The 1st meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, June 8, 2005, at 10:00 AM, at the Rosedale Manor Nursing Home in Covington, Kentucky. Representative Tom Burch, Co-Chair, called the meeting to order at 10:07 AM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Denise Harper Angel, Richard "Dick" Roeding, and Katie Stine; Representatives James R. Comer, Jr., Bob M. DeWeese, Joni L. Jenkins, Mary Lou Marzian, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, Kathy W. Stein, and Addia Wuchner.
Guests: Kay Carlew and Cindy Osborne, Loretto Motherhouse Infirmary; Rich Miller, Kentucky Association of Health Care Facilities; Gary Goetz, Ed Muntel and Sue Davis, NorthKey Community Care; Mary Hass, Brain Injury Association of Kentucky; Barbara Gunn and Donna Oehler, Senior Services of Northern Kentucky; Jim Goshin, Kentucky Association of Homes and Services for the Aging; Cathy Allgood Murphy, American Association of Retired Persons; Mary Haynes, Nazareth Home; Donald Saelinger, M.D., Patient First Physicians Group; Linda McAuliffe, Division of Mental Retardation, Cabinet for Health and Family Services; Donna Turner and Russell Harper, Christian Care Communities; Jean Wells, Wells Health Systems; Roseanne Nields and Tim McDermott, St. Elizabeth; John Burt, Department for Public Health, Cabinet for Health and Family Services; Pat Dressman, Campbell County Fiscal Court; Sr. Mary Luann Bender, St. Charles Care Center; Joy Freeman and Hollie Phillips, ARH; Lyn Leary and Laura Reid, Woodspoint/Seniorcare; Mary Middleton, Rosedale Manor; Paul Louis Knapp, Spectators; Reva Ballard, BBG; John Muller, Highlands of Ft. Thomas/Carespring; Katie Rienaber, Kentucky Association of Retired Persons; Thomas W. Keene, Senior Citizen Concern; John McGary, Legislative Research Commission; Barbara Ror, Child Policy Research Center; Dawn Denham, Boone County Success By 6; Gary Moore, Boone County Judge Executive; Michael Kathman, St. Luke Hospital; Donna Brown, Kentucky Association of Health Care Facilities and Kentucky Association of Chiropractics; and Karen Thomas Lentz, Long Term Care Pharmacy Alliance.
LRC Staff: Robert Jenkins, CSA; Barbara Baker, Tyler Campbell, Cindy Smith, Gina Rigsby, and Murray Wood.
Londa Knollman, Administrator of the Rosedale Manor Nursing Home, welcomed everyone and gave a brief history of the facility.
Next, Barbara Gunn, President and CEO of Senior Services of Northern Kentucky, stated that twenty-one percent of Kentucky's elderly live at or below the poverty level, and in the next forty-eight years the elderly population will triple. She said that federal and state resources for the aged have not increased in the past fifteen years. There is a global aging crisis in every industrialized country, and the United States is not prepared with the financial resources to meet this demand. She stated that it is unacceptable that the foundation of our country, our elderly, to go bed hungry. The legislature needs to support the elderly by providing more funds for needed resources. Kentucky has a responsibility to safeguard our senior citizens from abuse, neglect, and exploitation. Civil monetary penalty funds should still be used to supplement the state's ombudsman program.
Senator Stine asked if providers work with area churches to take up the slack, and Ms. Gunn stated that they do.
Representative Smith stated that if a household has two disabled senior citizens but are under the age of 60, they should be eligible for Meals on Wheels program. Ms. Gunn stated agreed.
Next, Dr. Don Saelinger, Patient First Physicians Group, stated that even if there is a way to adequately fund Medicaid, there is still a problem with access to healthcare for Medicaid recipients and the uninsured. Nationally, the growth in Medicaid spending averaged 10.2 percent per year from 2000 to 2004 due to increased enrollment and increased cost per enrollee. Medicaid reimbursement is very low when compared to Medicare and commercial insurance. He said that the state is under a court order to pay hospitals 95 percent of its costs. Dr. Saelinger said that the extra cost of insurance has shifted to employers.
Senator Denton asked when the court order was filed that ordered hospitals to be paid at 9598 percent of costs, and Dr. Saelinger stated it was summer of 2004. Commissioner Turner later stated that she did not know of any court order that required the Department for Medicaid Services to pay 95 percent of hospital costs.
