Rebalancing and RightSizing the South Dakota LongTerm Health Care System

1
Rebalancing and Right-Sizing the South Dakota
Long-Term Health Care System

• By Brooke D. Swier
• Health Care Law and Policy
• November 12, 2008

2

• Economy, efficiency, and creativity are
  essential in the delivery of services to older
  persons
• because of diminishing resources and
• a rapidly exploding consumer group.

• State of South Dakota Dept of Social Services,
  State Plan on Aging fiscal Years 2006-2009, at
  26 (2005).

3
Population Projections

• United States Census Bureaus 2000 census
• Persons aged 65 and older accounted for 14.3 of
  South Dakotas total population
• Nationally, the 65 and older population totaled
  12.4
• By the year 2010
• South Dakotas population aged 65 and older will
  increase to 14.6
• South Dakotas population over aged 65 will be
  144,459
• United States population aged 65 and older will
  account for 13.0
• By the year 2030
• Projected 65 and over population for South Dakota
  will total 23.1
• South Dakotas population aged 65 and older will
  be 185,064
• The national average of persons aged 65 and
  older will be 19.7
• South Dakota has a rapidly aging population and
  must examine its current long-term care policies
• Long-term care in the State must be rebalanced
  and right-sized

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The History of Long-Term Care in South Dakota
5
History of Long-Term Care

• In 1949, South Dakota had 59 nursing facilities
  with 988 beds
• In 1953, South Dakota had 100 nursing facilities
• In 1987, South Dakota had 137 nursing facilities
  with 8,451 beds

6
Certificate of Need Act

• In 1972, South Dakota enacted the State
  Certificate of Need for Health Care Facilities
  Act, S.D.C.L. 34-7A
• Legislature found that the unnecessary
  construction or modification of health care
  facilities increased the cost of care and
  threatened the financial ability of the public
  to obtain necessary medical services.
• The purpose of the Certificate of Need Act was to
  provide high quality care at lower costs, to
  promote health care planning, to avoid
  unnecessary duplication, and to provide a method
  to resolve questions concerning construction and
  modification of health care facilities.

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Governors Task Force and Elderly Initiative

• Because of the Certificate of Need laws,
  significant changes in the delivery of long-term
  care were seen in South Dakota
• In 1986, Governor Janklow established the South
  Dakota Task Force on Long-Term Care
• Purpose of Task Force
• Examine the existing long-term care system
  because the system was not adequately addressing
  the needs of the elderly in a fiscally
  responsible manner.
• Examine the most critical problems concerning the
  long-term care system and then provide
  recommendations
• 10 recommendations were set forth ranging from a
  pre-admission assessment pilot and enhanced
  geriatric education and training, to a
  modification of the certificate of need program.
• In 1988, Governor Mickelson formed an elderly
  initiative
• Repeal of the Certificate of Need Act
• Introduction of a three-year moratorium on
  long-term care bed expansion

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State Moratorium

• Certificate of Need Act was repealed by the
  Legislature in 1988
• Legislature enacted Regulation of Hospitals and
  Regulated Institutions
• 3-year moratorium on the expansion of nursing
  home beds
• S.D.C.L. 34-12-23
• each nursing home or supervised personal care
  facility in this state may operate no more than
  the number of beds as authorized by the
  Department of Health pursuant to this chapter
  and in existence on the effective date of
  34-12.1, 34-12-23 to 34-12-28, inclusive.
• Prohibited construction and operation of new
  nursing homes
• S.D.C.L. 34-12-24
• No new nursing home or supervised care facility
  may be constructed, operated, or maintained in
  this state unless the same is serving as a
  replacement for an existing facility and is
  required in order to (1) Eliminate or prevent
  imminent safety hazards as defined by federal,
  state or local fire, building or life safety
  codes or regulations (2) Comply with state
  licensure standards (3) Comply with
  accreditation or certification standards which
  shall be met to receive reimbursement under Title
  XVIII or XIX of the Social Security Act as
  amended to December 31, 1987 or (4) Respond to
  an emergency situation created by natural
  disaster such as tornadoes, floods, fire or
  explosions.

