DATE: December 1, 2004
PRESENT: Arthur Carlson, Larry Volz, Linda Borleske, Tom Bychinski, Paul Endres, Al Dippel, Joan Wheeler, Joan Fordham, Lowell Haugen, John Earl, Cindy Bodendein, Kerry Beghin, Jeanne Leeck, Bill Orth, Carol Jeffers, Sue Hebel, Diane Keylock, Kathy Schauf, Lisa Buttonow, Gene Wiegand
1 . Called to order at 8:30 a.m. by Art Carlson. The open meeting law requirements were met.
2 . Motion by Borleske, second by Volz to adopt the agenda. Motion carried.
3. Motion by Haugen, second by Endres to approve the minutes. Motion carried.
4. Chairman Carlson introduced Mr. Michael Thomas, Administrator of Manitowoc County Nursing Home.
Manitowoc County started the same process 8 years ago. At one time owned 2 nursing homes and eventually sold one. Sold to private sector which didn't work out well but eventually ended up in good hands. Kept the main nursing home that serves the "safety net" population which includes people who cannot receive services at other facilities due to their inability to pay or behaviors which prohibit them from being accepted at other facilities. County was committed to provide services for that population. The nursing home building was built in 1948 and had been remodeled and added on to in 1972. Building still didn't meet the needs of the population served today. Tax levy was steadily increasing. Was built for 300 and were running a census of about 180. Owned a Large, inefficient building, difficult to maintain, on 85 acres of land in a prime area of the city. County looked at whether or not they wanted to stay in the nursing home business. Building didn't meet the requirements of todays nursing home standards so had to get waivers every year for state survey. In the 1970's was primarily a Mental Health facility. When sold the other nursing home this one became more of a "standard" nursing home - accepted the Medicare, Alzheimer's clients etc. More of the population you would see in a typical county nursing home as opposed to a typical private nursing home. County homes are more likely to have residents with dementia (for example) who have unpleasant behaviors and would not be a good mix with other more typical nursing home residents. County realized they needed to serve the "safety net"population but the question became how. Very hard decision to make. Split the process in half and had one initial committee made up of two citizen members and six county board supervisors. First discussed the question of whether or not to stay in the nursing home business. Was very difficult and emotional for many people. Committee talked about building or closing down the nursing home. Also became an issue for employees and family members. Had a Keefe Study as well as two others for a total cost of $165,000. Studies were interesting but all over the board and told them nothing. Mr. Thomas was hired in the middle of the process and became frustrated because people forgot that they were talking about someone's home not just a building. Can't carve out the people portion of the decision. Talked with many other counties to gather information. Eau Claire got out of the business and the county administrator said it was the best decision they could have made, however after talking to county board members and citizens it became clear that it was a bad decision. Found that they had to travel out of the county for services. Information from one source is not necessarily the whole picture. Realized quickly that they wanted to keep the county nursing home in tact. Government needs to be involved in the business especially now in this time of transition with low reimbursement and increased costs. Committed to stay in the business. County has a population of 85,000 with no growth so tax base was not increasing. Formed a new committee with members of public works, HCC oversight committee, administrator, and county executive with a new mandate to look at ways to stay in the business in the most cost effective way - build new, stay in the old building, how to become more efficient etc. First decision was that the building they were in was the main reason the levy was so high. When designed the new facility kept several things in mind: to improve the quality of life of the people who use the services and secondarily to provide efficiencies to reduce the levy needed to operate. Advice is to keep that first and foremost in mind; this is a people business and you are talking about their homes. Committed to building a 13.5 million dollar facility at 150 beds. The new facility (moved in in 2003) did improve the quality of life of the residents. See many positive changes in residents' behavior and physical abilities. Reduced operating costs by $1.5M. One million was made up in utility costs and staff efficiencies. Downsized while still in the old building before moved to the new building. Currently in the process of downsizing the ICF/MR and were going to use the space and turn it into a CBFMR. Need waivers to do this, however have decided to re-license the area as a nursing home. This was decided since they have a waiting list of 73 and most of those are private pay and Medicare. Anticipate that the Medicare census will be around 20 in the upcoming year so will require less levy in 2005 than they did in 2004. New nursing home is just in the city limits. Sold the 85 acres for 3 