New Round of Funding for Senior Living Providers

The Department of Health and Human Services has announced additional funding that is to be distributed to health care providers. Senior living communities, particularly assisted living communities, are eligible to apply for this funding. The below post outlines the authorization, how to apply, and how providers can encourage Congress for more funding in the future. The words in this post our not my own.

Background: The Provider Relief Fund supports healthcare providers in the battle against the COVID-19 pandemic1. The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), has announced $20 billion in new funding for providers on the frontlines of the coronavirus pandemic. The funding will be distributed through the provider relief fund. For context, HHS has already issued over $100 billion in relief funding to providers through prior distributions. These distributions do not need to be repaid to the US government, assuming providers comply with the terms and conditions. Providers can begin applying for funds on Monday, October 5, 2020. Providers have until November 6, 2020 to apply to the Phase 3 General Distribution funding2.

Amount: Generally, providers who qualify will receive 2% of their patient care revenue plus more if HHS deems the provider requires additional funding based on the severity of the pandemic on the provider’s operations2.

Eligibility: HHS is making a large number of providers eligible for Phase 3 General Distribution funding, including:

  • Providers who previously received, rejected or accepted a General Distribution Provider Relief Fund payment.
  • Providers that have already received payments of approximately 2% of annual revenue from patient care may submit more information to become eligible for an additional payment.
  • Behavioral Health providers, including those that previously received funding and new providers.
  • Healthcare providers that began practicing January 1, 2020 through March 31, 2020. This includes Medicare, Medicaid, CHIP, dentists, assisted living facilities and behavioral health providers2.

How to Apply: To apply visit https://cares.linkhealth.com/#/

Make Your Voice Heard: Argentum is continuing to request funding from Congress for the management of the pandemic. As such, it is pressuring Congress to provide additional funding for screening, testing, and vaccinations. Argentum needs your help in reaching out to your Congressperson. It has created a very easy, pre-made template for you to search, select, and message your Congressperson here:

Sources

  1. https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/for-providers/index.html#how-to-apply
  2. https://www.hhs.gov/about/news/2020/10/1/trump-administration-announces-20-billion-in-new-phase-3-provider-relief-funding.html

Residential Assisted Living Communities-A Safe Care Option During COVID-19

Residential assisted living (“RALs”) have been around for years but have received a lot of attention due to their unique benefits when dealing with breakouts of illnesses. Here are some of the top reasons RALs are safer when dealing with COVID-19 or outbreaks of illnesses such as the flu.

 

Less Traffic

Home to fewer residents, RALs require fewer caregivers and support staff than larger communities. Therefore, the number of people entering the building on a daily basis is greatly reduced, and it’s easier for the smaller communities to monitor its staff members.

 

More Individualized Care

Most RALs have 1 caregiver for every 4 residents. This enables the staff to take more frequent temperature checks and closely monitor the residents for any early signs or symptoms. Additionally, caregivers can develop much closer relationships with residents and are able to detect eating, sleeping or other changes in their behavior.

 

Less Area Requiring Disinfection

RALs do not have a large lobby, recreation rooms, or multiple dining halls; thereby having much less surface area in their common areas to disinfect. A typical RAL has approximately 5,000 sq. ft., while a large facility housing 80-100 residents could have more than 100,000 sq. ft. to disinfect.

 

Written by Evermore Senior Living 

Edited by Senior Advisors Plus

paying for assisted living

When Will Health Insurers Pay for Someone’s Stay at an Assisted Living Community?

Assisted living communities have served an important role in the US’s health care continuum—often they have been the next stop for older people who have been discharged from a hospital or a skilled nursing facility. Assisted living communities assist their residents with medication management and activities of daily living. With such an important role serving seniors, why don’t insurers pay these providers to keep their constituents safe?

Apart from long-term care insurance, it is not common for health insurers to pay assisted living communities because many insurers and providers operate on a fee-for-service basis. That means providers charge the insurers for each procedure/line item. Under this payment structure, preventative care, like what is provided in assisted living communities is over looked by the insurers–much like your insurer now probably doesn’t pay for your vitamins or exercise classes.