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Extension and Exception to Moratorium

• Moratorium was extended in 1991, 1993, 1995, and
  2000
• State moratorium was extended indefinitely in
  2005
• Nursing facility moratorium is currently set at
  8,193 nursing facility beds
• Legislature has approved one exception to the
  moratorium
• S.D.C.L. 34-12-48
• Notwithstanding the provisions of 34-12-35.3
  and 34-12-39.1, a new nursing facility as defined
  in 34-12-1.1 may be constructed, operated, and
  maintained in an area if the facility is to be
  located on an American Indian reservation and is
  required to serve a local population previously
  unserved through lack of nursing facilities
  within a forty-five-mile radius. No more than
  one such nursing facility may be located within
  the same American Indian reservation, and the
  number of beds in the nursing facility may not
  exceed fifty. The nursing facility shall meet
  the specifications of chapter 34-12 for a
  licensed nursing facility in order to participate
  in the Medicaid program.
• The Cheyenne River Sioux Tribe has been permitted
  to construct a nursing facility
• Groundbreaking was held on June 29, 2005
• The project has yet to be completed

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The Changing Age of the South Dakota Citizen
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Age Projections

• South Dakotas population is aging at a rapid
  rate
• By 2025, the number of South Dakotans over the
  age of 65 will increase to 24 of the entire
  State population
• Growth of the population is not evenly dispersed
• Sioux Falls and Rapid City will experience the
  fastest growth
• Sioux Falls will experience growth of 250 in its
  elderly population by the year 2025
• Rapid City and the surrounding counties will
  experience a senior population growth of 235 by
  the year 2025

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House Bill 1156

• To address the uneven growth of the elderly
  population, House Bill 1156 was passed in 2006
• Required the Department of Social Services to
  conduct a comprehensive review of the States
  long-term care system
• Study was to examine a number of aspects of
  long-term care
• Financing long-term care
• Long-term care insurance
• Alternative long-term care approaches
• Barriers to the quality of long-term care
• Other states long-term care programs
• The Department of Social Services contracted with
  Abt Associates, Inc. to conduct the review

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Rebalancing and Right-Sizing Long-Term Care in
South Dakota
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Rebalancing and Right-Sizing

• The long-term care system must be rebalanced and
  right-sized
• Rebalancing
• Moving long-term care resources to areas in which
  seniors are geographically located
• Updating available services so the elderly are
  able to remain independent and active in their
  communities
• Right-Sizing
• Tailoring services to the needs of the specific
  community

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Rebalancing and Right-Sizing

• The aging population will put unique demands on
  the States long-term care system
• Capacity for long-term care must be shifted to
  growth areas where seniors will reside
• Seniors who reside in other regions must have
  access to care close to their communities
• As the population increases, a strain will be
  placed on the States resources

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Nursing Facilities

• Most identified form of long-term care is Nursing
  Facilities
• Services typically include nursing, therapy,
  medical services, dental services, and assistance
  with medications
• S.D.C.L. 32-12-1.1 defines a nursing facility
  as
• any facility which is maintained and operated for
  the express or implied purpose of providing care
  to one or more persons whether for consideration
  or not, who are not acutely ill but require
  nursing care and related medical services of such
  complexity as to require professional nursing
  care under the direction of a physician on a
  twenty-four hour per day basis or a facility
  which is maintained and operated for the express
  or implied purpose of providing care to one or
  more persons, whether for consideration or not,
  who do not require the degree of care and
  treatment which a hospital is designed to
  provide, but who because of their mental or
  physical condition require medical care and
  health services which can be made available to
  them only through institutional facilities.