Representative Burch stated that the United States pays more for health care than any other country and the outcomes are not any better. Dr. Saelinger said that the delivery system cannot continue as it is. He said that if the escalating costs as compared to the escalation of the gross national product goes continues until 2020, it is estimated that 40 percent of the gross national product will go toward health care as opposed to 13 percent now. Representative Burch stated that direction needs to come from health care providers on how to solve the health care problems, and he asked if Dr. Saelinger had any suggestions. Dr. Saelinger stated that the trend of cost shifting to patients would last three years and the sickest patients will pay more for health care because of the cost shifting. Dr. Saelinger said that he was unclear of an answer but there may not be an alternative but to go to a single payor national health system.
Next, Mary Haynes, RN, CNHA, Administrator of the Nazareth Home in Louisville, stated that the Kentucky Association of Health Care Facilities (KAHCF) signed a Quality First pledge to understand what the community wants and to understand quality. A Quality Task Force was formed to discover what kinds of management tools were available to help nursing homes understand how patients view the care provided in nursing homes. She said that Kentucky nursing home facilities are outperforming contiguous states.
Next, Neil Gulsvig, President and CEO of MyInnerView, Inc., stated that his company is an independent health care data management and research organization based in Wisconsin. The company's single mission is to help long-term care professionals improve the quality of care and accommodations they furnish the customers. The company fulfills the mission by providing management intelligence to the profession in the form of evidence-based management tools that enable professionals to monitor and improve performance. He said that his company maintains the largest private database of quality performance information for nursing homes outside of the federal government.
Mr. Gulsvig stated that the first task of his company was to determine, from the best research and experience in the field, which specific quality-critical data actually have direct explanatory and predictive value, and, are therefore, worth accumulating. The next task was to design a simple, low-cost, easy method to collect and analyze the data and quickly convert it into management intelligence that long-term care professionals could use to improve performance. He said that small amounts of core clinical and workforce performance numbers are collected each month from information that already exists in the facility and a Quality Profile that that can continually measure performance and improvements.
Mr. Gulsvig said that satisfaction surveys provide information that drives changes in care practices and leadership attitudes that are essential in improving outcome. He said that MyInnerView Quality Profile users are given the opportunity to compare results with all others in its database, as well as with specific peer groups of other facilities that are similar or different in location, size, ownership, and other ways. He said that in August 2004, a group of approximately forty nursing homes in Kentucky became early adopters of the MyInnerView program as part of the Kentucky Association of Health Care Facilities' adoption of the national Qualify First program developed by leading national long-term care organizations. The facilities logged monthly quality indicators and workforce metrics into MyInnerView's system, and initial surveys of customer and employee satisfaction were conducted. A full report on the project with recommendations will be available at the end of June.
Mr. Gulsvig stated that early results do not reveal any evidence of a general crisis in quality of care in Kentucky nursing homes but do indicate areas of vulnerability and priorities for improvement efforts.
Representative Stein asked if Mr. Gulsvig agreed that both evidence-based studies and anecdotal evidence should be considered when looking at quality of care. Mr. Gulsvig said both were needed. She asked for a list of the 40 facilities that participated in the survey, and he said that information would be made available by KAHCF. She asked if profit and not-for-profit facilities were included in the survey. He said that they were. Representative Stein asked about the mix of facilities. Ms. Haynes stated that effort had been made to include all areas of the state. Representative Stein said that his written comments stated "lower levels of satisfaction were expressed on certain individual items in the survey, and our company provided our Priority Action Agenda with these results to guide facilities on which issues to concentrate attention on" and asked which issues he was talking about. Mr. Gulsvig stated that each facility has a Priority Action Agenda. Mr. Gulsvig stated that the data showed there are areas of concerns specific to that facility. Representative Stein asked if one area of concern was the lack of staffing. He said that usually it is care and concern of management, not staffing, that is in the top area of concern. She said that staffing is a real concern from constituents across the state.
Representative Palumbo asked who received the surveys, and Mr. Gulsvig stated that the survey was mailed directly to family members, who were asked to mail them back in the postage-paid envelope as soon as possible. Representative Palumbo asked where he had obtained the list of names and addresses. Mr. Gulsvig stated that every medical record, by law, is required to list the primary responsible party, which is provided to him by the nursing home facilities. She stated that, due to privacy concerns, addresses should not be given out. Ms. Haynes said that there is no value if a survey is not completed. She asked about the percentage of surveys that were returned. He stated that the national average was 37.5 percent but in Kentucky it was 42-43 percent. Representative Palumbo asked if nursing homes where contacted to let them know about the company's services. He said that their team has two of the leading researchers in long-term care, and that the company has grown by word of mouth. Ms. Haynes stated that the association looked for a way to implement the Quality First Pledge, therefore, the association sought an independent evaluator. Representative Palumbo asked how the company was funded, and Mr. Gulsvig stated that facilities pay a fee to use his company's product.
