC-CT designation gives you the credentials to prove your assessment expertise; making you an invaluable asset for your facility, your residents, and the long-term care profession.

Click Here for additional details and registration information


LEAN Leadership Concepts
March 6: Lean Overview
April 17: Lean Problem Solving
June 12: Lean Deep Dive

All three workshops will be held in Lansing

As healthcare providers we must prepare ourselves for the new service delivery and payment models that are introduced from government and private payers. In this new world of managed care, bundled payments, value based purchasing, and accountable care, we know that organizations will need to be streamlined, efficient, and focused on outcomes in order to survive and thrive.

Lean is a system for making improvement that can be applied to any aging services provider. Doing things the way they have always been done is insufficient to keep pace with the rate of change. Leaders and staff members performing the same process day after day can become blind to the inherent problems with that process. Using a Lean approach will aid in the identification of problems and provide the necessary tools to make sustainable process improvements. The most effective Lean organizations start with leadership modeling the right behaviors which facilitate the desired culture of improvement. Using Lean leadership concepts will allow you to become a learning organization with a methodical system for process improvement and measured results.

Click Here for more information and to register.


Regulatory Day
March 27 ~ Okemos

As expected, 2018 began with continued regulatory changes for providers. We have already been addressing a lot of changes and we know more are on the horizon. To assist our members, we’ve assembled a team of high-level content experts; professionals who have first-hand knowledge of the regulatory changes. Join us for our full-day of regulatory updates that include:                                       

  • Larry Horvath, Bureau Director, LARA, will provide a Bureau update.
  • Michelle Roepke, Director of Federal Survey & Certification Division, LARA, will review the new long-term care survey protocol and briefly describe recent trends and citation patterns.
  • Margaret Chamberlain, Partner, Rolf Goffman Martin Lang, will provide an OIG update and address involuntary discharge requirements.
  • James Wiggins, Health Facility Professional and Nurse Aide Section Manager, LARA, will give an overview of Public Act 172 – Part 219 which covers C N A Reciprocity.
  • Laura Remis, Environmental Health & Safety Manager, LARA, will discuss how a surveyor will verify compliance with the new water management plan requirement for healthcare facilities.
  • Carolyn Stramecki, Project Director, Honoring Healthcare Choices-Michigan, will share more information about POLST (Provider Orders for Life-Sustaining Treatment) an approach to improving end-of-life care.

Click Here for more information and to register.


Building Better Working Relationships
March 29 ~ Lansing

Many of us who are managers or supervisors spend time thinking about the statement we have all heard “people leave managers, not companies.” According to a Gallup poll, 50% of employees who quit cite their manager as the reason for leaving the organization. A manager’s relationship is highly correlated with employee engagement and retention. As shown by Daniel Goleman's research, it is Emotional Intelligence (EQ) that makes and develops relationships and strong leaders. When an organization has managers and supervisors with higher EQ they will be effective leaders who interact with their staff, residents/patients, families and management more successfully.

Join us for this highly interactive session to learn more about your personal EQ, how to adapt your style to be more effective with others, how to build better working relationships and become an exceptional leader.

Click Here for more information and to register.


QAPI Certified Professional (QCP) Prep Workshop
April 25-26 ~ Lansing

An effective QAPI process and program will take you beyond compliance and enable your facility to truly transform the care you provide residents. Increase your knowledge by attending a two-day QAPI education workshop that will help you prepare for the comprehensive QCP certification exam.

To implement quality assurance and process improvement (QAPI) strategies in long-term care effectively, you need strong nurse leadership. To achieve that leadership, follow the QAPI principles taught in this course to help you fulfill your mission to provide the best possible care and quality of life for your resident.

Click Here then scroll down for additional details and registration information.


Medicare University
July 31-August 2 ~Okemos

Become the Medicare leader in your facility with this comprehensive three day workshop. This in-depth program will help you manage the reimbursement system, navigate audits, avoid risky practices, and stop drowning in confusing and ever-changing regulations.

Authored by the foremost experts in Medicare, this workshop will:

  • Increase your understanding the Medicare benefits, eligibility, and the difference between Part A, B, C and D;
  • Share the concepts of SNF skilled services, payment structures, and consolidated billing;
  • Define the qualifications and requirements for both Part A and B therapy;
  • Explain the Medicare claim review and provider appeal processes;
  • Allow you to gain confidence in the documentation process;
  • Assist you complying with billing requirements; and
  • Provide an understanding of the principles of the Beneficiary Notification Initiative.

Click Here  then scroll down for additional details and registration information.


Director of Nursing Services-Certified (DNS-CT) Prep Workshop
October 16-18 ~Okemos

Take your leadership and management talents to the next level with a preparatory workshop for AADNS’s Director of Nursing Services—Certified (DNS-CT) certification. Earning this credential validates your expertise, gives you the advantage among your peers, and helps you improve quality, communication, and resident care throughout your facility.

The DNS-CT credential from AADNS shows that you have the leadership and management skills and knowledge to excel as a DON. Certification indicates that you have met nationally recognized standards of expertise for directors of nursing services in long-term care, that you are up-to-date with the rules and regulations, and that you can lead and nurture your team.

This three-day workshop will complement your nursing expertise with leadership and management skills. Workshops are taught by individuals who go through rigorous requirements to become Master Teachers and who are experts in the field.

Click Here then scroll down for additional details and registration information.


Mark Your Calendars!

2018 Annual Leadership Institute
August 22-24, 2018 ~ Mission Point Resort, Mackinac Island


Thank You Content Contributors!


201 N Washington Square, Suite 920
Lansing, MI 48933
Phone: 517-323-3687
Fax: 517-323-4569

Our Mission: To advance the mission of our members to enhance the lives of seniors.
Our Vision: To become the voice of aging services in Michigan.

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