OFFICIAL NOTICE AND AGENDA - PDF Free Download

OFFICIAL NOTICE AND AGENDA of a meeting of the Nursing Home Operations Committee to be held at North Central Health Care, 1100 Lake View Drive, Wausau, WI 54403, Board Room at 7:30 am on Monday, October 31 st, 2016 In addition to attendance in person at the location described above, Board members and the public are invited to attend by telephone conference. Persons wishing to attend the meeting by phone should contact Debbie Osowski at 715-848-4405 24 hours prior to the start time of the meeting for further instructions. Any person planning to attend this meeting who needs some type of special accommodation in order to participate should call the Administrative Office at 715-848-4405. For TDD telephone service call 715-845-4928. AMENDED AGENDA 1. Call to Order 2. Public Comment for Matters Appearing on the Agenda 3. ACTION: Approval of 9/23/2016 Nursing Home Operations Committee Meeting Minute 4. Review of the Proposed 2017 Budget for Nursing Home Operations a. ACTION: Consideration of Alternate Service Delivery Model for Mount View Care Center to Balance the 2017 Nursing Home Operations Budget 5. Financial Report 6. Senior Executive Nursing home Operations and Quality Report K. Gochanour a. Demonstrated quality d. Regulatory compliance b. Fiscal responsibility e. Resident/family expectations c. Strong human relations 7. NCHC Comparison with Nation-wide Long Term Care Workforce Crisis K. Gochanour 8. Update on CNA Wages/ Long Term Care Workforce Crisis K. Gochanour/B. Glodowski/S. Matis 9. DON Position Statement K. Gochanour 10. Nursing Home Renovation Plan discussion K. Gochanour 11. Overview of Annual Survey and Plan of Correction K. Gochanour 12. Discussion of Future Agenda Items 13. Adjourn Presiding Officer or Designee NOTICE POSTED AT: North Central Health Care COPY OF NOTICE DISTRIBUTED TO: Wausau Daily Herald, Antigo Daily Journal, Tomahawk Leader, Merrill Foto News, Langlade, Lincoln & Marathon County Clerks Offices DATE: 10/27/16 TIME: 4:00 p.m. BY: D. Osowski

NORTH CENTRAL COMMUNITY SERVICES PROGRAM NURSING HOME OPERATIONS COMMITTEE MEETING MINUTES September 23, 2016 8:00 A.M. NCHC Wausau Campus Present: EXC Jean Burgener X Bill Metter X Bill Miller X John Robinson X Margaret Donnelly Also Present: Kim Gochanour, Brenda Glodowski, Becky Schultz, Craig McEwen The meeting was called to order at 8:03 a.m. Public Comments No comments were made. Minutes Motion/second, Robinson/Miller, to approve the 8/19/16 Nursing Home Operations Committee meeting minutes. Motion carried. Financial Report Nursing home showed a loss for August but it was less than the previous month. Nursing home census improved with an average of 204; Medicare was stable at 19. September census has improved again averaging 206 to date with Medicare at an average of 20. Expenses are below target overall in August. Biggest hurdle is with health insurance due mostly to several unusually high cost claims. We are evaluating our stop loss, working on plan design changes for 2017. Received the most number of referrals this month, 82, with 31 admissions. We are aware of several individuals who chose other facilities mostly due to location; majority went to Wausau Manor, Rennes, or Colonial Manor. Some had already been at these places and decided to return. Seeing a good month with admissions in September; beginning to see a good trend. Referral sources from other facilities are often times Medicaid (about 75%). Wisconsin is one of the lowest reimbursing states for Medicaid. We continually work to educate legislators as to why reimbursement needs to be increased. We are focusing on where we can meet the needs of individuals due to staffing. We have a 25 bed Medicare rehab unit; if it is full it is not ideal to place them on the long term care unit. With semi private rooms individuals choose to go elsewhere for a private room. Received 7 vent referrals and admitted 2 based on bed availability. Legacies is considered long term care but is memory specific; 107 beds and budgeted at 100; currently running 102. Upstairs budget is 64 currently at 58. Southern Reflections has open beds. Northwinds Vent has 27 beds with 26 full; and 25 beds on South Shore (rehab unit) with 5 openings currently. Anticipate our annual survey at any time. Wisconsin s top 10 federal citations were reviewed. MDS is changing in October. The MDS determines how we are reimbursed.