Senator Buford asked if the survey showed evidence on how the additional $55 million provider tax funds were spent, and Mr. Gulsvig stated that an evidence-based approach helps document interventions and the results.
Senator Roeding stated that staffing was not a top priority with his mother's care when she received assisted living or skilled care in a nursing home facility.
Senator Stine asked if there was a correlation nationally between reimbursement rates and the staffing turnover. Mr. Gulsvig stated this was an area that was being reviewed. He said that turnover and stability have a direct impact on falls and costs. She asked what facilities were doing to affect retention. Mr. Gulsvig stated that when staff replied to the survey, salary did not rank in the top three areas.
Representative Stein asked if residents, families, and staff can report anonymously, and Mr. Gulsvig stated that all the surveys were anonymous unless someone wanted more information or wanted the facility to contact them. She asked if there were a copy of the survey available for the committee to see. Representative Burch asked Mr. Gulsvig for a copy of the survey to be provided to the committee. Mr. Gulsvig said that the survey is a proprietary tool, and he cannot give out information on how a question is worded.
Representative Burch stated that quality of care was the most important issue when putting a loved one in a nursing home. Mr. Gulsvig said that the survey was a scientifically designed tool to make sure the questions were asked in the right way. Representative Burch stated that someone outside the nursing home should come in and rate the facility so deficiencies could be corrected. Ms. Haynes said that the analysis provides leadership of the nursing home facility a clear priority list of how to improve care.
Representative Lee asked if individuals in long-term care facilities who may not have visitors receive the same quality of care as those patients who have visitors more frequently. Ms. Haynes stated that communication is everyone's responsibility to make sure every resident receives the level of communication needed. Representative Lee asked if patients whose family members visit every day tend to receive better quality of care. Ms. Haynes stated that every resident needs support to have a voice in their care. Representative Lee stated that a large portion of patients do not have family member support. Ms. Haynes said that the survey would be answered by someone other than a family member. Representative Lee stated that he had great concerns about surveys that do not take into consideration patients who cannot take care of and speak for themselves. Mr. Gulsvig stated that, of the 40 facilities, some were not providing good quality of care.
Next, Bernie Vonderheide, Kentuckians For Nursing Home Reform, stated that he appreciates the commitment of the nursing home industry to improve the quality of care through the initiative with MyInnerView, but is concerned because it is only done on a voluntary basis. He said that the nursing homes that will participate will be those that already understand the importance of quality. The goal should be to improve quality in all nursing homes in the state. One initiative would be minimum staffing ratios. He said that the time has come to mandate a baseline of quality care for nursing homes and then let the professionals who run the facilities determine the skill mix to resident ratios. Thirty-seven states have state staffing regulations, but Kentucky is not one of them. Better training for nursing homes that fall below certain health care standards and better employee recruiting and retention are needed. He said that now is the time to pass legislation that will recognize outstanding nursing homes, assist those that fall short, and improve the quality of care.
Senator Denton asked how Kentucky compared to the 37 states that have staffing ratios in the average of deficiencies per state. Mr. Vonderheide stated that Kentucky is slightly above the averages, but he was concerned where the information comes from. Senator Denton said that the Inspector General in the Cabinet for Health and Family Services has this information recorded. She asked for information that would support Mr. Vonderheide's figures.
Senator Roeding stated that there has to be cooperation between the nursing home industry and the advocates. He asked for figures about staffing shortages in nursing homes and poor quality of care.
Next, Gary Goetz, NorthKey Community Care and Northern Kentucky Regional Planning Council, stated that in Northern Kentucky, as well as throughout the state, the goal is to provide excellent mental health, substance abuse, and developmental services to the individuals who need the services. He thanked the members for supporting the allocation of an additional $2,000,000 statewide for safety net services. Excellent services are good for the people who need and receive services, for their families and the community, for business growth, and more effective treatments, improved outcomes, and better use of state dollars. He stated that some regional challenges are: 1) a rapidly growing population that has created an increased demand for services that is outpacing the growth in funding streams; 2) the Department for Medicaid Services is still primarily based in payments systems that emphasize traditional services; 3) a statewide mental health service system that has been unable to respond to demands for safety net services to low-income individuals; 4) mental health, substance abuse, and mental retardation and developmentally disabled services must overcome the stigma to be seen as a legitimate health care service; 5) the budget has consistently underfunded the Northern Kentucky region on a per-capital basis for approximately ten years; 6) the critical needs for increased residential treatment options for youth and adults with substance abuse assessment and medications; and 7) jails continue to house many individuals with mental health and substance abuse problems that require additional treatment resources.