The Center for Medicare and Medicaid Services(“CMS”) in tandem with private insurers, are experimenting with a fee-for-value payment model. Through this model, a cohort of providers are paid a flat fee to manage the health of the insurance company’s constituents. In this model, the group of providers can earn more money by reducing the health care costs of the insured population.

As this new fee-for-value system rolls out, assisted living communities will have an opportunity to take payments from insurance companies as a way to reduce the cost of managing the health care costs of their constituents, most notably through lowering readmission rates into hospitals.

If assisted living communities become part of the formal health care continuum, many will have to change the way they do business. Now, a lot of assisted living communities operate as hospitality companies with a sliver of supplemental care. That’s because these communities must woo consumers in to their communities and we believe they do that through enhancing their hospitality features over care capabilities. The way we understand consumers is they generally require a minimum level of care and then focus on choosing a community with the nicest hospitality features that they can afford.

Under a system by which an insurance company pays an assisted living community, a community must show it knows how to manage a population of people effectively. To do this, assisted living communities may have to improve their health care capabilities. A few notable aspects that Dr. Kevin O’Neil pointed out in his interview with Senior Housing News is senior living communities must work on systems to help prevent falls and manage the medications of its residents better1. That means communities may need to have software systems in place to track metrics about their residents, to train their staff to spot people who are a fall risk, and to hire more staff to manage the communities’ residents better.

Two things need to happen for assisted living communities to take payments from insurers: (1) assisted living communities need to focus more on providing health care; and (2) insurers and providers need to organize under a fee-for-value system. When those two aspects occur in a given market, then you will see assisted living communities take payments from insurers as a result of caring for the insurers’ constituents.

Sources:

  1. https://seniorhousingnews.com/2019/11/11/affinity-pushes-innovation-sees-assisted-living-as-next-big-frontier-for-value-based-care/

FOR-PROFIT VS. NOT-FOR-PROFIT SENIOR LIVING COMMUNITIES

If you’ve searched “not-for-profit vs for-profit senior living communities” on Google, then you’ll know the search results are filled with posts from blogs on not-for-profits’ websites. You also may believe that not-for-profits, or nonprofits, are more genuine senior living communities. Be careful, the argument is not as simple as the nonprofits make it seem. Here’s why:

About 80 percent of senior residential care facilities are private and for-profit1. To outline the differences between for-profit and not-for-profit senior living communities, let’s quickly highlight some facts about each:

For-profits

  • Can generate positive net income, which is profit after operating expenses, interest expense, and taxes
  • Communities can be large or small
  • Can have government subsidy programs
  • Can have Medicare and Medicaid beds
  • Can be affiliated with not-for-profit hospitals
  • Can host religious ceremonies or have a large fraternal presence
  • May or may not remove residents from their communities for delinquent payments

Not-for-profits

  • Cannot generate net income, which is profit after operating expenses, interest expenses, and taxes
  • Communities can be large or small
  • Can have government subsidy programs
  • Can have Medicare and Medicaid beds
  • Can be affiliated with not-for-profit hospitals
  • Generally affiliated with a faith or fraternal organization that is mission driven
  • May or may not remove residents from their communities for delinquent payments

The major difference between for-profit and not-for-profit communities is that for-profits can generate positive net income. A nonprofit community will try to persuade you to think that this is a bad thing. A nonprofit might say, all-things-equal, a for-profit community will cut costs to be able to generate a profit to pass along to shareholders. That may sound good in theory, but it’s not a practical way to manage a community for long-term success.

Let’s say there are two neighboring communities that are identical, except one is a for-profit and the other is a not-for-profit. If the for-profit reduces its number of caregivers and then pays investors the savings, then which community would prospective residents choose? Under an efficient market, they would choose the not-for-profit community, because the caregiver-to-resident ratio is better. How is the for-profit going to respond? In this scenario, the market dynamic indicated that prospective residents are sensitive to the caregiver-to-resident ratio. The for-profit may find new investors or encourage its current owners and shareholders to invest back into the community. The for-profit may generate enough funds to hire even more caregivers than the nonprofit community. As a result, the for-profit begins operating a better business and winning new prospective residents.