The survey process is changing in 2017; anticipate a combination between our current standard survey with additional focus on quality indicator measures. o What is the significance of a survey and why is it important to us? Survey is how we are measured in the industry and it determines quality of care which can impact admissions, financials, civil money penalties, CNA training, Star rating, etc. Senior Executive Nursing Home Operations and Quality Report We are part of Aspirus Post Acute SNF affiliation group and will meet regularly. Information on upcoming meetings will be forwarded. A presentation could be provided later this year. Need to educate Marathon County on what the implications are if they move toward splitting the nursing home off from NCHC i.e. how this will affect residents, employees, etc. Brenda and Michael are talking with Brad Karger and Kristi Kordus on the details of the nursing home. The Long Term Care Workforce Crisis This a joint effort between WHCA (Wisconsin Health Care Association) and Leading Age (organization of non profit and county homes) talking about the workforce crisis i.e. the lack of people going into the healthcare industry. Press releases have been received regarding what changes in legislation are being requested regarding reimbursement to long term care facilities. Local legislators need to be contacted. o The January WACH annual conference will be another opportunity to talk to legislators. o It was suggested to invite legislators to NCHC during winter months. Kim and John will work together for an event with legislators at NCHC. o Margaret added that everyone in health care takes a loss with Medicaid. However, in the past we were able to balance it with Medicare and private insurance. Now, with the length of stay on patients reduced from 30 to 12 and with CMS bundled payments, the push will be not to admit to a skilled nursing facility (SNF) but rather to the home environment. Potentially 1:1 home care will be cheaper than in the hospital and SNFs. With Family Care the push is to keep individuals in assisted living and home health settings but the concern is for safety; lack of requirements for CNA s., etc. Kim will explore if additional information is available on how NCHC compares nationwide to the workforce crisis. We are currently in a staffing crisis mode with 33 CNA and 8 nursing position openings. Aggressive recruitment measures have been in progress for over a year; wage studies and comparisons completed, paying premium level wage higher than other area nursing home s with a $1000 sign on bonus. Unfortunately, we have not had many applications for CNA s and the need is great to hire additional staff. Currently staff is being asked to work 12 hour shifts, an on occasion up to 16 hours, and are burnt out. Looking at creative staffing, work/life balance, Senior Workforce program, etc. Admissions will be held on long term care units until staffing improves. Workforce philosophy has changed where the employee dictates when they can work vs employers dictating hours. Also discussing wage increase for staff but may not be across the board due to current financial situation; need to keep high performers and front line direct care givers. The past nine months have been very tough with the instability of the relationship between NCHC and the county.

Committee expressed concern with the number of work hours being required of staff and that a policy should be developed that there will not be shifts longer than 12 hours. Committee requested a proposal be developed on what it would take to maximize shift no more than 12 hours, cost of an improvement plan, impact to bottom line, and long term prospects. Also, look at context of living wage ($15.25/hour) what the cost of implementing a living wage would be including impact on reducing overtime, enhancing tenure, etc. Education for CNA s on the floor is being reviewed. We all tend to recruit from the same pool. Somehow we need recruit outside of Marathon County even considering exploring recruitment on an international level i.e. training, pay for certification, coordinated housing, etc. Leading Choice Network Update See Leading Choice Network PowerPoint slide information in meeting packet. Brenda will be attending the annual meeting, trying to participate on committees and have voice at the table. Motion/second, Robinson/Miller, to adjourn the Nursing Home Operations Committee meeting at 9:02 a.m. Motion carried. dko

North Central Health Care Nursing Home Combined Statement of Revenue and Expenses For the Period Ending September 30, 2016 Current Current Current Month 6155 Month 6300 Month YTD 56029 YTD 57540 YTD Prior Acutal PPD Budget PPD Variance Actual PPD Budget PPD Variance YTD 56933 (PPD) (PPD) Actual PPD Revenue Net Patient Services Revenue: Daily Services $1,516,706 $1,504,628 $13,439,148 $13,724,631 $13,505,475 Ancillary Services $590,488 $536,000 $4,562,700 $4,824,000 $4,532,532 Total Net Patient Services Revenue $2,107,194 $342.35 $2,040,628 $323.91 $18.45 $18,001,848 $321.30 $18,548,631 $322.36 ($1.07) $18,038,007 $316.83 Other Revenue County Appropriation $141,666 $141,666 $1,275,000 $1,275,000 $1,275,000 Department and Other Revenue $239,369 $31,296 $624,270 $281,660 $330,887 Total Other Revenue $381,035 $61.91 $172,962 $27.45 $34.45 $1,899,270 $33.90 $1,556,660 $27.05 $6.84 $1,605,887 $28.21 Total Revenue $2,488,229 $404.26 $2,213,590 $351.36 $52.90 $19,901,118 $355.19 $20,105,291 $349.41 $5.78 $19,643,894 $345.04 Expenses Direct Expenses $1,774,357 $1,612,374 $15,578,019 $14,619,364 $14,531,005 Indirect Expenses $720,177 $602,325 $5,411,318 $5,463,575 $5,506,237 Total Expenses $2,494,534 $405.29 $2,214,699 $351.54 $53.75 $20,989,337 $374.62 $20,082,939 $349.03 $25.59 $20,037,242 $351.94 Donations and Gifts $1,049 $0 $6,023 $0 $5,648 Nonoperating Gains/(Losses) $0 $0 $0 $0 $0 Total Nonoperating Gains/(Losses) $1,049 $0.17 $0 $0.00 $0.17 $6,023 $0.11 $0 $0.00 $5,648 $0.10 Excess Revenue (Expenses) ($5,256) ($0.85) ($1,108) ($0.18) ($0.68) ($1,082,196) ($19.31) $22,353 $0.39 ($19.70) ($387,700) ($6.81)