million and bonded for 10.5M. Got 14 acres of land from the city to build the new building. Felt they did the right thing for the right reason. Was very important to provide stability in long term care, improved the quality of life of residents and reduced operating costs. Felt they significantly raised the bar and other nursing homes in the county have begun remodeling. So, have improved the quality of care for the whole county. Last year were at 2.4M in county levy and currently looking at 2.2M. Project that operating costs should go down but so is reimbursement. Were at a 1-6 staff ratio (CNA's) in the old building and in the new are at 1-10. This is mostly due to the design elements of the new building. Costs per patient day were at 185/day for the average resident and now is at 200/day, however if they hadn't built would be approximately 240/day. Have contracted out as many ancillary services as could including laundry, housekeeping and therapy services. Attempted to contract out dietary however was blocked by the union. Were able to downsize dietary significantly however. Had a good reputation for providing quality care but had an old building. The reputation went with them and the waiting list continues to grow. For that reason they decided to keep the county name. The not for profit nursing home in their area is close in cost (private pay rate is $210/day) however the for profits cut as much as they can and costs are significantly less. Are still residents they cannot take. Do not have a locked unit - very expensive venture. Have two dementia units - one ambulatory and one non ambulatory. Have holistic program in the dementia units. Pump in aroma therapy which has significantly effect on behaviors. If the county ever wants to go out of the business a new building is easier to sell. Currently have a high quality provider out of Milwaukee who is interested in purchasing the building if they ever want to sell. Looking to the future with the influx of more people needing services - baby boomers - and the projected shortage of health care workers the building was built to provide the best possible care with the least amount of staff possible. Private for profit sector has much higher turn over rates that the county run facility. Their current staff turnover rate is very low because pay is better, have better benefits and treat their staff well. Staff the facility as it should be staffed. Government needs to stay in the business to set the pace.
Bill Orth stated that Outagamie County is very happy with what they did. Built a new facility within the last few years. HS in that county felt they could place most of their residents in county because of the way it was designed and staffed. Private sector was not interested in partnering with the county in efforts: Decision process too long; open meetings; union. Outcome of the move was that less dollars were spent on residents medications after the move. Impact on residents both emotionally and physically. Saw a decrease in levy however still have a significant levy because they accept almost everyone the HS refers.
Calumet is still working on the process. County home has not relied on tax levy subsidies in the past, however that situation is changing. Looked at partnering with the private sector, however had no luck in this area because decision processes were too long, didn't like open meetings and didn't want to deal with the union.
Jefferson County went through the process also however put a proposal before the board which failed and then did the study. Looked at all of the options. Difficulties with the union, tax levy of 2.3 in 2003 expected to be cut in half in 2004, felt little risk was involved because felt it is much easier to sell a new facility if they ever decided to get out of the business. Have a waiting list of 10 - 20. Capital cost were 10.6M 2 years ago. Still addressing issues of staff retention, looking for creative consolidations and have created an in-house pool where in house staff is used to fill in however it does not effect seniority or benefit accrual.
Juneau County built the nursing home and the new owner (local hospital) is paying that amount back. They did not have to deal with union issues there which has a significant effect. Has worked out pretty well, however HS still can't get difficult people placed at that facility. County board chair in Juneau County indicated that they transferred a lot of equipment over and had to pay an additional $800,000 in subsidies. Have a 60 bed facility and an additional 12 assisted living units. Employees were able to transfer over to the new facility without much difficulty because of a lack of union involvement. Sold old facility to a private party however do not know what is going to become of that property. Moved the location within the city of New Lisbon who donated the property. Did not want to see the beds moved out of the county.
LaCrosse County owns and operates two nursing homes. Hillview is traditional with geriatric care, elderly without special needs. 30% private pay and no tax levy subsidy. Lakeview is on site of old poor farm with specialized clientele who are not able to be served at other homes - behavioral issues etc. Set up committee including HS, Lakeview and Administration to develop alternatives for other service areas. Looking for revenue streams.