This doesn’t mean that for-profits are better because they can attract capital more easily than non-for-profit communities. Investors only want their community to be marginally better or to be perceived as better than the competition so that when a prospect comes, he or she chooses the investor’s community. A perceived-to-be-better-community may have allocated more funds to marketing, rather than hiring an additional caregivers. So don’t be tricked into thinking a community is nice because its handouts are plated in gold. Instead, analyze each community based on a predefined set of criteria.

Also, don’t let generalizations sway you to consider only one legal structure. For example, if you want to find a community that has a large veteran population, it is likely that you’ll find one that is a not-for-profit, but don’t exclude for-profit communities from your search. Some for-profit communities have large veteran populations too. The same thing would apply if you’re searching for a community that has many residents of a particular faith. While you are likely to find a not-for-profit that is affiliated with your loved one’s religion, there are also for-profit communities that have certain concentrations of residents of the same religion too.

Unless the cause of the nonprofit community means a lot to you or your loved one, don’t let the basis of your decision ride on the community’s legal structure. Instead, we advise that you ask your loved one what he or she wants, or ask yourself what he or she wants. Create a list, and then find a community that fits your criteria. If you’re having trouble creating a list, ask a senior advisor. He or she will be able to help you brainstorm some important lifestyle factors to consider, and then show you a few communities that best meet your criteria.

CHEAP CARE COMES WITH ETHICAL PITFALLS

If you’re searching for a caregiver, chances are you will hear a few companies quote rates that are approximately five dollars per hour lower than their competition. In this post, I explain why some firms charge lower hourly rates and why cheaper is not always better.

There are five main factors that affect the hourly rate charged to a family: location, qualifications of the worker, number of hours, profitability of the firm, and the business model.

1. The hourly rate can increase if the family lives in an expensive part of the country or the caregiver lives far away from the family. All things equal, a firm that employs a caregiver that lives closer to the family will be able to charge a lower rate than a firm that employs a caregiver who lives farther away from the family.

2. The more qualifications the caregiver has, the higher the hourly rate a firm will charge. For example in Washington D.C., a registered nurse (“RN”) may cost $40 per hour while a certified nursing assistant (“CNA”) may cost $25 per hour.

3. In most cases, the hours per day and the hours per week that a family needs a caregiver will affect the hourly rate—the more hours that a family needs a caregiver, the cheaper the rate.

4. Firms may charge more money just to be more profitable—while some firms may pay their caregivers higher wages, and therefore can justify their higher rate, more likely than not most firms of the same business model with above average prices are attempting to run a more profitable business by charging more for the same services.

5. There are two types of business models in the home care industry, registry and agency. The registry model is generally cheaper than the agency model. The rest of this post defines the registry model and explains why it is generally cheaper than the agency model.

A firm that employs the registry model does not hire its caregivers. Instead, the caregivers are independent contractors referred by the firm. Generally, a family will pay a billing company, which then pays the caregiver and the firm. The firm charges a referral fee as a portion of the hourly rate charged to the family for the caregiver’s services. The caregiver gets paid for the number of hours the family uses his or her services. Caregivers who work under the registry model are cheaper than the caregivers who work under the agency model because they typically do not get health insurance, retirement options, and other common employee benefits that come with working for a firm full-time. For this reason, families should ask themselves if they are comfortable employing someone who does not receive these benefits yet may work over 36 hours per week.

Many firms that use the agency model will say that the registry model is bad because the caregivers are not CNAs, they are not reimbursable by long-term care insurance, the families are responsible for scheduling other caregivers if their main one is absent, the families are liable for anything that the caregivers steal, and the families are liable for any injury to the caregivers.

