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AHCA/NCAL 58th Annual Convention and Exposition October 7-10, 2007 Boston, MA Effective Packaging of Personal Care Services in Assisted Living NCAL Day – October 7, 2007 2:15-4:15 pm. Presenters. Tom Melchior, Manager, LarsonAllen Minneapolis, MN

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AHCA/NCAL 58th Annual

Convention and Exposition

October 7-10, 2007

Boston, MA

Effective Packaging of Personal Care Services in Assisted Living

NCAL Day – October 7, 2007

2:15-4:15 pm

presenters
Presenters
  • Tom Melchior, Manager, LarsonAllen Minneapolis, MN
  • Rosemary Brandt, RN, Assisted Living Nurse Consultant, Tealwood Care Centers

Bloomington, MN

  • Dennis Acrea, Senior Vice President, Benedictine Health System

Cambridge, MN

  • Susan Taylor, Vice President, Health Service Innovations

St. Paul, MN

learning outcomes
Learning Outcomes
  • Understand the various approaches to service delivery and the pros and cons of each.
  • Learn how diverse organizations custom designed service packages to meet residents’ needs.
  • Recognize the revenue implications of flexible approaches to service delivery.
introduction and background

Introduction and Background

Assisted Living and the Senior Care Continuum

types of senior housing
Types of Senior Housing
  • Few/no services
    • Age-restricted townhomes & single-family homes, for sale or rental; may be part of a campus
    • Senior ownership, usually very limited services
    • “Active adult” single or multi-family, own or rent
  • Housing with services
    • Independent/congregate housing – some services (i.e., meals, housekeeping) may be included in the rent or all services may be optional
    • Assisted living – basic services (meals, housekeeping) usually included in the rent; some also include personal care services in the rent (often the case with memory care); others have all personal care as an option
assisted living services and housing
Assisted Living – Services and Housing
  • Variety of definitions of “Assisted Living”
  • “Assisted Living” refers to housing AND care
  • The care can be delivered in a variety of settings
  • Key is that supportive services are provided:
    • Meals, housekeeping, laundry, supervision
    • Assistance with ADL’s
    • Possibly activities/socialization, transportation
growth in demand for assisted living
Growth in Demand for Assisted Living
  • Persons Age 85+
    • 2.2 million in 1980
    • 4.3 million in 2000
    • 9.6 million in 2030
    • 15.4 million in 2040
  • In 2004:
    • 36,000 assisted living residences
    • Serving 900,000 persons
types of services
Types of Services
  • Real Estate (the “Room” of “Room and board”)
    • Housing unit (includes management, building maintenance, etc.)
  • Basic Services
    • Meals
    • Housekeeping
    • Laundry (may be provided as part of a personal care package)
    • Linen service (may be provided as part of a personal care package)
types of services continued
Types of Services - Continued
  • Personal care - assistance with ADL’s/IADL’s
    • ADL’s include: assistance with bathing, dressing, toileting, etc.
    • IADL’s include: assistance with housekeeping, shopping, medication
    • Persons with dementia (memory loss) may have additional needs such as redirection or special needs related to behavior
3 methods of service delivery
3 Methods of Service Delivery
  • All-inclusive
  • A la carte
  • Packaged plans
    • Fixed-service packages
    • Flexible-service packages
    • Time-specific packages
  • Packages offered for services other than “room and board” (room and board includes housing, meals, housekeeping, activities, and transportation)
all inclusive
All-Inclusive
  • All personal care services, including escorts, medication management, etc. is included along with “room and board” (housing unit, meals, utilities) for one fixed monthly fee
  • Tends to attract very frail seniors, due to level of services provided
  • Usually applies to smaller units, typically studios and often in shared units
  • Costs typically $3,500 and up, typically $4,000+
a la carte
A la Carte
  • All personal care services provided on an individual basis, “pay as you go,” billed monthly to the resident
  • Housing and meal costs (two to three meals per day) usually bundled, including utility costs
  • May provide the highest level of revenue, since “full price” attained for each service, but billing can be cumbersome
  • Services may be provided and charged 1) for each use (i.e., each medication reminder or per bathing assist) or 2) by time only (i.e., per 15-minute increment)
packaged plans
Packaged Plans
  • Most housing with services buildings provide services in packages; easier for residents/families to comprehend; easier for billing purposes
  • Packaged plans are a compromise between all-inclusive service plans and totally a la carte services
  • There are many ways service packages are organized. The categories of packages are:
    • Fixed-service packages
    • Flexible-service packages
    • Time-specific packages
fixed service packages
Fixed-Service Packages
  • Packages include specific services:
    • package A consists of bathing assistance 2 times per week and one med reminder per day;
    • package B consists of package A plus morning and evening cares (dressing and grooming assistance) and 2 med reminders per day, etc.
  • Residents take the package that best meets their needs based on the services included
  • 2 to 5 levels are usually offered (possibly more), 3 to 4 are typical
  • Often a resident can fit into one package with a limited a la carte service added to satisfy a specific need
flexible service packages
Flexible-Service Packages
  • Resident’s care plan based on a staff evaluation; services are based on resident’s individual needs
  • A point system is used to determine fees
  • This method provides the most individualized plan for residents and relates costs to specific needs
  • Billing is easy, since the cost falls into a specific service level based on the point total
  • 3 to 5 levels are typical, but some organizations have 8 or more
  • The greater number of levels often relate to a higher level of service provided (i.e., incontinence care) as well as more refined package distinctions
time specific packages
Time-Specific Packages
  • Services provided within specific blocks of time, i.e., one-half hour per day, one hour per day, etc. or perhaps by the amount of time per week required
  • Residents provided with whatever specific services needed within the time frame of the package… bathing assistance, dressing assistance, escorts, etc.
  • Medication reminders often provided separately
  • Costs determined based on time
why do a pre admission assessment
Why Do A Pre-Admission Assessment?