NORTH CENTRAL HEALTH CARE MEDICARE DAYS BY RUG CATEGORY 2016 ACTUAL BUDGET ACTUAL BUDGET YTD YTD YTD YTD RUG RUG DAYS DAYS REVENUE REVENUE ACTUAL BUDGET ACTUAL BUDGET CATEGORY RATE September September September September DAYS DAYS REVENUE REVENUE RUX $735.29 0 19 $0 $13,900 35 173 $25,735 $126,953 RUL $719.27 0 0 $0 $0 0 0 $0 $0 RVX $654.47 13 0 $8,508 $0 57 0 $37,305 $0 RVL $587.18 0 0 $0 $0 0 0 $0 $0 RHX $592.95 0 0 $0 15 0 $8,894 $0 RHL $528.87 0 0 $0 $0 33 0 $17,453 $0 RMX $543.93 8 0 $4,351 $0 22 0 $11,966 $0 RML $499.06 0 0 $0 $0 0 0 $0 $0 RLX $477.68 0 0 $0 $0 0 0 $0 $0 RUC $557.44 43 43 $23,970 $24,054 448 394 $249,733 $219,692 RUB $557.44 79 77 $44,038 $43,068 983 706 $547,964 $393,354 RUA $466.11 0 25 $0 $11,493 245 225 $114,197 $104,971 RVC $478.22 155 85 $74,124 $40,485 912 773 $436,137 $369,762 RVB $414.12 40 134 $16,565 $55,333 571 1221 $236,463 $505,737 RVA $412.52 50 52 $20,626 $21,361 378 473 $155,933 $195,094 RHC $416.70 66 21 $27,502 $8,562 178 188 $74,173 $78,203 RHB $375.04 22 27 $8,251 $10,172 254 248 $95,260 $92,907 RHA $330.18 25 17 $8,255 $5,699 202 158 $66,696 $52,051 RMC $366.07 0 27 $0 $9,779 161 244 $58,937 $89,311 RMB $343.64 19 14 $6,529 $4,943 47 131 $16,151 $45,144 RMA $282.76 37 13 $10,462 $3,718 85 120 $24,035 $33,962 RLB $355.92 0 0 $0 $0 0 0 $0 $0 RLA $229.33 0 0 $0 $0 0 0 $0 $0 ES3 $671.29 0 72 $0 $48,002 429 653 $287,983 $438,417 ES2 $525.48 14 0 $7,357 $0 95 0 $49,921 $0 ES1 $469.40 0 0 $0 $0 0 0 $0 $0 HE2 $453.38 0 0 $0 $0 0 0 $0 $0 HE1 $376.47 0 0 $0 $0 18 0 $6,776 $0 HD2 $424.54 0 0 $0 $0 0 0 $0 $0 HD1 $354.04 0 14 $0 $5,092 71 131 $25,137 $46,510 HC2 $400.51 0 0 $0 $0 0 0 $0 $0 HC1 $334.81 12 6 $4,018 $2,064 32 56 $10,714 $18,850 HB2 $395.70 0 0 $0 $0 0 0 $0 $0 HB1 $331.60 0 0 $0 $0 52 0 $17,243 $0 LE2 $411.72 0 0 $0 $0 0 0 $0 $0 LE1 $344.62 0 7 $0 $2,266 10 60 $3,446 $20,696 LD2 $395.70 0 0 $0 $0 0 0 $0 $0 LD1 $331.60 0 7 $0 $2,453 12 68 $3,979 $22,403 LC2 $347.63 0 0 $0 $0 0 0 $0 $0 LC1 $293.15 0 0 $0 $0 29 0 $8,501 $0 LB2 $330.00 0 0 $0 $0 0 0 $0 $0 LB1 $280.33 1 0 $280 $0 6 0 $1,682 $0 CE2 $366.86 0 0 $0 $0 0 0 $0 $0 CE1 $338.02 0 0 $0 $0 9 0 $3,042 $0 CD2 $347.63 0 0 $0 $0 0 0 $0 $0 CD1 $318.79 0 0 $0 $0 25 0 $7,970 $0 CC2 $304.37 0 0 $0 $0 0 0 $0 $0 CC1 $281.94 0 0 $0 $0 16 0 $4,511 $0 CB2 $281.94 0 0 $0 $0 0 0 $0 $0 CB1 $261.10 0 0 $0 $0 10 0 $2,611 $0 CA2 $238.68 0 0 $0 $0 0 0 $0 $0 CA1 $222.65 10 11 $2,227 $2,379 27 98 $6,012 $21,728 BB2 $253.10 0 0 $0 $0 0 0 $0 $0 BB1 $241.87 0 0 $0 $0 0 0 $0 $0 BA2 $209.84 0 0 $0 $0 0 0 $0 $0 BA1 $200.22 0 0 $0 $0 8 0 $1,602 $0 PE2 $338.02 0 0 $0 $0 0 0 $0 $0 PE1 $321.99 0 0 $0 $0 0 0 $0 $0 PD2 $318.79 0 0 $0 $0 0 0 $0 $0 PD1 $302.76 0 6 $0 $1,866 0 56 $0 $17,046 PC2 $273.92 0 0 $0 $0 0 0 $0 $0 PC1 $261.10 0 14 $0 $3,605 45 126 $11,750 $32,929 PB2 $232.26 0 0 $0 $0 0 0 $0 $0