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Nursing Facilities

• In 2000, South Dakota had 114 nursing care
  facilities which maintained 7,727 beds
• The number of citizens aged 65 and older was
  108,131
• The ratio of nursing facility beds to 1,000
  residents aged 65 and older was 71.5
• In 2006, South Dakota had 111 nursing care
  facilities sustaining 7,174 beds
• The number of elderly in the state was 111,183
• The ratio of nursing facility beds to 1,000
  residents aged 65 and older was 64.5
• South Dakota ranked 10th in 2006 with the number
  of licensed beds per 1,000 persons aged
  sixty-five and older in the State

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Nursing Facilities

• Nursing facility capacity and the number of
  licensed beds in South Dakota have decreased
• Since 2000, Nursing Facility utilization has
  dropped by 13
• Beds have been taken out of circulation and rooms
  have been converted from semi-private to private
• Nursing facility capacity in the State is
  unevenly distributed
• Projections for the year 2025 indicate
• Rapid City will add 10,500 seniors to its
  communities
• Sioux Falls will add over 12,800 seniors to its
  communities
• The State must redistribute capacity from
  non-metropolitan areas to population hubs

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Nursing Facilities

• The age of the States nursing facilities are
  rising
• Over 40 were built over 40 years ago
• 80 were built over 30 years ago
• Nursing facilities will be 50 to 60 years old by
  the year 2025
• Many facilities will require renovations to
  accommodate new care models
• Many of the oldest facilities are in the West
  River region where the elderly population is
  expected to grow considerably

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Nursing Facilities

• With the expected population growth in comparison
  to where the Nursing Facilities are located, a
  shift must occur
• Moratorium bed capacity and the number of unused
  and de-licensed nursing facility beds is highest
  in the East River portion of the State
• Fewer unused moratorium beds in the West River
  region
• This is significant because 22 counties in the
  State will double in elderly population between
  2000 and 2025
• Nursing facility beds must be shifted from areas
  in which beds are being unused or de-licensed to
  areas which are in need of beds to accommodate
  the growing population

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Nursing Facilities

• Residents are very attached to their homes and
  their communities and are reluctant to move, even
  if better long-term care may be provided
  elsewhere
• With the expansion of medical centers
  predominantly in the Sioux Falls and Rapid City
  regions, some older citizens are moving to these
  health care hubs
• Many view Nursing Facilities as being all
  encompassing in terms of long-term care
• Perception is changing because seniors are
  expressing a desire to stay independent for as
  long as possible
• The decline in Nursing Facility use has been
  aided by the rise of Assisted Living capacity in
  the last decade

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Assisted Living Centers

• S.D.C.L. 34-12-1.1 defines an Assisted Living
  Center as
• any institution, rest home, boarding home, place,
  building, or agency which is maintained and
  operated to provide personal care and services
  which meet some need beyond basic provision of
  food, shelter, and laundry in a free- standing,
  physically separate facility which is not
  otherwise required to be licensed under this
  chapter.

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Assisted Living Centers

• Residents live in a homelike environment
• Normally residents live alone in an apartment
• Residents are typically provided
• Housekeeping services
• Two meals a day
• Leisure programs
• 24-hour supervision

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Assisted Living Centers

• In the 1990s, South Dakota experienced an
  increase in Assisted Living Centers
• Between 1997 and 2006
• Assisted Living beds increased from 1,623 to
  3,502
• In 2006
• South Dakota had 156 Assisted Living Centers

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Assisted Living Centers

• Scattered throughout the State
• 18 counties have no Assisted Living Centers
• 8 of the counties have highly Native American
  populations
• 7 of the counties are Centrally located

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Assisted Living Centers

• Increase in Assisted Living Centers has decreased
  the use of Nursing Facilities
• Many areas need to increase Assisted Living
  Center capacity if dependence on Nursing Facility
  care is going to continue to be reduced by this
  alternative care method
• Because Assisted Living Centers are not available
  in all areas of the State and the population of
  the State is rapidly aging, the placement and
  growth of Assisted Living Centers must be
  considered in the larger picture of long-term
  care expansion

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Home Health Care

• Health care delivered in the home
• Usually includes visits to the persons home a
  few hours per day and a few days per week
• Goal is to permit individuals to live in their
  own home or community for as long as possible at
  a cost less than that of residing in a nursing
  home