Services Needed/Wanted

Services Available

Facility Criteria

Alternative Sources of Care

when is the assessment done
When Is The Assessment Done?

Prior to Admission

Prior to Initiation of Services

How Is The Assessment Done?

____________________________

Communication

Observation

what is assessed
What Is Assessed?

Physical Status

Functional Status

Cognitive Status

Where Does the Assessment Take Place?

______________________________________

Home

Hospital

Long Term Care Facility

Other Senior Living Facility

who contributes to the assessment
Who Contributes To The Assessment?

Potential Tenant

Family Members

Facility Staff (if in another facility)

Medical Personnel

what tools are used in the assessment
What Tools Are Used In The Assessment?
  • Pre-Screening Questionnaire
  • Mental Status Questionnaire
  • Assessment for Self-Administration of Medications
the assessment
The Assessment

Home Environment

Communication

Personal Hygiene Needs

Nutrition/Diet Needs

Mobility Needs

Elimination Needs

Mental Needs

the assessment continued
The Assessment - continued

Physical Needs

Social Support Needs

Medications

Vulnerability

service charges based on assessment
Service Charges Based on Assessment

Ala Carte

Pay only for services needed/wanted

Determination ofcost

Based on region

Time needed to complete task

packaged services
Packaged Services

Memory Care

Three Levels

All-inclusive

incidental charges
Incidental Charges

Based on time involved

Non-scheduled services

Tenant requested

case study
Case Study

83 year old gentleman

Recently widowed

Lives at home

Daughter lives in area

Very supportive family

case study continued
Case Study - continued

House in disarray

Urine odor

Wheelchair folded up in corner

Difficulty hearing

Cat

case study continued30
Case Study - continued

Incontinent care

Bathing assist

Medication assist

Assistance with hearing aid

assisted living service packages alternative plans

Assisted Living Service Packages – Alternative Plans

AHCA Annual Convention and Exposition - 2007

key elements of success
Key Elements of Success
  • Management is up to the task
  • Ability to project revenues and expenses
  • Know operating efficiencies
  • Clear value for monthly service fee(s)
  • Careful monitoring of Aging in Place
  • Active monitoring of resident profile
  • Tracking Local Occupancies of Assisted Living
  • Up-to-date data regarding service delivery models Integration with referral sources/spectrum providers
physical location of the facility
Physical Location of the Facility
  • Attached to an existing SNF
  • Stand alone facility, on-site of SNF
  • Stand alone facility, off-site

