REFORM IN MOTION

Lessons from the SeniorChoices Long Term Care Demonstration 

May, 2007

Village Care of New York

Herbert H. Fillmore
Executive Vice President SeniorChoices

Arthur Y. Webb
President & CEO

Support for this report provided by a grant from the New York State Department of Health to Village Center for Care, Grant Number:   C-012150

Initial Report (October, 2005- March, 2006)

Suggested citation:

Fillmore, H., Webb, A., Reform in Motion, Lessons from Village Care’s  SeniorChoices Long Term Care Demonstration Project, http://www.vcny.org, 2007

Copyright 2007 © Village Care of New York.

Acknowledgements

We would like to thank the following individuals and entities for their contributions to this report, and/or the work of SeniorChoices.  The Board of VCNY, Charles Persell, Board Chair,  Msgr. Chuck Fahey, SeniorChoices Committee Chair, Allison Nidetz, VCNY PACE administrator, Neil Pollack, VCNY Village Nursing Home Administrator, Natalie Zarrillo, VCNY Care Advocate, Renee Cottrell, Director, Lightbulb Project, Kathy Triche, PhD, Director NNORC, Ellen Flaherty, PhD, VCNY VP for Quality, Allison Silvers, VCNY Director of Strategic Grants and Business Development, Lou Ganim, VCNY Director of Public Relations, Emma DeVito, COO & EVP of VCNY, the other members of the executive team at VCNY, the staff of the Village Nursing Home who participated in the architectural design sessions and Building for the Future Committee, staff and leaders of 1199 SEIU, the leaders and staff of the New York State Department of Health,  the The Fan Fox & Leslie R. Samuels Foundation

for early support of our NNORC  work, the Tuttle Foundation for support of the Lightbulb Project, the New York State Health Foundation for support of Day Rehab,  Diana Sung and her team at Perkins Eastman Architects, Alex Stark, Feng Shui consultant, Manny Halperin, Ergonomics consultant,  the staff and leadership of the Caring Community, Saint Vincent’s Manhattan, the Rusk Institute Rehabilitation Network, our many other community partners, and the seniors of lower Manhattan who inspire and teach us every day.

Foreword   

Arthur Y. Webb, President & CEO, Village Care of New York

Our board and staff have been deeply engaged in preparing Village Care to lead and manage change. In preparing this report, it gave us a chance to step back and   see what we have done over the past 18 months. We are proud of our work and the leadership that our staff demonstrates everyday.

Trying to balance our day to day work while introducing a major transformation was extremely challenging. During the past 18 months, it has taken all the patience, persistence, and promotion by our board and senior executives to make progress on our promise of a better day for seniors in our community.

The people we serve everyday are always in the front of our thinking. Indeed, if the seniors do not see value in what we are doing, then it really does not matter what new services or reform we produce. It is all about meeting needs at the local level. Being in tune and staying in touch are key to our efforts.

There are two essential lessons from our work that are reflected in this report: first is a vision of what the system of care will look like 10 years from now; and second is the absolutely essential requirement of having ALL staff at all levels of the organization deeply engaged and committed to this vision. On both counts we are making strides.

Village Care
SENIORCHOICES DEMONSTRATION

Executive Summary- First 18 months

Under legislative demonstration authority established in 2005 in Public Health Law section 2807-x, Village Center for Care (VCC) has embarked upon a four-year initiative to implement an integrated residential and community long term care system named SeniorChoices. This report documents the progress and lessons learned from our first eighteen months of operations.

Our most significant milestone was the creation of a new model for skilled nursing facilities. We also made strides in shifting the overall focus of our senior services from institutional to community-based care and from care provision in single sites to care provision and management across time, place and discipline.

Creating a new, state-of-the-art facility required a dedicated team of clinical and administrative staff, nationally recognized architects, Perkins Eastman, a construction firm, “green” consultants, and engineers.  This team balanced cost, design, clinical needs and customer preferences to design a state-of-the-art nursing center. 

This facility, named the Village Center for Rehabilitation and Nursing (VCRN), will maximize independence, dignity, and quality of care. More than 50 percent of the rooms will be private. Dining areas are “home-like.” The rehabilitation space offers the best equipment available. On two special residential floors, end-of-life, palliative care will be delivered in a calming environment that will allow family and friends to gather for the last journey of life.

Another important feature of this facility will be the utilization of the latest information technologies, including an Electronic Medical Record (EMR) and decision support system to improve clinical care, promote worker empowerment and assist with care management and transitions within and across the system of care we are building. An additional key technology will be the advanced wireless communication devices deployed throughout the building for all staff to promote teamwork and more responsive customer service. 

In anticipation of the new facility, we also undertook extensive work to define new roles for frontline workers. To this end, 1199 SEIU acted as partners in laying out a process to define these new roles, develop needed training and prepare transition plans for current job-holders. 

