Show Me the Money Funding in Long Term Care Homes Presented by: Karen Bertrand, Region 5 Vice President Beverly Mathers, Senior Director, Labour Relations Stacey Papernick, LRO South District Service Team, LTC Non Institutional Project Team, Nursing Homes Lead Matthew Stout, LRO West District Service Team, LTC Non Institutional Project Team, Homes for the Aged Lead June 5, 2018 Objectives Sources of funding.. Ministry of Health and Long Term Care (MOHLTC) envelope system. Differences Not for profit vs for profit LTC homes. Current government funding of nursing initiatives in LTC. Recent funding announcements. 2 Why Do We Want to Know How LTC Homes are Funded? Why we want employers to Show Me the Money to: 1. Ensure residents receive RN care for their complex conditions. 2. Reduce admission wait times for complex care residents. 3. Increase Bargaining Unit positions. 4. Rescind layoffs; prevent the elimination of ONA positions. 5. Accountability for spending on nursing and personal care. 6. To create disincentives to the erosion of RN work. 3 1
How are LTC Homes Funded? Not for profit homes include Homes for the Aged, charitable or municipal, and some nursing homes. For profit homes are all nursing homes, owned and operated, corporate or owner. 4 How are Long Term Care Homes funded? MOHLTC Envelope System based on Case Mix Index (CMI) levels of care. Supplemental funding. Claims based funding. Resident co payments. 5 MOHLTC Levels of Care Funding Model CMI Each home is assigned CMI on an annual basis early January (April 1 to March 31 CMI year). CMI based on an annual assessment using Resident Assessment Instrument (RAI) Minimum Data Set (MDS). RAI is standardized assessment tool for admission, quarterly, significant change in health status and annual assessments for each resident. 6 2
MOHLTC Levels of Care Funding Model Case Mix Measure (CMM) Using RAI MDS homes collect administrative and clinical data during a resident s period of care. It is reported on a quarterly basis into the Continuing Care Reporting System (CCRS) administered by the Canadian Institute of Health Information (CIHI). 7 MOHLTC Levels of Care Funding Model CMM The first step using RAI is the MDS the assessment, includes screening, clinical and functional status information using standard information and codes and as a whole it is an assessment of the condition of a resident. Assessments are done in the areas of cognition, skin, activation, medication, treatments/procedures, discharge potential/overall status. 8 MOHLTC Levels of Care Funding Model CMM The second step is the Resident Assessment Protocols (RAPs); they are frameworks to organize the MDS information. More information is gathered about the resident to identify causes of problems and possible solutions. Problems are identified by a RAP trigger and helps to solve a problem. 9 3
The Resource Utilization Group (RUG III) grouping methodology categorizes assessments (MDS and RAPs) into groups that have similar clinical characteristics and levels of resource use. Based on the level of acuity, the RUG III methodology supports evidence based system and facility level planning, quality improvement and case mix adjusted resource allocation. 10 CCRS data reported for Ontario LTC facilities is grouped using the 34 group version of RUG III. Seven hierarchical clinical categories: 1. Extensive services 3 groups. 2. Special rehabilitation 4 groups. 3. Special care 3 groups. 4. Clinically complex 6 groups. 5. Impaired cognition 4 groups. 6. Behavioural problems 4 groups. 7. Reduced physical functions 10 groups. 11 RUG = Resource Utilization Group The RUG group assigned to an assessment is based on resources used during the assessment observation period (not resources required). Each assessment is reviewed to determine which of the 34 RUG groups might apply more than one RUG group might apply. 12 4
The cost weights CMI values are used to assign one RUG group for the assessment and the RUG group with the highest CMI value is used for the RWPD reports this is Index Maximizing Classification. 13 The production of RUG Weighted Patient Day (RWPD) reports can be thought of as an accounting process through which Clinical Care Reporting System assessment data (Admission, Re entry, Discharge Assessments, etc.) are converted into lines of a ledger. Weighted patient day information is a way to estimate resource use. 14 For each reporting period, the first step is to create unweighted RWPD events for each resident. The clinical and administrative data from the assessments are then used to assign a RUG group to each assessment. Next, the number of days covered by each assessment (Patient Days) is calculated. Finally, weighted RWPD events are created by multiplying the number of patient days by a CMI value. 15 5
RWPD reports will be run quarterly. The RUG group and CMI from an assessment apply for all patient days until the next assessment: Admission assessment must be completed within 14 days. Quarterly assessments. Significant change assessment. Discharge. 16 MOHLTC Levels of Care Funding Model Problems with CMI: The CMI is a cost weight reflecting the relative resource use by an individual within a specific RUG group, compared to the overall average resource use for all Ontario LTC residents. The CMI is not a direct measure of the cost of care. Patient Re Indexing Factor CMI system re allocates the funding pie but does not change the size of the pie, it only preserves each home s share of the pie based on its RWPD. 17 MOHLTC Levels of Care Funding Model Problems with CMI: Funding is based on assessment data that is a year old and does not meet actual resident care needs. Funding does not reflect the increase in resident acuity and co morbidities. It only measures one category of care needs. 18 6