6.03

case study metro
CASE STUDY - Metro

29 Independent Living Units

30 Assisted Living Units

package plan methodology
Package Plan Methodology
  • Heavily dependent on relationship with clients and families
  • Easy to Explain
  • No surprise bill
  • Consumer friendly
  • Assessment tracks increased services
  • Allows negotiated risk
  • Staff has flexibility
personal care package a
Personal Care Package A
  • Our Monthly Service Fee provides you with a base of support which includes our Personal Care Package A:
  • Noon Meal
  • 24-Hour onsite staff
  • 24-Hour emergency response system
  • Weekly light housekeeping
  • Activities and Spiritual programs
  • Scheduled shopping transportation
personal care package b
Personal Care Package B
  • Daily Continental Breakfast & Supper
  • Weekly Bed and Bath Laundry Service
  • 24-hour emergency call system response – up to 3 times per month –

($5.00/additional call)

  • Daily Wellness Check
personal care package c
Personal Care Package C
  • All the services in Personal Care Packages A, B and….
  • Personal Laundry Service–pickup, wash, dry, fold and deliver up to 3 loads per week (does not include dry cleaning).
  • 24-hour emergency call system response - up to 5 times per month -($5.00/additional call)
  • Personalized service plan with staff assistance in the areas indicated in our assessment.
personal care package d
Personal Care Package D
  • All the services in Personal Care Packages A, B, C and …
  • 24-hour emergency system response - up to 10 times per month – ($5.00/additional call)
  • Medication Assistance - up to 3 reminders per day
  • Personalized service plan with staff assistance in the areas indicated in our assessment.
personal care package e
Personal Care Package E
  • All the services in Personal Care Packages above and…
  • 24-hour emergency call system response - up to 15 times per month –($5.00/additional call)
  • Weekly Medication Set up
  • Medication Assistance – up to 6 reminders per day
  • Personalized service plan with staff assistance in the areas indicated in our assessment.
personal care package g
Personal Care Package G
  • All the services in packages above as needed and…
  • 24 – Hour Emergency Call System Response as needed
  • Daily Confusion Management – providing escorts, cueing and reminders for those who require regular daily assistance and oversight
  • Daily Incontinence Management (tenant must provide any needed incontinence products)
  • Personalized service plan with staff assistance in the areas indicated in our assessment
triggers to higher levels of service plans
Triggers to Higher Levels of Service Plans
  • ADL Assessment
  • Non-scheduled ADL Assist
  • Medication Management
  • Medical Monitoring
  • Escorts and cueing due to cognitive needs
  • Wander Alert Door Monitoring
continued stay criteria
Continued Stay Criteria
  • Able to function safely and appropriately
  • Performs ADL with available assistance
  • Feeds self or needs minimal assistance
  • Mobility with devices or available assistance
  • Manages continence w/ available assistance
  • Does not endanger self or others
  • Behaviors managed w/ available assistance
staffing assumptions
1998 Staffing