Questions and answers: Mr. Thomas indicated they did downsize significantly - took advantage of downsizing money available from state. Downsized to 150 eventually. Regret that they went that low - would prefer to be at 175 to serve more of their waiting list. Caution to not take the numbers of the Keefe Study as the number you should downsize to. Look closely to determine what your number should be. Bill indicated that the MA resident who needs to be in a nursing home but can't be handled locally is very difficult to place. Are fewer and fewer places available. If you are able to place them out of the county it doesn't cost the county anything but they are away from family and friends. We have to pay to have mentally ill residents placed. We currently have 4 residents in Lakeview and are paying approximately $200 - 300/day. There is no reimbursements for those people. If they could be taken care of locally it would probably cost less and the resident would remain in the county. Currently have approximately 6 seriously mentally ill residents placed out of county. Jeanne stated that another thing to be taken into consideration are the cites and deficiencies which a facility can get by taking a difficult person that the facility can't staff to take care of. Penalties are very severe. We have to be able to care for them safely. HS has to call around and the facility has to decide for itself if it will take the resident or not based on staffing etc. Burden of placing a resident is often on HS and the family. Cost of care for difficult MA clients is very high and reimbursement is low so facilities have to limit the number of those types of residents they accept. Also may be limited by the licensing. Fines can be as high as $10,000/day. Question is where the difficult people will go. In light of the baby boomers who are coming into the system, Federal/state and local governments are trying to develop alternate settings of care. CBRF's, Family homes etc. Need a wider variety of services available to care for the population. Problem is not everybody can be served in their home, not everybody can thrive in an adult family home, some people need the intense supervision of a nursing home and is cheaper to care for them there. As the ICF/MR is phased out and only institutional care is covered, the institution is no longer an option. Also doesn't seem to be much planning as far as how we maintain the facilities that we need (state level) Some discussions about allowing supplementation of the MA rate. Currently are unable to do it. Used to be able to get a supplement for behaviors many years ago. There are a number of nursing homes that have dementia units which is where there will be growth in the future. There are varying levels of care within the dementia units as well. The four flights of stairs in this facility is always an issue. The HCC could fill another dementia unit. Currently county is trying to place between 2 - 5 people with dementia each month. We have waiting list but when we have a bed they aren't necessarily ready to come into a facility. Most often it is permanent that the person is in the facility. Mr. Thomas indicated that they do provide a small day service program for clients with dementia/Alzheimer and respite care for DD clients. No question that all ICF/MR's will be closed with some regional centers perhaps open. Jeanne indicated that our population is divided between the behavioral young, active, physically healthy people and sick, older, long term residents which makes for difficult planning. Mr. Thomas indicated that it would cost his HS Department about $31,000 per year to serve their DD population in the community. This rate could change as they now have decided to pay on level of care. DD residents are being placed in a variety of places including adult family homes, shared apartments, CBRF's and some will stay in the nursing home. Eventually the money will run out and that will be a problem. Working with private agencies to provide for the residents as well as. Costs can be captured for the seriously mentally ill but the MA dementia person who is difficult to manage will be hard to place. Will not be facilities out there to place them. Counties may have to provide the service. To do projections just have to take the numbers you know and apply that. It is a providers market now.
Wheeler summarized by saying that the consensus of the Manitowoc ad hoc committee was that counties need to take care of those "safety net" people even if money is lost. We aren't in the business of making money but want to lose as little as possible. People will not be left out on the street - there will be providers out there, but at what cost? Is cheaper and the quality is better to provide services at the Health Care Center than it was to develop alternative cites such as CBRF's or place them in state institutions. Over $2M cheaper for his county. After the new facility was built were able to retain more difficult people, however those that had been placed out of the county were still unable to return because of the nature of their illness/behaviors. DD clients must be in the most integrated setting possible which a community placement does provide. Transportation is always a problem whether it is to get clients to a day program or for appointments etc. Is not reimbursed for the most part.
Gene had copy of Dane County's "Task Force on the Aging of Dane County" which is a summary of how the Baby Boomer generation will influence social, economic, community and political developments in the future. Points not only to skilled nursing and those kinds of services but the entire range of services. Will have to rely on the full spectrum of services including home care, family support - including day services and respite care as well. Had some copies of the report or gave the website - www.co.dane.wi.us. Will make some copies of the report. Gene wanted to get a clear understanding of where we are going from here. Felt it is time to start working on the decision making process and summarizing the findings of the committee to begin to develop a written recommendation. Some members felt we need more time to analyze the information presented. They felt they weren't ready to make a recommendation. Gene clarified that the committee should develop a recommendation to hold the kinds of discussions that are necessary to make sure all share the same level of understanding and information. Joan Fordham felt it would be helpful to talk to someone who has closed a facility recently and felt that that was the correct decision. Felt it would be helpful to ask questions of them also to get a different perspective. Eau Claire county sold their nursing home and Gene would be willing to contact the County Administrator and ask him to speak to this committee. It was a financial decision. Juneau County also no longer owns the nursing home however were not able to appear before this committee today. Mr. Thomas stated that it may depend on who you talk to at the county level for accurate information depending on their role in the county.
Information on cost of selling/closing the nursing home.
