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Home My WebLink AboutOIH - Presentation to Board of Selectman FinalThe Future of Eldercare on Nantucket The Role of Our Island Home 1 AGENDA 1.Evolution & Current State of Eldercare 2.Current State – Our Island Home 3.Planning for the Future 4.Stakeholder Input 5.Options / Analysis 6.Discussion 2 Mental Hospitals 1820s Almshouses 1905 Early Institutions 1942 Licensed Nursing Home 1960 “modern” Nursing Home 1980s Assisted Living 2000 Small House The Future Care at Home Pre 1820s Care at Home The Evolution of Eldercare 3 Current State - Long Term Care 4 1999 Supreme Court Olmstead Decision Directs Deinstutionalization “Confinement in an institution severely diminishes the everyday life activities of individuals…” Least restrictive environment 5 Massachusetts: “Community First” Olmstead required states to develop plans to provide for least restrictive environment and deinstitutionalization 6 VISION Empower and support people with disabilities and elders to live with dignity and independence in the community by expanding, strengthening, and integrating systems of community-based long- term supports that are person-centered, high in quality and provide optimal choice. GOALS o Help individuals transition from institutional care o Expand access to community-based long-term supports o Improve the capacity and quality of community-based long-term supports o Expand access to affordable and accessible housing with supports o Promote employment of persons with disabilities and elders o Promote awareness of long-term supports 7 Result: Funding Shifts Massachusetts National 8 Current State - OIH 9 Operational Analysis – OIH Publicly Reported Quality Data 10 Operational Analysis: Culture 9 8 3 0 9 60 89 35 102 15 9 32 48 241 0 50 100 150 200 250 300 Care Practices Environment Family and Community Leadership Workplace Practice Staffing Outcomes and Occupancy Artifacts of Culture Change Artifacts of Culture Change OIH Scores Compared to Benchmarks Benchmark Score Reflects Highly Bureaucratic Traditional Institutional Model of Care 11 Current Operation: Fiscal Analysis Department Totals PPDs Nursing Dietary Laundry, Hskpg, Plant G&A Payroll Benefits Totals 2014 Northeast 90th Percentile 99.48 15.50 26.76 22.47 18.08 182.29 2014 Northeast 50th Percentile 134.04 19.06 38.62 32.32 23.46 247.50 2014 Northeast 10th Percentile 177.18 26.74 52.95 45.94 39.06 341.87 OIH 222.87 51.86 44.34 65.10 115.99 500.16 Comparison to 10th Percentile 45.69 25.12 (8.61) 19.16 76.93 158.29 difference in $$$s 672,377 369,647 (126,704) 281,999 1,132,099 2,329,417 (ppd difference x total patient days) Salary Costs PPDs DON, RN & LPN Aides Other Nursing Admin Soc Svcs, Act, Ancil Svcs Dietary Laundry, Hskg, Plant G&A Totals 2014 Northeast 90th Percentile 29.85 30.59 4.01 5.51 7.12 4.78 3.94 85.80 2014 Northeast 50th Percentile 47.48 36.54 9.04 22.03 10.05 9.85 8.21 143.20 2014 Northeast 10th Percentile 67.66 47.76 19.51 37.01 13.97 17.19 16.65 219.75 OIH 67.42 92.71 19.47 15.32 40.65 29.84 20.73 286.15 Comparison to 10th Percentile (0.24) 44.95 (0.04) (21.69) 26.68 12.65 4.08 66.40 difference in $$$s (3,532) 661,531 (589) (319,188) 392,599 186,156 60,098 977,076 (ppd difference x total patient days) Revenue Dynamics Expense Structure Average Daily Rates: Government Payor Sources 2014 2015 ytd2016 Avg Medicaid Rate 197.25 197.15 192.78 Avg Medicare Rate 349.48 394.54 311.38 PPD = Per Patient per Day expenditure 12 Current Operation: Projected Forward * Excluding Town subsidy and State CPE receipts for municipally-owned providers 13 Planning for the Future 14 Future Population & Needs Population #% of Total #% of Total #% of Total (2010-2015)(2015-2020) Total 10,172 100.0%10,680 100.0%11,070 100.0%0.8%0.9% 55 to 64 1,285 12.6%1,493 14.0%1,574 14.2%2.9%1.4% 65 to 74 692 6.8%961 9.0%1,173 10.6%6.2%5.8% 75 to 84 373 3.7%436 4.1%511 4.6%2.4%4.5% 85+162 1.6%202 1.9%206 1.9%4.8%0.5% 55+2,512 24.7%3,092 29.0%3,464 31.3%3.9%3.1% 65+1,227 12.1%1,599 15.0%1,890 17.1%4.9%4.8% 75+535 5.3%638 6.0%717 6.5%3.1%3.2% % Annual Change20102016 Older Adult Population by Age and Year Our Island Home Market Area 2020 Income #%#%#%(2000-2015)(2015-2020) <$15,000 114 35.1%113 26.3%117 23.3%-0.1%0.7% $15,000 - $24,999 9 2.8%46 10.7%48 9.6%27.4%0.9% $25,000 - $34,999 30 9.2%65 15.2%76 15.1%7.8%3.4% $35,000 - $49,999 56 17.2%62 14.5%72 14.3%0.7%3.2% $50,000 - $74,999 39 12.0%40 9.3%53 10.6%0.2%6.5% $75,000 - $99,999 7 2.2%25 5.8%30 6.0%17.1%4.0% $100,000 - $124,999 28 8.6%17 4.0%23 4.6%-2.6%7.1% $125,000 - $149,999 8 2.5%17 4.0%23 4.6%7.5%7.1% $150,000 - $199,999 14 4.3%17 4.0%23 4.6%1.4%7.1% $200,000+20 6.2%27 6.3%37 7.4%2.3%7.4% Total 325 100.0%429 100.0%502 100.0%2.1%3.4% $35,000+172 52.9%205 47.8%261 52.0%1.3%5.5% $50,000+116 35.7%143 33.3%189 37.6%1.6%6.4% $75,000+77 23.7%103 24.0%136 27.1%2.3%6.4% $100,000+70 21.5%78 18.2%106 21.1%0.8%7.2% Households 75+ by Income Our Island Home Market Area 2000 2015 2020 % Annual ChangeRelatively high %-age of 75+ with less than $35k income Relatively small market for 75+, regardless of demand for Nursing Home services 65+1,890 17.1% 75+717 6.5% 15 Mitigating Factors in Bed Need Projections Decrease in Disability Due to Medical Advances 16 Mitigating Factors in Bed Need Projections Primary reimbursement is from the Government which is committed to Community Based Services 17 Planning Requires a Fundamental Shift in Thinking OIH as Primary Care Provider for Frail Elders OIH as Part of a Comprehensive System of Care 18 Mitigating Factors in Bed Need Projections Approximately 25% of current OIH residents have low care needs and could be cared for in an alternate setting 19 Project Size Projections Based on demographic projections alone, need is for 60 seniors to receive care from the LTC system. Mitigating factors point to a project sized at 30 Nursing Home Beds and 10 Affordable (Medicaid funded) Assisted Living beds. 20 Input from Stakeholders •Nantucket Government •Resident Interviews •Other community leaders in - –Healthcare –Community-based services –Demographics •Community group meeting •Sherburne Commons leadership •Concerned citizens •Focus Groups –Family members –Direct care staff –OIH leadership staff 21 Themes of Interviews with Stakeholders Common Some Few Nantucket needs a Nursing Home OIH needs replacement Taxpayer burden is high – need to reduce Do whatever is best for the residents Keep at current site – view and historical significance Move to Sherburne Commons and sell the current site to the Land Bank No land sale to commercial entity No partnership with Sherburne Commons Don’t want “pods” no need to change Close OIH Do nothing – already have too many expensive town projects underway 22 Small House Research Demonstrated Outcomes Improvement in 7 domains of Quality of Life –Privacy –Dignity –Meaningful activity –Strength of relationship –Autonomy –Food enjoyment –Individuality Improved Quality of Care - Elders maintain self-care abilities - longer - Less depression -Less boredom -Less loss of appetite and weight loss -Less wheelchair dependence Improved Quality of Care - Elders maintain self-care abilities - longer - Less depression -Less boredom -Less loss of appetite and weight loss -Less wheelchair dependence -Fewer pressure ulcers Compared to traditional nursing homes -Higher direct care time : 23-31 more minutes/day -Higher family satisfaction -Higher staff satisfaction Dementia Care Small House recommended by Alzheimer's Foundation as excellent model of care for individuals with dementia 23 Analysis of Options 24 Factor Analysis of Nantucket Eldercare & OIH’s role in Delivery System “Community First” No new Nursing Home beds available in MA Take care of our own on Island Medicare – Hospital has swing beds Medicaid – Stagnant Private – Limited Government – responsibility to constituents to keep tax burden reasonable Research demonstrates better outcomes in deinstitutionalized models of care 25 White Box Options 1)Maintain the Status Quo 2)Remodel Existing OIH 3)Sale to Outside Entity Before or After Construction 4)Traditional Nursing Home on Existing Site or Sherburne Commons 5)Small House Nursing Home at Existing Site 6)Small House Nursing Home at Sherburne Commons 26 1) Maintain the Status Quo Financial Quality of Life & Quality of Care Demographic & Reimbursement Elasticity Other Factors Escalating losses related to: •Static reimbursement rates •Escalating operating costs •Escalating demand for repair & maintenance costs •Potential loss of state-funded CPE revenues •Building issues could produce citations and civil