North Central Health Care Nursing Home Patient Days By Payor Mix-2016 January February March April Actual Budget Actual Budget Actual Budget Actual Budget Days % Days % Days % Days % Days % Days % Days % Days % Self Pay 809 12.56% 682 10.48% 797 13.39% 638 10.48% 910 14.30% 682 10.48% 775 12.64% 660 10.48% Commercial 473 7.34% 279 4.29% 487 8.18% 261 4.29% 435 6.84% 279 4.29% 383 6.25% 270 4.29% Medicare 760 11.80% 713 10.95% 537 9.02% 667 10.95% 645 10.14% 713 10.95% 669 10.91% 690 10.95% Medicaid 4399 68.30% 4836 74.29% 4132 69.41% 4524 74.29% 4373 68.73% 4836 74.29% 4304 70.20% 4680 74.29% Total 6441 100.00% 6510 100.00% 5953 100.00% 6090 100.00% 6363 100.00% 6510 100.00% 6131 100.00% 6300 100.00% Occupancy 86.6% 87.5% 85.5% 87.5% 85.5% 87.5% 85.2% 87.5% May June July August Actual Budget Actual Budget Actual Budget Actual Budget Days % Days % Days % Days % Days % Days % Days % Days % Self Pay 856 13.24% 682 10.48% 826 13.59% 660 10.48% 861 14.00% 682 10.48% 993 15.73% 682 10.48% Commercial 429 6.63% 279 4.29% 431 7.09% 270 4.29% 388 6.31% 279 4.29% 419 6.64% 279 4.29% Medicare 661 10.22% 713 10.95% 558 9.18% 690 10.95% 554 9.01% 713 10.95% 607 9.62% 713 10.95% Medicaid 4520 69.90% 4836 74.29% 4265 70.15% 4680 74.29% 4346 70.68% 4836 74.29% 4293 68.01% 4836 74.29% Total 6466 100.00% 6510 100.00% 6080 100.00% 6300 100.00% 6149 100.00% 6510 100.00% 6312 100.00% 6510 100.00% Occupancy 86.9% 87.5% 84.4% 87.5% 82.6% 87.5% 84.8% 87.5% Sept October November December YTD Actual Budget Actual Budget Actual Budget Actual Budget Actual Budget Days % Days % Days % Days % Days % Days % Days % Days % Days % Days % Self Pay 914 14.85% 660 10.48% 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 7741 13.82% 6028 10.48% Commercial 429 6.97% 270 4.29% 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 3874 6.91% 2466 4.29% Medicare 593 9.63% 690 10.95% 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 5584 9.97% 6302 10.95% Medicaid 4219 68.55% 4680 74.29% 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 38830 69.30% 42744 74.29% Total 6155 100.00% 6300 100.00% 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 56029 100.00% 57540 100.00% Occupancy 85.5% 87.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 85.2% 87.5%