Jeanne stated that the information was gathered from several areas and none is current to today. No facilities have recently closed. Gathered information from Ozaukee County, County Homes Association, Brian Schoenbeck, Lasata Home, Annual Nursing Home Survey, interviews with personnel department, Keefe Proposal, Phone interviews as well. Much of the information regarding what a bed is worth is dependent on location, payor mix etc. Took averages, indicated sources etc. Mr. Orth indicated that he categorized all 103 residents from information provided by Jeanne into 5 categories the 5th being the most difficult to care for. Second area is total cost per month of placing them in an appropriate living arrangement and included the annual cost as well. Next column is potential for reimbursement from all pay sources and finally came up with the net county levy per month for care. The annual gross cost to place all the residents is $9,935,952.00. The net projected costs would be $4,499,612.02 If could place the category 5 people who are on MA in another nursing home it wouldn't cost us anything. But, currently could not find enough beds in the area to place all of those residents. We did survey of available nursing home beds within a 50 mile radius and came up with beds available on that day. Total varies from day to day and some with empty beds did not give us the staffed bed numbers which are less. Also, based placement of assuming that there would be places to put residents. Sauk County or private enterprises would have to build CBRF's or other facilities to place residents.
Some discussion of how long the board has to discuss the information. Mr. Carlson stated that the committee had to present it's findings at the February board meeting. Mr. Kriegl stated that the mandated time frame of this committee can be changed and felt a lot of data is being presented which needs study. Gene's concern is to not spend an inordinate amount of time trying to analyze data. Have a responsibility in a timely manner to put forward a recommendation.
Jeanne indicated that the data is old and that waiting even 6 months would make some of it obsolete. Two options were considered - the impact on Sauk County if the Health Care Center were sold and managed by a private organization and the impact on the county if Sauk County closed the nursing home and relocated its residents. Keefe talked to Reedsburg Hospital and St. Clare and neither was interested in purchasing the HCC. The $15,000 stated for the value of a bed is high but was an average. Most buyers would not be interested in purchasing our old building that is so large and inefficient. Most would only be interested in the beds. The HCC is predominately MA funded so that is another downside. We are 75% MA; St. Clare Meadows is 58%; Greenway Manor is 61%; Snyders is 58% and Maplewood is 68%. Negotiating takes time and county resources. We would also loose control of the quality of the care. The number of citations also has to be included. Greenway Manor and Maplewood respectively have 7 and 8 citations. They have a lower staff ratio than ours however we have been citation free for two years running. If the Nursing Home is closed, the cost of care for the county shifts to Human Services, courts and other agencies. There are also potential environmental costs such as demolition and asbestos removal which could be as high as $700,000. County chargebacks lost would be $45,300 (per the Accounting Dept.) Loss of IGT funds for 2003 would be $1,092,402. Actual cost of gas and electricity for 2003 was $177,193 which does not include building upkeep or equipment replacement. Legal costs are difficult to determine but were estimated at $50,000. A summary of costs is attached to these minutes.
Closing and getting out of the Nursing Home business.
No other county has closed its nursing home in the last 25 years, would create access problem in western part of the county, and other nursing homes could not absorb the additional residents. We would no longer have an in-county option for more difficult to place residents due to acuity, behavior or pay source. The cost of care would shift to Human Services which would range from $4.5M to $9.9M per year depending on the reimbursement received. There would be a loss of charge backs to the county and we would either have to demolish or remodel the building to make it marketable. The beds would have to be sold and establishing the market value is very difficult to determine. It would create a large depression in the skilled nursing bed market in Sauk County - SCHCC comprises over 28% of the skilled beds in the county and we serve a larger percentage of MA residents than any other Sauk County Home. Would be residual costs and liabilities regarding staff such as sick pay, severance, workers compensation, maintenance and employee wages and incentives. Unemployment benefits would also be a large cost to the county with many variables depending on the job market in Sauk County at that time.
Cost of building a RCAC would be approximately $100,000 per unit. There would also be a loss of $7 million in expected revenue per year due to loss of current census. Discussed the survey of available beds within a 50 mile radius of the HCC. There were 30 beds available in the Madison area however many had multiple citations related to abuse, quality of care and staff training. Were 36 openings within 25 miles of the HCC and of the five facilities Maplewood and Greenway Manor had the most deficiencies with 8 and 7 respectively and Wisconsin Dells next with 4. The facilities with the most openings in the 40 - 50 mile radius had the most number of deficiencies. The average number of deficiencies in Wisconsin is 4.
