Transcript Minneapolis VAMC CNH Oversight Team Annual Review of

Care Providers of Minnesota
December 12, 2006
“Contracting with Private
Nursing Homes to Assure
a Continuum of the Highest Quality
of Care for Veterans”
Dan Goedken, MSSW, LICSW
Coordinator, CNH Program
Minneapolis VA Medical Center
612.567.4530
1
A brief personal resume:
1968-1971, US Army
1971, started in the VA (Iowa City, Milwaukee)
1976, BSW, U of Iowa
1979, MSSW, U of Louisville
1988, joined staff at Minneapolis VAMC
10 years as Coordinator, CNH Program
4 GAO, OIG federal inspections of CNH Program
5 years as SW Supervisor
Married to a Army Reservist Nurse
2
An overview of the
national VA system:
VA medical system consists of
integrated networks of care (VISNs)
that are focused on pooling and
aligning resources to better meet
local health care needs and provide
greater access to care…………
3
4
Nation-wide, there are over 1,300 VA
care facilities, including….
163 hospitals,
 850 community-based outpatient clinics,
 206 veteran counseling centers,
 137 VAMC nursing homes, and
 43 domiciliary facilities

5
6
Regardless of where the veteran resides,
all veterans need to be enrolled
in the VA to receive VA health care
~~~~~~~~~~
For veterans not enrolled,
call the nearest VAMC
For Minneapolis VAMC area,
call VA Patient Access Center
612-467-2071
7
ONCE ENROLLED…..
(REGARDLESS OF LENGTH OF MILITARY SERVICE
OR COMBAT INVOLVEMENT)
ALL VETERANS
ARE RECOGNIZED IN
ONE OF TWO
VA ELIGIBILITY CATEGORIES
8

Nonservice-connected (NSC)
Veteran does not have injuries or illness that were
determined (rated) by the VA to have been incurred or
aggravated by their military service.

Service-connected (SC)
Veteran has been determined by VA to have a disability
or illness incurred or aggravated by their military
service. Rating will range from 0% SC (noncompensable) to 100% SC ($2,400+/month). SC
veterans are potentially “Millennium Act” veterans.
9
Although the NSC and SC rating is the over-riding
eligibility determination, there are other secondary
eligibilities that might create access to particular
VA clinics or specialized care:







Agent Orange Exposure
Ionizing Radiation Exposure
Atomic Veterans
Prisoners of War
Military sexual trauma
OIF/OEF Polytrauma Care
Purple Heart
10
Some veterans will be billed for services.
1. Service connected veterans receive services
almost entirely without co-payments or charges.
2. Non-service connected veterans, depending on
a financial means test, may have charges:
Medications ($8/month per prescription)
Inpatient days, similar to Medicare
Outpatient clinic charges ($15-50)
Contracted care in the community
11
Now a closer look at VA funding
for enrolled veterans to receive
care in the community through
VA contracts.
12
VA coverage depends on
enrollment and medical determination
1. Home Care
Skilled Care
Homemaker
Home Health Aide
2. Contract Adult Day Health Care
13
3. VA
provides nursing home care
in three different settings:
VAMC Nursing Home Care Units


In-house programs
Minneapolis, St Cloud, Sioux Falls, Fargo
State Veterans Homes


Per diem payments
Minneapolis, Fergus Falls, Laverne, Silver Bay, Hastings
Contract Nursing Homes



Based either on MA or MC case mix formulary
Each VA has it’s own CNH program
A closer look at CNH…………….
14
The three current CNH patient funding
priorities, based on nationally established
requirements….




Respite (NTE 30 days a year)
Hospice Care
Long-term (Millennium Act) coverage for SC
veterans
Short-term contracts (discretionary, $)
15
…by the numbers, the Minneapolis VAMC
CNH Program, as of 12/1/06……..
