7. 8. 9. 10. 11. aides, should be established along with the mechanisms to use these aides Tax rebates and other forms of financial incentives should be given to Outreach services will need to be expanded to assure that all people in The State Health Planning and Development Agency should consider establish- Once a comprehensive system of home based services is established, immediate consideration should be given to the controlled release of Medicaid patients in skilled nursing facilities (determined to be nonskilled patients) back into home care settings. Before release, these patients and their families should be interviewed by a multidisciplinary team to include a physician with a specialty in geriatrics/gerontology, a home health nurse, a medical social worker and a physical therapist to develop a plan of care that would include rehabilitation approaches and self-help practices to assist the patient to develop to his/her greatest potential. Arrangement should be made to ensure that patients receive the services as indicated by that plan of care through time. 12. A Patients' Bill of Rights should be developed for any group of patients who do not have a written patients' rights code, and mechanisms to enforce existing codes should be strengthened. CONCLUSION The Task Force emphasizes the need to view institutionalization as a final alternative for chronically ill persons. Only when a multidisciplinary assessment team has certified that a combination of other supportive services will not be adequate to meet individuals' needs, should institutionalization be considered. The Long Term Care Task Force supports the implementation of the recommendations of the 1974 Hawaii Comprehensive Master Plan for the Elderly (Gordon Associates) related to health care for the elderly which noted that Hawaii should: "Develop a refined network of both restorative and home care that could (Gordon This network or continuum of care cannot be totally supported by state and federal revenues given present ceilings on Title XX spending and given limitations on funds for social and health support services under the Older Americans Act. The Task Force emphasizes the need for government, labor, business, private human service agencies, community organizations, trusts and foundations, third party insurance companies, and the United Way to work together to determine ways to supplement the financing of community support services to restore, conserve and enhance the ability of chronically ill persons to live independent lives to the degree to which they are capable. Without a commitment to alternative care by the various groups mentioned, Hawaii will continue to spend exponentially increasing amounts of revenue on institutions because of the lack of community based services and the rapid increase of Hawaii's elderly population. APPENDIX I HCSCH PROBLEM STATEMENTS ON INSTITUTIONAL LONG TERM CARE The following appendix is a compilation of the major observations and problem statements identified by the HCSCH Long Term Care Task Force from June 1978 to June 1979. These observations emerged as a result of the discussion process which the Task Force implemented to more clearly understand the nature of the different levels of institutional long term care in Hawaii. APPENDIX I ACUTE CARE NURSING FACILITIES 1. Federal regulations require acute care hospitals to formulate a discharge plan for patients within seven days of their admission. This regulation may result in the development of a patient waiting list before these patients are actually ready to be transferred. There have been cases where the acute care hospital has called skilled nursing facilities (SNFs) to reserve an SNF bed before a patient is ready to be transferred. Task Force members recommend that acute care facilities cooperate to develop a central waiting list of patients waiting placement in long term care institutions based upon their expected date of transfer. Members of the Task Force recognize that this problem will probably be more clearly focused in the near future because the Pacific Professional Standards Review Organization (Pac-PSRO) is now (since May 1, 1979) determining whether an acute care Medicare/Medicaid patient requires skilled or nonskilled services. 3. 2. The problems of a patient waiting list for transfer from hospitals to long term care institutions complicates attempts to estimate the numbers of long term care beds needed currently and in the future. There are as many as one hundred patients per day in acute care hospital beds who belong in long term care beds but cannot be transferred due to the high occupancy rates and lack of vacancies in skilled nursing and intermediate care facilities (ICFs). However, when all the beds have been created for which there are outstanding Certificates of Need, this slack will be taken up. ADDENDUM (10/1/79) Further problems have arisen because Pac-PSRO is assessing patients more exactly in relation to the Federal regulations than did Medicaid, and Medicaid no longer permits the transfer of patients to SNFs who are not labeled "skilled" by the criteria. The anomaly has therefore arisen that acute care facilities are unable to move their patients out, while SNFs have empty beds. There is thus an urgent need for the creation of more ICF beds or potential ICF beds by designating some SNFs as "swing beds." This could come about through redistribution of existing long term care beds provided incentives are developed for caring for long term care patients at home. If the division between SNF and ICF beds were abolished altogether, long term care facilities would be better able to respond to current patient requirements whether at the ICF or SNF level. SKILLED NURSING FACILITIES (SNFs) 1. The moral and ethical issues of certain practices need to be confronted by the community with assistance from health and social service professionals. For example, the practice of prolonged tube feeding, while much less frequent on the mainland, is quite prevalent in SNFs in Hawaii. The Task Force noted that a combination of factors may contribute to this practice, including administrative practices set up by each institution and the lack of consensus in the State on what constitutes extraordinary life sustaining measures. 2. Financial coverage from third party payers (i.e., Medicare, Medicaid, and HMSA) for services rendered in SNFs and ICFs depends on the way in which physicians write orders for patient care. The physician must specifically state the services the patient should receive, since the third party will not reimburse any service not ordered by the physician. 3. Under Medicare, several entities are responsible for eligibility review once a patient is admitted to an SNF. The Honolulu County Medical Society Utilization Review Committee is contracted to provide this review for eleven facilities. Hospital based SNFs have their own in-house utilization review programs following federal guidelines. HMSA also determines eligibility. Members of the Task Force noted that there are some grey areas and sometimes differences of opinion regarding criteria for reimbursement between fiscal intermediaries and the nursing facilities. Most often the nursing home has to pay the tab if there is a retroactive denial. When Pac-PSRO extends its activities to nursing homes, it will eliminate retroactive denials, since the designations will be taken concurrently. 4. Reimbursement from Medicare and Medicaid does not cover the total cost to the institution of patient care in inpatient nursing facilities. Private paying patients are subsidizing the care of Medicare/Medicaid patients in inpatient long term care facilities by paying higher rates for their care. This reimbursement differential may be contributing to the difficulty of placing Medicare/Medicaid eligible patients in skilled and intermediate nursing beds from the acute care level. The backlog of patients in acute hospital beds waiting placement in lower levels distorts the true picture of the need for long term inpatient beds and contributes to higher medical care costs. |