monetary penalties Fiscal burden remains on Town Continued issues with quality outcomes and meeting state requirements None – will not meet changing demands of population Lacks expansion space Ethical responsibility to provide best quality of care in the least restrictive environment Legal responsibility to comply with Olmstead Some stakeholders have strong conviction to keep OIH at current location 27 2) Reconstruct Existing Building Financial Quality of Life & Quality of Care Demographic & Reimbursement Elasticity Other Factors Escalating losses related to: •Static reimbursement rates •Escalating operating costs •Escalating demand for repair & maintenance costs •Potential loss of state-funded CPE revenues •Building issues could produce citations and civil monetary penalties Fiscal burden remains on Town Continued issues with quality outcomes and meeting state requirements None – will not meet changing demands of population because it lacks expansion space to add community based services Costs of reconstruction of existing building unreasonable because of Federal/State regulations which require that renovation of any part of a facility bring the entire facility up to the current code. This represents a rebuild Some stakeholders have strong conviction to keep OIH at current location 28 3) Sale to Outside Company Before or After New Construction Financial Other Factors Fiscal burden no longer on Town, but … Unlikely that any buyer would purchase due to: •Current level of operational losses and presence of systemic challenges to achieve profitability •Sale to third party would eliminate state-funded CPE revenues (allocated only for municipally-owned nursing homes) •Lack of short term rehabilitation market •General lack of interest in facilities with union contract in place •Logistical challenges and expenses associated with Island location Sale option has been explored, to no avail Even if sale were consummated, no control over continued operation for the long-term Risk of closure high due to specific dynamics that would likely lead to mounting losses 29 4) Construction of Traditional Nursing Home Building – Existing Site or Sherburne Commons Financial Quality of Life & Quality of Care Demographic & Reimbursement Elasticity Other Factors Existing site – more expensive to build, and more expensive to operate New site - less expensive to build, but still more expensive to operate Town subsidy higher than other alternatives, regardless of site If remain at existing site - no potential sale to Land Bank, thus a loss of revenue from the sale to offset construction costs Fiscal burden remains on Town Will not improve Quality of Life in the same manner as afforded in a person centered home like environment Current site: None – will not meet changing demands of population because it lacks expansion space to add community based services Building plan eliminates ability to change programs to meet changing needs Some stakeholders have strong conviction to keep OIH at current location 30 5) Construction of a Small House Complex at the Existing Site Financial Quality of Life & Quality of Care Demographic & Reimbursement Elasticity Other Factors Existing site – not feasible to build given site restrictions; and even if it were feasible, not programmatically optimal Town subsidy higher than other alternatives, regardless of site No potential sale to Land Bank, thus a loss of revenue from the sale to offset construction costs Fiscal burden remains on Town Integral facility is not feasible to be placed on site without impacting existing facility Detached homes do not provide larger community gathering areas Current site: None – will not meet changing demands of population because it lacks expansion space to add community based services Building plan eliminates ability to change programs to meet changing needs Some stakeholders have strong conviction to keep OIH at current location Storm surge vulnerability Construction phasing required 31 Nantucket Storm Surge Analysis Nantucket Hurricane History 1924: Unnamed, Cat. 1 1938: Great New England Hurricane, Cat. 3 1944: Great Atlantic Hurricane, Cat. 2 1954: Hurricane Edna, Cat. 3 1954: Hurricane Carol, Cat. 3 1960: Hurricane Donna, Cat. 2 1985: Hurricane Gloria, Cat. 2 1991: Hurricane Bob, Cat. 2 Class 