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Home Health Care

• Can be classified two ways
• 1) Skilled Service
• Nursing
• Physical/occupational/speech/language therapy
• Dental care
• Nutritional counseling
• Laboratory services
• Social work coordination
• 2) Supportive Services
• Personal care
• Homemaking
• Chores
• Transportation

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Home Health Care

• Home health care allows seniors to live
  independently for as long as possible and often
  delays the necessity for Nursing Facility care
• AARP of South Dakota published a State survey in
  2002 addressing the aging residents of the State
• 53 of South Dakota AARP members reported that it
  is very important to stay in their homes for as
  long as possible
• The survey concluded that respondents would be
  willing to contribute financially more to home
  health care if they were able to remain in their
  homes

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Home Health Care

• Although seniors are willing to pay for home
  health care services, South Dakota ranks 2nd
  lowest in the nation for home health episodes per
  100 elders
• In 2005, South Dakota averaged 5 Medicare or
  Medicaid-paid home health episodes per 100 while
  the national average was 12 episodes per year
• The low rate of utilization of home health
  services in South Dakota is possibly due to
  several factors
• Lack of providers
• Access problems
• Practice patterns which discourage use of the
  home health care services
• In 2005, 19 counties were not served by home
  health services

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Home Health Care

• South Dakotas home health care system is unable
  to provide adequate services to the aging
  population because too many counties are unable
  to provide services
• Moving South Dakota to national norms for home
  health care delivery would require doubling
  capacity immediately and increasing capacity 3 to
  4 fold by 2025 simply to meet population growth.
  Abt Associates

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Home and Community Based Services

• Provides seniors the ability to live in their own
  homes and communities for as long as possible
• Services include
• Adult Day Services
• Senior Center Services
• Nutrition Programs
• Homemaker and In-Home Personal Care Services

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Home and Community Based Services

• Adult Day Services
• Designed for individuals who live with family but
  are unable to be alone during the day
• Also available for those who live alone but
  prefer not to be alone during the day
• Dont need comprehensive nursing care

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Home and Community Based Services

• Adult Day Services may include
• Nursing care
• Meals
• Transportation to and from the facility
• Social activities
• Self-care training
• Nutritional services
• Therapy
• Data on Adult Day Services is difficult to obtain
• Reported that 34 counties had no Adult Day
  Facilities in 2007
• Services are not evenly distributed throughout
  the State
• Of the 34 counties with no Adult Day Services
• 12 are in the Central region
• 5 are in the West region
• 5 are in the Northeast region
• 3 are in the Southeast area.

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Home and Community Based Services

• Senior Center Services
• Provide the elderly with a place to gather and
  socialize
• Offers 1 or more meals per day
• Some offer wellness programs, health education,
  counseling, social activities, and some limited
  health care services typically in the form of
  screenings
• All but 2 counties were served by a Senior Center
  in 2007
• 18 counties had only 1 senior center
• In almost all regions, there are so few senior
  centers that each one has to serve between 500 to
  1,000 seniors

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Home and Community Based Services

• Nutrition Programs or Senior Meals
• Affordable way for seniors to maintain their
  health
• People 60 and over and their spouses can eat at
  senior meal sites
• Congregate Meals
• Served in a group setting at a senior center, a
  school, an elderly housing facility, a community
  building, a church, or a restaurant
• Seniors are able to socialize with others, and
  some services such as nutrition screening and
  education are provided
• Meals delivered to a home are often referred to
  as Meals on Wheels
• Available to people over age 60 who are homebound
  because of physical or emotion conditions
• Volunteers deliver the meals who are able to
  check on the wellbeing of the person

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Home and Community Based Services

• Nutritional programs are offered in all but 2
  counties
• Buffalo and Harding have no nutrition programs
• Barriers recognized to expanding these programs
  to reach the remote areas include travel time and
  the cost of transportation
• Travel distance limits the number of seniors who
  are able to receive the home-delivered meals
• Others are unable to reach communities with
  congregate meals

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Home and Community Based Services