The truth is that these are generalizations and cannot be extrapolated to all registry firms. Some registry firms only contract with CNAs, charge fees that are reimbursable by long-term care insurance, will schedule another caregiver if the main one is absent, will reimburse the family for the value of stolen goods, and cover the liability of the caregiver if he or she is injured on the job. There are registry firms that operate this way in Maryland and Washington D.C.

Of the five main factors that affect a caregiver’s hourly rate, factors (1) and (4) families can control by shopping around to different firms, (2) and (3) will be determined by how much care their loved one needs, and (5) depends on the family’s feeling toward the ethics of hiring a contractor who may not receive employee benefits for doing the same work that an agency-caregiver would do and who receives employee benefits. From what I can tell through my research, (5) affects the hourly rate by approximately $5.50.

If you contact a senior advisor, he or she can refer a firm that employs the business model that you prefer, help you get the care that you need, confirm that you are protected, negotiate to lower your cost of care, and ensure that you are paying a reasonable rate. If you want to learn more, here is a link to contact us.

PROPOSED REGULATION CHANGES TO DISRUPT D.C.’S CAREGIVING AGENCIES, AGAIN

D.C.’s Board of Nursing’s mission statement reads:

The mission of the Board of Nursing is to safeguard the public’s health and well-being by assuring safe quality care in the District of Columbia. This is achieved through the regulation of nursing practice and education programs; and by the licensure, registration and continuing education of nursing personnel.”

In addition to other titles, D.C.’s Board of Nursing oversees certified nursing assistants (CNAs) and home health aides (HHAs). These are certifications to people that caregiving companies hire, and each certification corresponds to a different degree of responsibility. Within Washington D.C., CNAs are only allowed to provide personal care in senior living communities, while HHAs can provide personal care in communities and in the homes of their clients. Home care firms hire CNAs and HHAs depending on their business’s needs.

In D.C., caregiving firms were under the impression that they may apply for two types of licenses, a Nurse Staff Agency license and a Certificate of Need. The Nurse Staff Agency license is a license that a registry uses to refer caregivers to homecare agencies and facilities, such as assisted living and skilled nursing facilities. It’s useful for a company that staffs senior living communities with caregivers. There’s also the Certificate of Need, which is required for an agency who would like to provide care, including skilled services to patients in their home. D.C. takes precaution with administering these licenses due to the complexity of the services which may be provided. On average, it takes an agency two years to get approved for a Certificate of Need (CON). A homecare agency license or a homecare license in addition to a Certificate of Need is required to provide skilled services.

Approximately 12 years ago, D.C.’s Board of Nursing sent a ‘Cease and Desist’ letter to the homecare agencies that did not hold a healthcare license. The letter instructed agencies to apply for a homecare license or stop providing care.  As a result, homecare agencies were directed to apply for either a Nurse Staff Agency license or a Homecare License. However, D.C. was not issuing new CONs at that time.

A few years later, D.C. stated that NSAs should not be providing care to patients in the home, but should only be functioning as a staffing agency for homecare agencies and facilities. Trade associations and other long term care groups met with D.C. and requested that they work together with D.C to create a strategy for appropriate licensure. The concern was for the patients being served and the caregivers as their clients, mostly seniors, would lose their caregivers. In addition, many businesses may end up in bankruptcy, which may cause a spike in unemployment. However, nothing happened for years.

About three months ago an alert went up on the D.C. Department of Health’s website that reignited the issue. The alert said that caregiving agencies who held an NSA license but were providing care in the home were operating in violation of the law. Agencies were advised they must obtain a homecare license and Certificate of Need if they want to continue to operate by providing care in the home. Once again the trade associations and their members gathered to discuss the impact with the Board. This time, it appears the Board is working with the caregiving agencies to smooth the transition. As a result of these discussions, emergency legislation was passed by DC and a new Home Support Services licensure has been created. This allows for personal care services only, to be provided by DC HHAs.