MOHLTC Funding Envelopes MOHLTC Levels of Care Funding Model An annual per diem funding/resident/day is adjusted based on the home CMI and the per diem is based on a CMI of 100. Nursing and Personal Care (NPC) tied to per diem April 1, 2018 $100.91, plus $2.03 RPN per diem. Program and Support Services (PSS) tied to per diem April 1, 2018 $9.79. Other Accommodations (OA) tied to per diem April 1, 2018 $55.28. Raw Food tied to per diem not to CMI $9.00. 19 MOHLTC Funding Envelopes MOHLTC Levels of Care Funding Model Nursing and Personal Care (NPC) direct care staff, nursing and medical equipment. Program and Support Services (PSS) program staff, therapy, recreation equipment and supplies. Other Accommodations (OA) wages, equipment and supplies for dietary, laundry and housekeeping and furnishings, operating, maintenance and administration costs. Raw Food raw food and nutritional supplements. 20 Resident Co Payment Room Rates Maximum Room Rates July 1, 2018 A portion of the envelopes are paid by resident co payments for meal and accommodation costs (room and board): Basic $1,848.73 per month (July 1, 2018: basis daily rate x1+cpi=2018 co payment) Semi Private $2,228.63 per month Long Stay $2,640.78 Short Stay $39.34 per day 21 7
MOHLTC Funding Envelopes MOHLTC Levels of Care Funding Model Annual LTCH Service Accountability Agreement (L SAA) based on assigned CMI for CMI year of April 1 March 31. If CMI is <100 receive lower per diem if > 100 receive higher per diem. This revenue related funding is LHIN managed. http://health.gov.on.ca/en/public/programs/ltc/lsaa_policies.as px 22 Supplemental Funding Streams MOHLTC Direct Funding Revenue Related Accreditation change in provider. Pay Equity Funding 2003 agreement with union proxy pay equity covering Jan. 1/99 Dec. 31, 2005. High Wage Transition Funding increases in salaries and benefits. Lab Services Funding phlebotomy $55 per session and courier $25. Municipal Tax Allowance 85% reimbursement (nonmunicipal homes only). 23 Supplemental Funding Streams MOHLTC Direct Funding Capital Related Construction Costs 2015 manual with specifications and subsidy policy. The following are claims based: Accreditation. High Intensity Need. Municipal Taxes. Construction. 24 8
The Difference Not For Profit vs For Profit LTC Homes Additional Sources of Funding Not For Profit Municipal taxes provide for other sources of funding. Property tax relief. All envelope funding is spent on resident care, none is withheld for profits. Results in better staffing, better quality home environment, adequate supplies. LTC homes have six months after March 31 to reconcile their annual LHIN financial statement, this allows them to move the monies around to balance the NPC and PSS envelopes and maintain OA as profit. 25 Nursing Initiatives Government Funding New Graduate Guarantee funding for full time positions with benefits for 7.5 months new program 2016 2017 $33 million. Late Career Initiative 2016 2017 allocated $2 million age 55 + break from physical aspects of bedside nursing. Behaviour Supports Ontario (BSO) 2018 $10 million in funding for BSO to help residents with dementia and other complex behaviours and neurological conditions. 26 Recent LTC Funding Announcement April 2018 Budget Unconfirmed Pending Election June 7 Build 5,000 new beds by 2022, >30,000 new beds over the next decade, includes 500 new beds for indigenous communities, >1,500 new beds for specific cultures, including francophone, in addition to the 30,000 existing beds that are being redeveloped. $50 million out of $300 million over three years to hire one RN at every home, and increase the provincial average to four hours of resident care per day by 2022. Ensure staff with specialized training in behavioural supports, palliative and end of life care. 27 9
Recent LTC Funding Announcement April 2018 Budget Unconfirmed Pending Election June 7 Other measures in the budget aimed at residents in LTC that raise overall base funding to 3.5 per cent, include: 6 per cent increase in the annual food budget. A further $10 million investment in the BSO program to improve dementia care including training for all staff. $5 million for high intensity needs funding. $8 million for equipment to prevent resident falls and injuries. 2 per cent increase for convalescent care. 28 Ideas for Next Steps to Make Employers Show Me the Money 1. Require discussion and a copy of the annual L SAA annually, include quarterly financials and request Annual Report (Financial Reconciliation & Recovery) most collective agreements require a LTC Home Service Accountability Agreement (L SAA). 2. Ask for copies of other funding agreements, e.g., BSO. 3. Discuss government initiatives or new funding allocations at each Union Management Committee. 4. Request disclosure in a layoff or elimination of financial statements, agreements and the quarterly RAI MDS Submissions submitted to CIHI. 29 Questions? Show Me the Money Funding in LTC Homes 30 10
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