8.00 FTE P C A

1.00 FTE RN

1.00 FTE LPN

0.50 FTE Housekeeping

0.50 FTE Maintenance

1.00 FTE Manager

12.00 FTE Total

2007 Staffing

8.88 FTE

1.40 FTE

0

1.43 FTE

.50 FTE

1.00 FTE

13.21 FTE Total

Staffing Assumptions
key elements of success50
Key Elements of Success
  • Management is up to the task
  • Ability to project revenues and expenses
  • Know operating efficiencies
  • Clear value for monthly service fee(s)
  • Careful monitoring of Aging in Place
  • Active monitoring of resident profile
  • Tracking Local Occupancies of Assisted Living
  • Up-to-date data regarding service delivery models Integration with referral sources/spectrum providers
pros and cons of the three methods of service delivery
Pros and Cons of the Three Methods ofService Delivery
  • All-inclusive
  • A la carte
  • Package plans
all inclusive53
All-Inclusive
  • Apartment, utilities, meals, building amenities and personal care services included
  • Is based on assessment and service plan but staff are “free to go” with providing assistance as needed
  • Is easy to administer and bill for
  • Difficult to sell as it appears expensive compared to other approaches
  • Difficult to sell because people believe they will not use all of the services
a la carte54
A la Carte
  • Apartment, utilities, building amenities, some meals, some services (i.e. housekeeping) included
  • Additional services are offered on a fee-for-service basis as determined by the assessment
  • Can be based on per service (i.e. med admin), and/or time (i.e. nursing care)
  • Requires staff training in documentation
  • Requires clear communication with resident/family members
a la carte continued
A la Carte - continued
  • Difficult to sell as family members often underestimate the time/work involved in delivering the service (i.e. laundry)
  • Difficult to accurately account for all services; dependent on well trained staff and use of software
package plans
Package Plans
  • Includes apartment, utilities, meals, base level of services (i.e. housekeeping and laundry)
  • Based on assessment, typically using a point system
  • Points add up to levels of care and priced accordingly
  • Can be difficult to sell as not all services in a package are seen as needed
  • Easily administered for service delivery and billing
marketing strategies
Marketing Strategies
  • Consider your market position: what is your competitive advantage in using a particular approach?
  • Consider your pricing position: do you appear to be the most or least expensive?
  • Can potential residents/family members easily compare? You may want to do it for them!
marketing strategies58
Marketing Strategies
  • If you are All-Inclusive
    • Emphasize that they will know exactly what they are getting and will be paying for.
    • No surprises!
    • “Mom will get everything she needs and you won’t be bothered with the details.”
marketing strategies59
Marketing Strategies
  • If you are A la Carte
    • Emphasize the assessment process
    • Constant communication with resident and family on changing health care needs
    • Teach staff to “up sell” when interacting with residents and family members
marketing strategies60
Marketing Strategies
  • If you offer Packages
    • Emphasize the assessment process
    • Suggest that although not all services are needed now, they may be and no additional charges will be made
    • Again, “no surprises” in billing
marketing strategies61
Marketing Strategies
  • Other suggestions from the audience:
if change is needed
If Change is Needed
  • Reason for change
    • Current system is not capturing all costs (most often seen in A la Carte)
    • Aging in place or greater assistance needed
    • Target market doesn’t understand (constantly compared to competitors who have other advantages: newer building)
if change is needed63
If Change is Needed
  • Communicate, communicate, communicate
    • With current residents/family members (grandmother people in)
    • With staff
    • With public
    • Change all marketing/leasing/assessment materials
tips to remember
Tips to Remember
  • Whatever you say you will do, do it
  • Follow your admissions and discharge criteria
  • Be willing to be flexible if someone “doesn’t fit”
  • Develop an approach that works for you
    • Philosophically
    • Market demand changes
    • Staff can understand and manage it
    • Change it if it doesn’t work
financial implications example 1
Financial Implications – Example 1
  • All Inclusive - $4,000 per month
    • $2,500/month housing and basic services
    • $1,500/month for all services
    • 40 residents x $1,500 = $60,000 x 12 months = $720,000
  • What are the care needs of your residents? Not all will need the full level of services provided
  • If fees are not set to equal the full level of services, some residents with lower care needs may be subsidizing others with higher care needs
financial implications example 2
Financial Implications – Example 2
  • Bundled Packages (equal number of residents utilizing each package)
    • 10 residents x $1,500 = $15,000 x 12 months = $180,000
    • 10 residents x $1,000 = $10,000 x 12 months = $ 120,000
    • 10 residents x $ 600 = $ 6,000 x 12 months = $ 72,000
    • 10 residents x $ 300 = $ 3,000 x 12 months = $ 36,000

$408,000 TOTAL

financial implications example 3
Financial Implications – Example 3
  • Bundled Packages (different number of residents utilizing each package)
    • 5 residents x $1,500 = $ 7,500 x 12 months = $ 90,000
    • 5 residents x $1,000 = $ 5,000 x 12 months = $ 60,000
    • 10 residents x $ 600 = $ 6,000 x 12 months = $ 72,000
    • 20 residents x $ 300 = $ 6,000 x 12 months = $ 72,000

$294,000 TOTAL

revenue summary
Revenue Summary

Revenue:

  • Example 1: All inclusive - $ 720,000
  • Example 2: Bundled packages - $ 408,000
  • Example 3: Bundled packages - $ 294,000
  • A la Carte: ? ? ?

Expense:

  • Expenses based primarily on staffing levels
  • What level of staffing will be required to meet the care needs of residents?
  • A la Carte “most efficient”
financial considerations
Financial Considerations
  • If time or point systems used, expense will increase within a package plan until resident “jumps” into the next package level
  • Market or operational considerations may have a greater influence over package types than revenue/ expense considerations.
presenters contact information
Presenters’ Contact Information

651/674-0654

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Questions???

Effective Packaging of Personal Care Services in Assisted Living

NCAL Day – October 7, 2007

2:15-4:15 pm

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