Mr. Goetz stated that primary regional needs are: 1) proportional allocation of funds to more adequately support mental health and substance abuse services; 2) appropriate funding of the Medicaid program to allow appropriate reimbursement across the continuum of services and enable broader service payment to cover evidence-based treatment; and 3) flexibility in funding dollars to allow for matching the use of dollars to local identified needs.
Representative Marzian stated that 840,000 Kentuckians suffer from mental illness, and Kentucky ranks forty-fourth in the nation in mental health funding. She said that $25 million dollars per year is needed for mental health services to move up in the rankings.
Next, testimony was heard from Representative Addia Wuchner, Judge Executive Gary W. Moore, Chairman, and Dawn Denham, Executive Director of Boone County Success by 6®, and Barb Rose of the Children's Hospital Policy and Research Center in Cincinnati. Representative Wuchner stated that 90 percent of brain development occurs from birth to three years of age. The earlier a delay is recognized the more a parent can help their child reach full potential. Once a child falls behind, he or she never catches up. Representative Wuchner said that Boone County is ranked second in percentage population growth in Kentucky and the Cincinnati region and ranked eightieth in the top 100 fastest growing counties in the United States.
Judge Executive Moore said that representatives from six countywide agencies started meeting once a month to review the findings of the Kids Count book and explore underlying causes of identified problems. They discovered that many children enrolling in school in Boone County were not prepared to succeed. They also discovered that, while many different agencies offer programming geared to young children, these efforts on occasion lacked focus and coordination. In 2003, the countywide agencies joined forces with United Way and adopted Success by 6®, developed goals and action plans, and began kindergarten assessments. In June 2004, the first executive director was hired.
Representative Wuchner said that Success by 6's mission was to unite Boone County to ensure all children are healthy, safe, nurtured, and prepared to succeed in school. The focus areas are early literacy, nutrition and physical activity, poor dental care, inadequate prenatal care, and early care and education. She said that strategies included raising community awareness, increasing the capacity for providers, improving the delivery of services, and building the capacity of families. In September 2004, Boone County Success by 6® was awarded a federal Early Learning Opportunities Act grant in the amount of $717,600. The grant allowed them to have assessment data analyzed by the Child Policy Research Center, launch an intense community awareness campaign, begin a home visitation program that fills the gap of Boone County families that are not eligible for other home visitation programs, and purchase a 40-foot mobile vehicle that would serve as a Community Center on Wheels to deliver services directly into neighborhoods.
Ms. Denham said that each school conducted several days of screening in the summers of 2003 and 2004, and that 2005 screenings are now in progress. Children were screened by school employees, and the Boone County Health Department was assisted by employees of the Boone County Parks Department in collaboration with the Boone County Public Library and Boone County Cooperative Extension District. Parents were contacted by phone to schedule a screening, fliers were displayed in various locations around the county, screening time averaged one and one half hours per child, and screening was set up arena style. She stated that the information found during the assessments were 1) age and length of county residence influenced social and emotional health; 2) children in two-parent families seemed to be better prepared to succeed in school; 3) 97 percent of the children tested within the expected average range on the adaptive component; 4) thirty-two percent of the children tested were overweight or at risk of being overweight, according to their Body Mass Index (BMI); 5) cognitive abilities were lowest among overweight children; 6) fifty-three percent tested below what is expected from a child entering kindergarten on the literacy assessment; and 7) dental problems were a health barrier.
Representative Wuchner stated that quality early learning reduces crime rates, teenage pregnancy, welfare dependency, job training costs, special education costs, and grade repetition. It increases success in school, graduation rates, workforce readiness, job production, and community engagement. She said that the goals of the Family Assessment Mentoring Education (FAME) are 1) to enhance early childhood development and promote health, safety, literacy, and well being of families living in Boone County; 2) to provide professional preventive health-related services to families with children in their early developmental years; and 3) to increase awareness of available community services and provide resource information to families based on their needs.
Representative Burch asked for the number of children between 0 and 6 years of age. Ms. Denham said between 5,000 and 6,000. He asked if information was available about how many children went to school hungry or were in need of clothing and shoes. Ms. Denham stated that specific question was not part of the information collected in the Success by 6® program, but this information was found through other programs. Representative Burch and Senator Denton commended the group for its collaborative efforts.
There being no further business, a motion was made to adjourn at 12:30 p.m.