51
Counties of jurisdiction in MN and WI
63
CNH facilities
$9,453,256 Spent in FY 2005
491
Millennium Act veterans reviewed, 2000
232
Veterans on contract in FY 2005
155
Millennium Act veterans, 12/1/06
16
THREE YEAR CNH SUMMARY
2004
2005
2006 (YTD)
Days of care
47,573
49,045
57,276
Number of
placed veterans
287
232
260
Mill Act
veterans reviewed
78
77
117
17
The Minneapolis CNH Staff
Primary Team
1
1
5
4
1
3
1
Coordinator
Contracting Officer
Clinical Social Workers
Nurse Coordinators
Dietician
Life Safety Inspectors
RN/Quality Improvement
Consultative Team
1
1
1
1
1
1
1
Geriatrician
Physiatrist
HBPC Director
Clinical Pharmacist
Physical Therapist
Occupational Therapist
Speech Pathologist
18
Contracted veterans residing in a CNH
regularly receive outreach visits from the VA.
Social Work or Nurse
Limited other follow-up by mental health or other disciplines
Telephone or visit
Chart review, assessment visit with patient, speak with staff
Ensures continuity of care/coordination between the CNH and VA
Quality oversight of the plan of care
Troubleshooting issues
Review for appropriate discharge planning
Life safety inspector every 3 years
19
So why would a nursing home
want a VA contract?
Broadens the pool of available funding
Higher daily funding than MA provides
Increased opportunities to serve America’s veterans
Increases the gender mix/more male referrals
May contribute to Culture Transformation
Unique geographic offering
Access to increased VA clinics for support
VA RN and SW visits to veterans on contract
20
And there are certainly reasons why a nursing home
may not want a VA contract….
Paperwork
Accountability
Perceived too few referrals for the effort
NH is too small to offer unique options to the VA
NH occupancy is generally already 100%
NH is not 100% fire sprinkled
Therapy VA pre-authorization
21
On average, the Minneapolis VAMC maintains
60+ nursing homes on contract.
In any given year, we non-renew/loose 4-6 facilities.
And we add a similar number,
based on, among other reasons……..
22
VA needs assessment for a new CNH:

current availability of VA funding,

implications for growth/decline in the current contract facilities,

density/proximity of existing contract facilities,

tendency for openings within the existing pool of contracted
facilities,

unique facilities that serve specialized needs,

the desire to providing ample business to existing contract facilities
to warrant their continued affiliation.
23
A primer on the MVAMC VA contract……

Medicare PPS case mix formulary (53 levels); VA follows CMS for MDS
timetable: admission, 14, 30 day, quarterly, annually, significant change.

An all-inclusive contract. Per diem rates include a semi-private room, meals,
nursing care, rehabilitation, respiratory, oxygen therapy, medical/nursing supplies.

Most oral medications are included up to 8.5% of the per diem, as well as most
durable medical equipment items, X-rays, and routine lab tests. Medication costs
that exceed 8.5% of the per diem, are billed to the VA at the AWP. High costs
meds may be better dispensed by VA.

Specialized equipment (i.e. air fluidized bed) can be pre-authorized.

VA-paid travel to VA appointments.

VA will reimburse the CNH for incurred MD costs. VA follows CMS standards
for physician visits (i.e. frequency, documentation, and 24/7 coverage).
24
Contractual stipulations when a veteran is on a VA
contract in a CNH…..
Coverage planning: always verify that patient will be covered by the VA.
PC: The NH MD needs to solely provide the PC for the CNH veteran.
No other payment source for same day coverage. It is fraud to bill two
different federal payer sources for services provided within the CNH for the
same day of coverage. For example, billing the VA for per diem, and MC for
the MD, therapy, medications. (Exception is when a veteran is on hospice: VA
will pay R&B, MC will pay for hospice agency to provide end of life meds,
hospice staffing, consultation)
Medications: VA does not supply routine medications for the CNH patient CNH acquires medications AWP from their own pharmacy source.
PT, OT, or SLP: needs to be pre-authorized by the VA.
25
Expectation of timeliness
~ of submitting invoices
~of VA payment
Invoices (per diem, medications, pre-approved ancillaries)
to the VA should be current (within 15 days following the
month of when services when were provided)
From the date VA receives the invoice, VA is required to make
electronic payment to the CNH account within 30 days
If the VA electronic payment is delayed in excessive of 30
days beyond the invoice reception date, VA automatically pays
a interest penalty for each day beyond 30:
invoice amount x .55750 daily interest
26
VA CONTRACT
“To be considered for a VA contract,
or to annually renew an existing contract,
VA takes the approach that
a broad review of all available data is essential”
27
To assess for a new VA contract, and
to annually renew an existing VA contract,
we review the following formal documents……
1. Copy of State License.
2. 2567 state survey, including noted corrections and revisit
3. CNH Continuous Improvement Plan
4. Current CNH annual staff training/competency summary
5. Fire Marshal inspection
7. Indemnification liability insurance certification
8. CNH Emergency Preparedness Plan
28
We also assemble the
available web-based information:
NH Compare
quality measures
staffing reports
Minnesota Health Facilities Complaint Office
Minnesota Nursing Home Report Card
OSCAR 3 and 4.