• Homemaker and In-Home Personal Care Services
• Assist with various tasks around the home
• Seniors are able to live independently but need
  assistance with simple tasks
• Grocery shopping
• Light cleaning
• General errands
• Every county in South Dakota is served by a
  homemaker agency
• As of 2006, 40 counties had no homemaker agencies
  in their county
• In 2006, every county had 1 person using
  homemaker services
• Major barrier identified as preventing these
  services from expanding include providers, who
  often receive fixed reimbursements that do not
  cover travel expenses
• The South Dakota Department of Social Services
  has revamped the rates for reimbursement twice to
  try and assist rural providers with rising travel
  costs

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Recommendations for Improving Long-Term Care in
South Dakota
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Rebalancing and Right-Sizing

• South Dakotas long-term care system must be
  Rebalanced and Right-Sized
• South Dakota must encourage development of
  services in areas which are underserved and the
  services must be financed
• Several recommendations have been put forth to
  provide the State with potential options that
  best fit the needs of South Dakotas population

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Moratorium Exception

• South Dakota could create an exception to the
  State moratorium and allow bed trading
• The moratorium is not going to be able to meet
  the rising needs of the State
• There is insufficient nursing facility capacity
  in high growth areas and a surplus of capacity in
  low growth areas
• A bed trading provision to the moratorium statute
  could be created
• The total number of nursing facility beds would
  remain fixed
• Providers in areas with insufficient nursing
  facility capacity would be granted permission by
  the State to accommodate the needed capacity
  based on a given set of criteria

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Financing Long-Term Care

• Many nursing facilities will need to make capital
  improvement to existing facilities
• Communities must invest in strengthening other
  forms of long-term care, including Assisted
  Living Centers, Home Health Care, and Home and
  Community Based Services
• Use a Revolving Loan Fund (RLF) or other
  financing mechanisms to provide
  Medicaid-certified nursing facilities in South
  Dakota with low-interest financing for capital
  improvements and to provide financial assistance
  to foster the growth of Home and Community Based
  Services
• Would allow providers to build and remodel
  current structures
• Would ensure that the areas most in need of
  long-term care services would receive necessary
  funding

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Funding Long-Term Care

• Modify the current Medicaid reimbursement
  structure to better fund structure depreciation
  and capital improvements in all
  Medicaid-certified Nursing Facilities
• Potential opportunities for federal funding to
  support rebalancing of the long-term care system
• Several programs have been designed to assist
  states in eliminating barriers to Home and
  Community Based Services and managing long-term
  care in an integrated setting
• Many states have taken advantage of federal
  grants to rebalance their long-term care systems
• South Dakota has not sought federal funding
  through this avenue

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Meeting the Continuum of Care Needs of the
Elderly in South Dakota

• Department of Social Services created a Task
  Force in 2008
• Primary purpose was to develop recommendations
  for the Governor and the Legislature based on the
  findings of the Abt Associates, Inc.
• The Task Force was divided into 3 sub-groups
• Expansion of Home and Community Based Services
• Recommend how to improve existing Home and
  Community Based Services
• Rebalancing/Right-Sizing Long Term Care
• An adjustment in the current moratorium is
  necessary in order to shift beds from areas of
  low need to areas of high need
• Financing
• Transferring beds would have an impact on the
  Medicaid program because nursing facilities in
  high need areas would need to construct or
  remodel current structures to accommodate the
  increased capacity

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Conclusion

• Demand for long-term care is projected to grow
• The number of persons over age 65 will double by
  the year 2025
• Long-term care services are not in high-need
  areas
• Long-term care system must be Rebalanced and
  Right-Sized
• State moratorium on Nursing Facility beds must be
  revised so beds may be transferred from low need
  areas to areas of high demand
• Alternative long-term care services such as
  Assisted Living Centers, Home Health Services,
  and Home and Community Based Services must be
  expanded statewide
• Long-term care system must be properly funded
• With new statutory language, the addition of
  alternative long-term care services, and proper
  funding, South Dakota can Rebalance and
  Right-Size long-term care in order to best serve
  the seniors of the State

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Questions