However, it’s going to be tougher for the agencies to continue to do business in DC as they had once done. In addition to licensing requirements, the Board is placing more mandates on D.C. caregiving agencies, which may reduce the number of firms that conduct homecare in D.C. One notable proposed change is that agencies must have office space within D.C. that is staffed 40 hours per week. How firms have been reacting to this proposal shows that the Board is serious about its policy changes this go-around. Already, homecare agencies have been partnering with senior living communities to secure office space in their buildings, in addition to leasing spaces of their own. Some agencies may drop out of the DC market as rental rates and additional staff push their costs too high to justify operating in D.C. Fewer firms in D.C. may mean fewer available caregivers to care for seniors at their homes.

Another requirement is that the Home Support Agencies can only use DC HHAs to provide care. Currently, many agencies are using DC CNAs, these aides must transition to DC HHAs if they are to continue working in client homes.  There is normally 32 hours of education followed by an exam in order to make that transition. The association is currently working with DC DOH to see if there is any way to expedite the process so that clients continue to be served.

​Stay tuned for updates.

A HELPFUL TOOL: MASLOW’S HIERARCHY OF NEEDS

Abraham Maslow created a pyramid that generalizes human needs. His idea was that a person must satisfy the aspects defined in the lower tiers of the pyramid before he or she can focus on the ones above. If you’re confused about why your loved one is unhappy, you may find it helpful to review Maslow’s Hierarchy of Needs in my post below:

​Maslow’s Hierarchy of Needs is a framework that generalizes the needs that a person must meet to self-actualize. What is self-actualization? It’s the desire to become everything one is capable of becoming1. A person who self-actualizes may experience life with an overwhelming sense of joy, have a thirst for learning, and try new things.

How can someone experience life with an overwhelming sense of joy if he is starving? According to Maslow, he can’t. According to Maslow, that person will only be able to concentrate on one thing: food. Maslow’s theory is that people must fulfill lower-level needs before being able to suffice their higher-level needs. Below is a graphic of Maslow’s Hierarchy of Needs1:

You can think of each tier as a bucket; however to move to the next tier—starting from the bottom—one does not need to fill his or her bucket 100%. Each person is different by how full his or her bucket needs to be in order to concentrate on the next tier up1. As people begin to focus on higher tiers within the pyramid, they move towards self-actualizing, which is closely associated with life-satisfaction and happiness.

Your aging loved one may not be happy and this pyramid may help you understand why. Is she getting enough food, is she safe, does she have friends to hang out with? Work your way up the pyramid and determine if there is something missing in your loved one’s life. Then think about a possible solution.

Caregivers and senior living communities can do a great job fulfilling the physiological, safety, and sense of belonging needs. Arguably, they can help your loved one’s self-esteem too. While I wouldn’t dare to say that caregivers and senior living communities will completely fill the buckets of the bottom three needs, I will say that they make a good effort to do so. According to Maslow theory, if a caregiver or senior living community only partially fills the bottom three buckets, then that person’s circumstances will be better off than they were before.

Do what you can to improve your loved one’s life. You don’t need to try to fill each of his or her buckets completely. According to Maslow, only about 2% of the population self-actualizes in their lifetimes. People can go in and out of self-actualization as they age too. Traumatic life events may bring someone out of self-actualization while other life events may motivate them to be all they can. No matter where someone is in his or her life, Maslow’s pyramid remains a useful object for us to turn to whenever we are trying to assess the direction of our lives2. Do your best to fill each of these buckets as much as you can.

You may think that hiring a caregiver or moving into a senior living community may sound great in theory, but you’re still concerned about the costs. Don’t be. Talk to a senior advisor; he or she may be able to put you in touch with programs that will help subsidize your loved one’s expenses and even protect you from paying anything out of pocket. County, state, and federal governments understand that aging loved ones can be a stressor on the family, which causes disruption in other parts of society as well. There are many public programs to help relieve the burdens that fall on families. Talk to a senior advisor and he or she may be able to help you create a plan that will bring you peace of mind.

Sources:
1. https://www.simplypsychology.org/maslow.html
2. https://www.youtube.com/watch?v=L0PKWTta7lU