Referral Date Source of Reference Vent Admitted Admission Date if Reason if Not Admitted Payer Source Admitted 9/1/16 Bellin Health, Green Bay No No no room r/t staffing 9/2/16 STC No No 9/7 Dc to Colonial Manor 9/2/16 AWH No No 9/5 D/c to UW Madison 9/2/16 AWH No Yes 9/9/16 Mediare (A) Managed Care 9/2/16 AWH No No Going to Stoney River Medicare A Manage Care 9/2/16 AWH No Yes 9/3/16 Medicare A 9/2/16 AWH No Yes 9/6/16 Medicare A 9/4/16 STC No No Went to Benedictine 9/5 Medicare Part A&B 9/5/16 STC No No Out of county 9/5/16 BHS No Yes 9/21/16 Medicare A 9/5/16 BHS No Yes 9/21/16 Medicare A 9/6/16 St Cloud Hospital No No Went to Aspirus Hospice House 9/9 Hospice? 9/7/16 STC No No 9/12 D/C back to Copper Leaf we have no room Tricare 9/7/16 AWH No Yes 9/12/16 Medicare A 9/7/16 AWH No No Couldn't accept d/t staffing Medicare Part A&B 9/7/16 Winnebago No Yes 9/7/16 Medicare A 9/7/16 STC No Yes 9/8/16 Medicare A Manage Care 9/7/16 STC No No No out of county Arise Health Plan 9/8/16 AWH No No 9/10 Dc to Wausau Manor we couldn t accept d/t staffing VA 9/8/16 STC Yes Yes 9/9/16 Medicaid Hospice 9/8/16 Atrium No No No LTC available Medicaid 9/9/16 AWH No Yes 9/9/16 Insurance 9/9/16 AWH No No Not an appropriate neighborhood Insurance 9/9/16 AWH No Yes 9/13/16 Insurance 9/12/16 AWH ED No No No coverage(no3 day stay) DC to Azura Memory Care Medicare 9/12/16 StClares No Yes 9/13/16 Medicare A Manage Care 9/13/16 AWH No No out of county Medicaid/CCCW 9/13/16 StClares No No high acuity/low staffing Medicare A 9/13/16 StJoes/Family No No out of county/needs long term care Medicare A Manage Care 9/13/16 Mendota Mental Health Institute No No out of county Private Pay 9/14/16 Select Specialty Madison No No out of county/no NWV room Medicare A 9/14/16 Select Specialty West Allis Yes No No NWV room Medicare A Manage Care 9/14/16 AWH No No no room d/t staffing Medicare A Manage Care 9/14/16 Stoney River Rehab No No no room on LTC Medicaid 9/14/16 AWH No No out of network Humana MC 9/15/16 AWH No Yes 9/16/16 Medicare A 9/15/16 AWH No No out of network Humana MC 9/15/16 AWH No No returned to group home w/hospice Medicare A 9/16/16 AWH No No DC to home w/wife Medicare A 9/16/16 StClares No No low staffing on PAC 9/16/16 BHS No No unable to meet needs(hyper verbal/sexual, pacing) Medicare A 9/17/16 AWH No No DC to Inpatient Rehab Managed MA

Referral Date Source of Reference Vent Admitted Admission Date if Reason if Not Admitted Payer Source Admitted 9/18/16 AWH No Yes 9/19/16 Medicare A 9/19/16 Golden Living Tomahawk No No out of county/legacies beds tight Medicaid 9/19/16 AWH ED No No went to an ALF(no coverage here no 3 day stay) Private Pay 9/19/16 StClares No No out of county/legacies beds tight 9/19/16 ThedaCare Shawano No No out of county/legacies beds tight 9/19/16 StJoes/Family No No out of county/legacies beds tight VA 9/19/16 AWH No Yes 9/20/16 Medicare A 9/19/16 Select Specialty Madison Yes No No NWV room/low staffing Medicare A 9/19/16 AWH No No DC to Colonial Manor(closer to home) Medicare A Manage Care 9/20/16 AWH ED No No no coverage/can't pay 30days upfront(30 day mandate) Private Pay 9/20/16 AWH No Yes 9/21/16 Medicare A 9/20/16 Select Specialty Madison Yes No low NWV staffing Medicare A 9/20/16 AWH No Yes 10/9/16 Medicare A 9/21/16 The Renaissance No No No LTC available/not appropriate for Legacies Private Pay 9/21/16 AWH No No D/C to Wausau Manor(family preference) Medicare A 9/22/16 StJoes No No out of network/out of county Humana MC 9/22/16 AWH No Yes 9/22/16 Medicare A 9/22/16 Aspirus HOSPICE No No going to Hospice House VA 9/22/16 Select Specialty Madison Yes No low NWV staffing Medicare A 9/22/16 AWH No No expired 9/30/16 @ AWH none 9/23/16 AWH No No low PAC staffing Medicare A 9/23/16 AWH No Yes 9/26/16 Medicare A 9/23/16 StClares No No D/C to Bethel Ctr (we have no beds) Medicaid 9/23/16 Madison VA Hospital No Yes 9/30/16 VA 9/23/16 AWH No Yes 9/30/16 Medicare A Manage Care 9/25/16 StClares No No D/C to Pride TLC Medicare A Manage Care 9/26/16 AWH No No No NH benefit out of network Humana MC 9/26/16 StClares No No D/C to Atrium 9/28 Managed MA 9/26/16 AWH No No D/C to Wausau Manor Medicare A Manage Care 9/26/16 StClares No No D/C to Wausau Manor(was there before,closer to family) Medicare A 9/27/16 AWH No No Patient refused SNF Medicare A 9/27/16 AWH No No D/C to Wausau Manor 9/28/16 Medicare A 9/27/16 AWH No No D/C to BHS 9/29/16 Medicare A Manage Care 9/28/16 Vibra Hospital, IL yes No no beds available Medicare A/VA 9/28/16 AWH No Yes 10/4/16 Private Pay 9/28/16 StJoes No No Not an appropriate bed to ensure his needs none 9/29/16 Froedert Milw yes No can't meet needs noncompliant/family drama Managed MA 9/29/16 AWH No No D/C to Wausau Manor 10/4/16 Medicare A Manage Care 9/29/16 AWH No No wound care/dialysis/out of county Medicare A 9/29/16 AWH No No D/C to Benedictine Medicare A 9/30/16 AWH No No out of network Managed MA