NH watch list
29
And initiate regular telephone contact with …….
Veterans Benefit Administration
Guardians, conservators, fiduciaries
Nursing Home Ombudsman
Hx of complaints, trends
Amenableness to complaint resolution
Evidence of consultation efforts by the NH
Staffing/turnover issues
Integration of resident/family council process
Support of cultural transformation
General view of care provided
30
Acquire comparative data from the
Department of Health…

Average # of state survey deficiencies

Deficiency free inspections
(If this state’s percentage of deficiency-free
inspections are above the VA acceptable 20%
threshold, VA is required to report to CMS.)
31
When a VA contract is up for annual renewal,
we also review our own VA electronic medical
records (from the monthly SW and RN visits
to the CNH) of the veterans served on contract
during the last year…..
Clinical observations
Quality improvement efforts
Patient/family satisfaction or complaints
General observations of CNH
Observations of staffing issues/turnover
32
So….the CNH Team routinely…..
and at the time of annual renewal….
Assembles a portfolio of primary and secondary data
Applies stringent application of VA standards, and
RN and SW complete regular follow-up visits to contracted veterans,
and
Team reviews the medical records (both VA and CNH records, and
Has regular communication with Ombudsman, VBA, and
QI/Continuous Improvement initiatives
And when warranted, actively communicates with the state survey
team to examine particular performance issues.
33
We then annually assemble this
assortment of data and apply
seven national VA
standards….
34
SEVEN VA CNH STANDARDS
1) Are there three level ‘G’ or higher
deficiencies in the current survey?
2) In the current survey, are the total
number of health requirement
deficiencies twice the state average?
35
3) In the current survey, is there a level ‘E’ or
higher deficiency in any of the following
areas:
Restraints (F221 or F222)
Abuse (F223)
Staff treatment of patients (F225 or F226)
Dignity (F241)
Licensure (F491)
36
4) In the NH Compare review are the
RN hours per resident day below
the state average?
5) In the NH Compare review are the
total nursing staff hours per
resident below the state average?
37
6) Are six or more of the MDS quality
measures from NH Compare above
the state average?
7) In the current survey is there a
level “E” or higher deficiency in
any of the following areas:
a.
b.
c.
d.
e.
Nursing services (F353)
Nursing aide training (F494, F495, or
F496)
Regular in-service training (F497)
Proficiency of nursing aides (F498)
Staff qualifications (F499)
38
To consider the contract, we apply the 7 VA standards….
and review all other relevant performance information…
in the determination process..…..
If a newly proposed contract, proceed or decline
Renewal of existing contract (most common)
Renewal with added clinical oversight
Renewal with additional stipulations
Suspension of placements
Suspension/termination of contract
39
In summary, through the contract
program, VA believes that
enhancing the NH care
for veterans within
the CNH further
enhances the
care for all
residents.
40
For the current CNH programs affiliated with the VA,
we thank you for your genuine commitment, your business
relationship, and enduring care provided to veterans
and their families!!
41
Even if your nursing home does not have a VA
contract, the facility can still partner to provide limited
services to the veteran……
(based on the veteran’s unique VA eligibility (SC/NSC, etc),
some planning & pre-authorization)
VA hospitalization: 612-467-2019
Brief VA payment for emergency private hospitalization:
612-467-2003
VA-paid transportation to VA appointment: 612-467-4290
42
Other services:

Outpatient care (specialty or primary care/medications:
612-467-2019

Prosthetics equipment (specialized wheelchairs, etc): 612467-2001

Review for discharge planning & home care services: 612567-1994
43
in the end…..
….”the willingness with which our young people are likely to
serve in any war, no matter how justified, shall be directly
proportional to how they perceive the veterans of earlier wars
were treated and appreciated by their nation.”
-George Washington
44