2 Hurricane o Portion of site closest to shore may be inundated with up to 3-ft of storm surge US DEPT OF COMMERCE National Oceanographic & Atmospheric Administration Source: NOAA S.L.O.S.H. (Sea, Lake, and Overland Surges from Hurricanes) 32 Nantucket Storm Surge Analysis Class 3 Hurricane o Majority of site may be inundated by storm surge with depths up to 6-ft. National Oceanographic and Atmospheric Administration 33 Nantucket Storm Surge Analysis Class 4 Hurricane o Majority of site may be inundated by storm surge with depths up to 9-ft. US DEPT OF COMMERCE National Oceanographic & Atmospheric Administration 34 Best Fit with Existing and Future Eldercare Needs on Island: 6) Construct a Small House 30 Bed Nursing Home and 10 bed Affordable Assisted Living at Sherburne Commons Financial Quality of Life & Quality of Care Demographic & Reimbursement Elasticity Other Factors Construction costs less than most other alternatives, more than some Least expensive model to operate (in terms of Town subsidy required) Potential revenue from sale of land to Land Bank Fiscal burden remains on Town, but marginally less than other models Expected improvement in Quality of Life and Quality of Care Very elastic – potential for site to become the hub of community services – a one stop center for services and providers Provides flexibility to shift houses to meet service demands if needs or reimbursement changes Easy transition- build then move 35 36 Typical 10-Bed Home Plan 37 TOTAL = 8,657 SF Summary Options – FY2020 Scenario: Number of SNF Beds Number of AL Units Project costs (Uses) Cash Flow: Loss from Operations Debt service Routine capital Net Cash Flow Traditional Bdg- Existing Site Traditional Bdg- New Site Small House - New Site Small House - New Site 40 40 30 40 - - 10 - 21,640 18,461 23,864 23,864 (2,829) (2,829) (1,851) (1,959) (1,634) (795) (1,203) (1,203) (40) (40) (40) (40) (4,503)$ (3,664)$ (3,094)$ (3,202)$ Current State 45 - - (4,454) - (150) (4,604)$ ($000’s) * Excluding Town subsidy and State CPE receipts for municipally-owned providers 38 Summary Options – FY2020 Represents net cash flow losses after factoring in financing costs related to construction, and ongoing capital expenditures * Excluding Town subsidy and State CPE receipts for municipally-owned providers 39 Summary Options – FY2020 Represents net cash flow losses after factoring in financing costs related to construction, and ongoing capital expenditures * Excluding Town subsidy and State CPE receipts for municipally-owned providers 40 Summary Options – FY2020 Represents losses solely from Operations across different scenarios * Excluding Town subsidy and State CPE receipts for municipally-owned providers 41 Additional Recommendations 42 Additional Recommendations: Recruitment of Health Care Staff Investigate the Student Loan Forgiveness Programs that are available to professional staff if they are employed in an underserved area 43 Additional Recommendation: Consider a Management Company Added cost of Management Company could be more than offset by the Potential Benefits: Operational expertise will improve budgetary and quality outcomes Shifts operational burden away from the Town while retaining ownership Provides access to pool of talent for succession planning 44 Additional Recommendations: Formalize Coordination of Services Involve key stakeholders to: •Review existing services •Identify needs and gaps in services •Create a 5-year plan for building a comprehensive eldercare system that echoes “Community First” 45 Additional Recommendation: Consider Alternative Ownership Structures Engage legal counsel to fully explore: •Establishment of a Public Benefit Corporation to own/operate OIH •Conversion of OIH to a freestanding not for profit/voluntary corporation 46 Additional Recommendations: Quality Improvement Initiate a Quality Improvement Program for Quality of Care and Quality of Life utilizing the Advancing Excellence in America’s Nursing Home Platform 47 Additional Recommendations: Public Awareness Campaign The State-funded Home Modification Loan Program The Massachusetts Partnership Long Term Care Insurance Reverse Mortgages 48 Discussion Thank you for the opportunity to collaborate with the Town of Nantucket ! 49 Typical Resident Unit Plan 50 51 52 53 54 55 56