Number of Referrals Received December January February March April May June July August September October November Year 2015 80 54 79 40 68 63 59 67 77 77 66 46 2016 61 69 70 36 57 40 38 82 83 90 80 70 60 50 Year 40 30 2015 2016 20 10 0 Number of Referrals Received

November December Number of Vent Referrals Received Number of Vent Referrals Admitted June July August September October November December June July August September October Year Year 2016 8 3 7 7 2016 0 0 2 1 9 8 7 6 5 4 3 Series1 2 1 0 2.5 2 1.5 1 0.5 0 Series1

January February March April Percentage of Referrals Admitted May Year 2015 53.80% 51.90% 44.30% 45.00% 40.60% 39.70% 44.10% 37.30% 20.80% 44.20% 47.00% 19.60% 2016 42.60% 43.50% 38.60% 58.33% 36.84% 25.00% 50.00% 37.80% 27.00% June July August September October November December 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% Year 2015 2016 10.00% 0.00% Percentage of Referrals Admitted

2016 Referrals Who Didn't Admit January February Year We're Full 0 0 4 3 1 4 3 8 5 Went to Another Facility 20 15 16 3 13 9 6 24 20 Discharged Home 4 3 3 0 2 1 2 0 0 Out of Network 1 3 4 3 2 1 0 2 5 Insurance Didn't Authorize 0 3 0 0 0 0 0 2 2 Out of County 3 1 5 4 8 5 2 3 12 Acuity/Needs to High 3 5 7 0 6 7 3 4 4 Refused SNF 0 1 0 0 1 0 1 1 1 No Skilled Needs 0 1 1 2 0 0 0 2 0 Expired 2 6 1 0 2 1 2 2 1 Other (didn't like room, r/t prev hx here, staffing) 2 1 2 0 1 2 0 3 11 TOTAL 35 39 43 15 36 30 19 51 61 March April May June July August September October November December 70 60 50 40 30 20 10 0 We're Full Went to Another Facility Discharged Home Out of Network Insurance Didn't Authorize Out of County Acuity/Needs to High Refused SNF No Skilled Needs Expired Other (didn't like room, r/t prev hx here, staffing) TOTAL January February March April May June July August September October November December

LeadingChoice Network October 2016 Annual Meeting We want to thank all of our members who attended LeadingChoice Network s First Annual Meeting. There was a lot of information covered at the meeting from Roles and Responsibilities of LCN Members to basic training on antitrust laws presented by Rob Heath and John Kramp from Reinhart Law to LCN s 2016 2017 Strategic Plan. An email was sent on September 29 th with the PowerPoint presentation to the Member Representative for each Member organization. You can request the PowerPoint again from Stacy at assistant@leadingchoice.net. Health Plan Contracts Here is an update of our status with the Health Plans we have been negotiating with. Health Plan Status Gundersen Credentialing completed. We are signing it tomorrow, Friday, the 21st Molina Agreement on terms, credentialing documents are going out to not yetcredentialed facilities very soon. We recently learned that their Commercial coverage area is much larger than their Medicare Advantage coverage area (see map below), so many more LCN facilities will be included in this contract than initially thought. Unity Pending Negotiations; they want to work on contract in Jan, 2017 Health Partners Security United Health / Optum United Sierra Network Health Humana Medica Dean The Blues Pending Negotiations; they are still determining if they will expand network. Discussions will likely continue into November. Pending Negotiations; while we are trending in the right direction, discussions are on going regarding performance requirements to remain in their network. Although discussions remain on going, they are likely in the final stages and we do not have an agreement on a SNF contract for 2017. If no agreement is in place, we will continue to meet with and share data with UHC throughout 2017 in preparation for a 2018 contract. Delayed through 2017; we will continue to meet with and share data in preparation for a 2018 contract. The 120 Day negotiating window for LCN has been called off (see section below describing the 120 Day Provision) They have backtracked from an initial verbal agreement and have indicated they are not interested in a contract with LCN for 2017. We will make one more attempt. If it is not successful, we will cancel the 120 Day window. An update will be provided next week. Agreement on terms, credentialing is on going Pending negotiations; discussions are ongoing and positive. Pending negotiations; discussions are likely to continue into November