In addition to our work on a new nursing home model we also designed and implemented a new set of specialized residential and community services—often in partnership with others—that offer specialty care in response to the needs expressed by consumers and professionals in the community. 

These efforts will provide alternatives to traditional long term residential beds.  We doubled the number of short-stay rehabilitation beds at the Village Nursing Home to 70 beds, with new specialties in cardiac, wound, orthopedic and stroke care as part of the Rusk Institute Continuing Care Network.  New specialized dementia, Parkinson’s, and behavioral services were introduced into community programs.  We developed a short-stay day-rehabilitation program for the interdisciplinary post-acute care of individuals in a day care setting. We implemented a new Neighborhood Naturally Occurring Retirement Community program to provide case finding, health screening and referral services to seniors who are isolated and underserved.  One hundred and twenty five Long Term Home Health Care Program (LTHHCP) “slots” were opened in Manhattan. We submitted an application for 80 Assisted Living Program (ALP) beds. Finally, we secured the authority to pursue a Program of All Inclusive Care for the Elderly (PACE) license, and planning is well underway for that program to open at the end of 2008.

Lessons for Village Center for Care as a provider

1. Building specialized capacity to serve complex cases is required to meet emerging needs: One of the most exciting and productive lessons came from implementing specialized services. This specialization increased our capacity to serve complex patients in multiple settings and established a platform for future growth.  Consumers and other providers are demanding specialization. As care moves into the community, it is necessary to take some of the specialty services that were housed in institutions and make them available in the community.

2. Involving the Community: The Village Nursing Home was “saved” by the community 30 years ago. We have very strong ties to our community. We worked closely with the community in the design of the new nursing home and exploring alternatives to institutional beds. We learned that our community and families are not averse to moving away from institutional-centric approaches, but they are cautious, and want the alternatives to feature strong clinical care, a full set of choices, and demonstrate the ability to help seniors negotiate transitions.

3. Building Community Services Requires New Ways of Doing Business: VCC has opened many new programs with the goal of offering a wider array of choices. We found that getting approval, maintaining compliance and achieving fiscal viability is extremely hard while simultaneously transforming our organization to manage more services across a number of non-institutional settings.

4. Importance of Partnerships:  The needs of seniors are complex and must be met in a variety of settings. A truly comprehensive system will provide integrative mechanisms across those settings. It will begin by building on clinical partnerships and grow those into program partnerships. We have seen success in this area with NYU/Tisch/Rusk, St. Vincent's Hospital and Medical Center, the Caring Community, specialty associations and specialty providers.

5. Quality Outcomes for Systems are Needed: We need new quality measures to track and evaluate the transition of patients across settings. We will be developing these measures and others that are good indicators for the quality of care advocacy.

 

Lessons for Policy Makers

1. Regulatory and Licensing need to move at the pace of change: The major lesson is that the governmental approval process needs to be examined to bring it into line with system building at the provider level. Building an integrated residential and community care model requires having all the pieces in place in a timely manner.  

For example, we are downsizing our community’s skilled nursing capacity from 200 beds at VNH to 105 beds at VCRN. However, the individuals who would have been admitted to the 95 decommissioned beds still have a need for care.  Many of those individuals have advancing memory loss and need some congregate residential care, albeit not 24 hour skilled nursing. Our solution for this issue is to create a specialized Assisted Living Program (ALP) in the community. The regulatory approval process for that ALP will need to be brisk if that program is going to be “on line” when the existing nursing home closes and the ALP beds are needed. This problem of trying to synchronize the regulatory approval process to “bring up” new programs while rightsizing older ones is not unique to us.

2.   Construction cost bed caps need to be revised: Real estate and construction cost escalations are extreme in Manhattan and current reimbursement methodologies do not recognize these realities and will restrict the replacement and growth of new centers for care.

3.   Certain building requirements need to be re-examined: There are some regulatory requirements that contribute to unnecessary costs. In this environment, even marginal unnecessary regulatory requirements can have a large dollar impact.

4.   Capacity to serve SNF patients in the community: Dollars are needed for diversion and SNF outplacement for residents seeking to return to community: examples include rent deposits, potential modifications to the home and brief rent supplementation while securing additional funds. The most common barriers to diversion and resident outplacement are lack of housing and patients’ mental health conditions. Regulations and payer policies limit efficient/effective combination of resources (example: limited ability to provide coordinated medical day and home care)

5.   Dementia care cannot be managed in the home over long periods of time: We are finding that in an urban environment we cannot create sufficient safe capacity in the home. There is not sufficient “social capital” in the community or among relatives and friends to fill the needs for supervision, and scattered housing is economically inefficient. We need dedicated ALP beds to serve the dementia population and transfer the expertise we have gained in the nursing home to this setting, where most of our residents could live safely.

6.   A new licensed entity is needed to promote comprehensive coordinate systems of long term care, the Long Term Care Integrated Delivery System (LTC IDS).