Mr. Kriegl again felt the need for more information and perhaps a longer amount of time to digest the information presented. Still are many decisions to be made such as do we build or not and what kind of facility do we build. Have to also decide how we address the needs of the elderly in Sauk County. General discussion of the mandate of this committee and when certain decisions should be made. Gene felt a building committee would be formed after this committee has made its recommendations to go into more detail of building etc. Decisions will be made in sequence. Mr. Kriegl felt we should have a good idea of what we are going to do with the old facility and what kind of new facility we want to build if we recommend building. Mr. Thomas indicated that they broke their committees down into smaller units with specific charges so the decision process was quicker. No one committee can make all of the decisions. Needs to be a process. Joan Wheeler indicated that she felt the mandate of the committee is to look at the big picture with the HCC as a small part of that picture. Have discussed single point of entry in the past and need to discuss that more and where the HCC fits. Felt we need to look at our role - do we want to fund something that is costly. Trish Vandre indicated that we need to look at providing the services to our population in the most cost effective way. Many of our elderly can't afford to pay for these services on their own. What do we do with these people if we don't do it? We are mandated to care for this population, however we are not mandated to own and operate a Nursing Home. Mr. Thomas also felt the newspaper coverage needs to be sensitive to the fact that the residents are reading the newspapers and we are discussing their future. Jeanne said we also need to realize that our editorials need to be accurate and the facts presented in an honest way. Linda Borleske indicated that she felt we can meet the February deadline and our mandate was to decide if we should stay in the business and after our public hearings we would get a better understanding of what our constituents want and will have the information we need. Next step would be to establish another committee to discuss how we can meet the needs of our residents in a cost effective way. Joan Wheeler felt that was only a part of the mandate. We also need to look at the whole picture of services for the elderly. Gene felt after the public hearing the committee needs to sit down and begin drafting recommendations to take to the county board. Part of that process will be to discuss if all have learned the same things. Discussed letter to the committee sent by Judy Ashford. Felt the committee should respond to her as conclusions are reached.
Discussion of where public hearing will be held.
5. Motion by Bychinski, second by Borleske to have the public hearing on December 15 at the HCC and a second public hearing in Baraboo within a week. Motion carried.
Hearings will both begin at 8:30. The hearing on the 15th will be in the Resident Dining Room of the HCC and the second will be in Baraboo on December 22 at 8:30 a.m. in room B-30. Discussion item will be on the agenda to allow the committee to meet after the hearings as time allows.
6. Motion by Volz, second by Borleske to adjourn. Motion carried.
Meeting was adjourned at 11:55 a.m.
_______________________________
Paul Endres, Secretary
| Estimated Costs to Taxpayer of Changes in Operation of SCHCC | |||
| Estimation in $ | Net Gain (Loss) To Taxpayers | ||
| Revenue Assumption | |||
| Bed Sale 126 x $15,000 | A | 1,890,000 | |
| Cost Assumptions | |||
| Improve for Sale | B | 1,300,000 | |
| Improve to Code | C | 7,600,000 | |
| High Accuity Supplement | D | 22,000 | |
| Demolition | E | 550,000 | |
| Liability of Employee - Vac Sick | F | 385,000 | |
| Maintenance for One Year | G | 177,193 | |
| IGT Revenue Loss | H | 1,092,402 | |
| Legal Fees | I | 50,000 | |
| Charge Back Loss to County | J | 45,300 | |
| Unemployment | K | 840,000 | |
| Cost of Relocating Residents | L | 4,450,000 | |
| Sale Scenarios Including IGT Loss of Revenue | |||
| Improve for Sale; No Demolition | A-BDGHIJ | 2,686,895 | (796,895) |
| Improve to Code; No Demolition | A-CDGHIJ | 8,986,895 | (7,096,895) |
| Bed Sale; Building Demolition | A-DEGHIJ | 1,936,895 | (46,895) |
| Sale Scenarios NOT Including IGT Loss of Revenue | |||
| Improve for Sale; No Demolition | A-BDGIJ | 1,594,493 | 295,507 |
| Improve to Code; No Demolition | A-CDGIJ | 7,894,493 | (6,004,493) |
| Bed Sale; Building Demolition | A-DEGIJ | 844,493 | 1,045,507 |
| Closing Scenarios Including IGT Loss of Revenue | |||
| Demolition Only 1st Year | A-EFGHIJKL | 7,589,895 | (7,589,895) |
| Demolition Only 2nd Year forward | L | 4,450,000 | (4,450,000) |
| Closing Scenarios NOT Including IGT Loss of Revenue | |||
| Demolition Only 1st Year | A-EFGIJKL | 6,497,493 | (6,497,493) |
| Demolition Only 2nd Year forward | L | 4,450,000 | -4450000 |
Ad hoc Committee Analysis Details - 12/1/04
A. BED SALE ESTIMATE