Molina Coverage Area 120 Day Provision The following is a description of the 120 Day Provision process for LCN s exclusive negotiating window. Participant shall not conduct any negotiations with particular Health Plans or enter into any agreements with those Health Plans while Network is conducting negotiations with those Health Plans. Network shall notify Participants in writing when negotiations with a Health Plan begin and end, and the length of such Network negotiations with a Health Plan shall not exceed one hundred twenty (120) days. Clinical Protocols and Best Practices INTERACT (Interventions to Reduce Acute Care Transfers) Implementation As stated in our previous webinars and news bulletins, our first Best Practice is INTERACT. Based on the results of a recent online survey, we have identified SNFs in the first stage of implementing INTERACT. We will begin scheduling regional workshops for the INTERACT Champions in these Stage 1 facilities. At that time, we will present an action plan. Once those facilities have completed Stage 1, we will conduct another round of regional workshops that includes all LCN SNF s Champions. In the meantime, if your facility would like assistance with your implementation of INTERACT, Susan Peterson is LCN s clinical consultant and is available. You can contact the LCN office or Susan directly at susan.peterson3@comcast.net. Submitting Data When we sent out our Readmission Metrics Surveys to the INTERACT Champions, we also sent out the INTERACT Hospital Readmissions Rate Tracking Tool spreadsheet. If you are currently tracking readmissions with another method but still using the INTERACT calculations, for instance through your EMR, you are not required to complete the Hospital Readmissions Rate Tracking Tool. No need for duplicate data entry. We will be asking SNFs to submit for monthly summary data on readmissions. We will also be scheduling a webinar in the near future to assist facilities implementing the INTERACT Hospital Readmissions Rate Tracking Tool.

Operational Updates Website and Email We have officially rolled out our website (www.leadingchoice.net). There will be changes throughout the year to our site as more information is updated. Please note that LCN does not have a secure email system, so do not send any patient data that could be a HIPPA violation. LCN Email Salutation Dictionary Given the large number of emails from LCN, a definition of the salutations we are using may be helpful. We will be using the following titles when sending out our emails: Dear Member Representatives these are our contacts for each of LCN s 67 member organizations, typically CEOs or Administrators Dear SNF Leadership and Administrators these are our contacts for each of LCN s 89 SNFs, typically Administrators Dear Senior Housing Leadership these are our contacts for each of LCN s 150 senior housing facilities While we have a complete list of Member Representatives, the other two lists are largely incomplete. A separate email will be sent to Member Representatives asking for the names and emails of their SNF Leader(s)/ Administrator(s) and Senior Housing Leader(s). Changes to Facilities If your facility has a change in how many beds or units it has, or if there is a change in Administration or Leadership, please make sure to email Stacy (assistant@leadingchoice.net) so that we can make sure to update our database.

Nursing Assistant Shortage Complicated by Wisconsin Regulation The Wisconsin Director of Nurse Council, (WDONC) represents nursing leaders in Skilled Nursing, Assisted Living, Hospice and other Long-Term Care Facilities. Our members are Directors of Nursing, Assisted Directors of Nursing, Staff Development, Nurse Managers, Administrators, Suppliers and Consultants, among others who are looking to advance nursing in the continuum of care. Our purpose in sharing a position paper on the healthcare worker crisis facing the long term care industry is to heighten awareness specifically on the Certified Nurse Aide (CNA) shortage. Our organization believes that this shortage has been directly impacted by the rules and regulation imposed by the State of Wisconsin through it s regulation of nurse aide training requirements. Although according to studies this staffing crisis is multifaceted the WDONC has chosen to focus on revised legislation to positively impact this issue. Indirectly this will also decrease the cost to the Wisconsin Medicaid program. Impacting the availability of nursing assistants will in turn assist us in resolving the turnover of nursing leadership in long term care which can directly be tied to the quality of care that is delivered to the states most vulnerable citizens. The WDONC is proposing the elimination of the 120 hours nursing assistant training requirement and a return to the federally mandated 75 hour requirement. This change will increase the financial ability of individuals interested in healthcare careers to enter the field in a time frame that is comparable to other entry level positions, will decrease the financial burden on the individual and still adequately prepare them for entry as a health care worker providing basic cares to Wisconsin citizens in need of care in long term care continuum due to illness and/or disability. Training programs should still be allowed to determine the hours that they wish to train nursing assistants as they were prior to the implementation of the legislation requiring the 120 course. But the legislation should only mandate the federal requirement of 75 hours.

History: In 1987 the federal government enacted the Omnibus Reconciliation Act or OBRA. In that regulation 75 hours of training were mandated for nursing assistants before they could work in federally certified nursing homes. This mandate was to assure basic training for entry level healthcare workers. Wisconsin s statutory regulation related to nursing aide training is DHS Chapter 129. In 2008 the Wisconsin Rule was changed to require 120 hours of training as opposed to the federally mandated 75 hours. In 2013 Act 357 was passed in an effort to bridge the ability of CNAs from other states to obtain certification in Wisconsin if they were already certified it other states. It provided direction to accept certification from other states if the individual had been trained; competency tested and worked 2088 hours. It also provided for the ability to created a shortened training course consisting of an additional 45 hours allowing CNAs from other states that did not have the work experience to gain the additional hours without having to take an entire 120 hours course. Facts: The healthcare worker shortage that encompasses both licensed nurses and CNAs has well documented with studies dating back to 2008. The study completed in 2008 projected a continue need for additional workers secondary to the increased demand for long term assistance by the aging of America. The Wisconsin Hospital Association in 2014 reported vacancies in hospitals at 7.1 percent for CNA positions. Today, 2016 a study conducted by Leading Age, Wisconsin Healthcare Association, Wisconsin Assisted Living Association and Residential Services Association of Wisconsin reported vacancies of 14.5 percent in the caregiver category. This report also notes that the CNAs entering the healthcare career is continuing to decline with statistic showing 24% less individuals applying for certification and a decline of 5.431 in individuals renewing their CNA certification. There is no doubt the staffing problem exists. Finding solutions for these shortages in the long term care environment is complicated by poor wages, underfunding of the Medicaid program and workforce numbers in total but it is further crippled by self imposed regulatory requirements above the minimum standards set forth by the federal government. DHS 129 requires 120 hours of training to become a certified nursing assistant in the state of Wisconsin. Our neighboring states of Minnesota, Michigan and Iowa require only the 75 hour course for certification. Individuals from these neighboring states are not recognized as being adequately prepared to work in Wisconsin unless certain other criteria are met. This criteria is so burdensome that many trained individuals work in fields other than healthcare due to wage disparity, difficult entry into the healthcare workforce due to regulatory issues surrounding certification and the need to earn a living immediately. To enter the healthcare industry as a Certified Nursing Assistant the individual must apply and be accepted into an approved nursing assistant course. These courses are approved and

monitored by state of Wisconsin to assure compliance with the standard set forth in DHS 129. The applicant is paying on average $700 for this course. If the course is offered through the technical college environment there is often additional student fees incurred. The applicant then must successfully complete the course by attending and then passing both a written and skills test. The courses are offered in an accelerated fashion with completion within a month attending classes full time, may be conducted by semester or other offering to meet the individual needs. After the course is completed a state approved competency test is conducted costing $110.00 plus approximately $8.00 in additional fees. This evaluation consists of both a written and skills test. Wait time for testing times varies throughout the state but is reported by the State of Wisconsin to be in an acceptable range of on average 2 weeks. This leaves the individual seeking an entry level position out of the healthcare industry for a minimum of 6 weeks. Points of Discussion: The implementation of an increase in training was with the good intention of improving the quality of care to the elderly and disabled in Wisconsin. Through federally reported quality indicators there is no documentable impact on the quality provided that can be linked to increased staff training in the state of Wisconsin. There is no evidence that longer training has impacted the quality of care. What is documented is that nursing leadership retention directly impacts the quality of care. Citations in nursing homes at the highest level called immediate jeopardy are at record levels with only 2008 being higher. Therefore, the intended purpose of the increased training hours for nursing assistants has failed. Entry level positions in other fields are often associated with no time commitment for training and better wages. Therefore, the employable seek jobs that provide income immediately, especially if their primary reason for being in Wisconsin seeking employment is to supplement them as they complete their education in one of Wisconsin Colleges. Nursing homes in particular are already mandated through regulation to assure that care is being provided by properly trained and qualified individuals. The responsibility to meet this regulation is on the employer not the State of Wisconsin. The long term care industry needs every individual interested in healthcare career to be able to enter that career with reasonable training and financial expectations. The Directors of Nurses in long term care have an unacceptable turnover rate which directly impacts the residents they care for. The WDONC in a study of 79 leaders in long term care found that 63% of them identified staffing as their number one challenge.

Recommendations: The WDONC supports the return to the 75 hour nursing assistant federal training requirement. This simple regulatory change from the required 120 hours to the 75 hour course: Will improve the ability of providers of Wisconsin s long term care to attract, hire and retain the much needed Certified Nursing Assistant. Will allow long term care facilities to provide the training that is necessary to meet the needs of their particular resident/client population. Will allow regulators to hold nursing homes accountable to well trained and qualified staff through existing federal regulations. Will decrease both the financial and time investment by the potential healthcare worker interested in entry level career opportunities. Will allow individuals certified in neighboring states to become certified and work in Wisconsin long term care without additional cost and time to the worker. It allows properly trained and willing workers to provide services to our elderly and disabled instead of seeking employment in other industries. This move will not resolve the entire healthcare worker shortage we are facing. Since 2008 we have done little to significantly impact the ability to attract healthcare workers we have only watched the crisis develop. Now that crisis is upon us, we must take action. Returning to the federally mandated training requirement of 75 hours can be that one thing that has an impact on both increasing the numbers of available trained and certified nursing assistants with the indirect effect of nursing leadership retention. This proposal does not ask for additional Medicaid dollars but make as reasonable request for less regulation.

Dear Leg slator My name is I am connected to long-term care in Wisconsin, because I am a Wisconsin's long-term care provider commun ty has a workforce crisis that is: o Leaving people with disabilities and the elderly without needed care Forcing businesses to close due to revenue losses or inability to hire Direct Care Workers lncreasing reliance on public assistance by Direct Care Workers due to low pay; and Jeopardizing sustainability of Wisconsin's Long-Term Care system The workforce issue is important to me because: I am asking you to support policies that strengthen the long-term care workforce-the Direct Care Workers who serve our most vulnerable Wisconsin citizens. Your support will help end this crisis! More information at: www.wiwo rkforcea I I ia nce.com My contact information is: Emailaddress: Add City/State_Phone: