AMERICAN HEALTH CARE ASSOCIATION 2012 QUALITY REPORT

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1 AMERICAN HEALTH CARE ASSOCIATION 2012 QUALITY REPORT

2 Improving Lives by Offering Solutions for Quality Care. AHCA advocates for quality care and services for frail, elderly and disabled Americans, serving as the nation s largest association of long term and post-acute care providers. Our members provide essential care to approximately one million individuals in 8,690 not-for-profit and proprietary member facilities. AHCA represents the long term care community to the nation at large to government, business leaders and the general public. We serve as a force for change, providing information, education and administrative tools that enhance quality at every level.

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4 A NEW DAWN IN AMERICA S SKILLED NURSING CARE CENTERS The long term and post-acute care profession is focused on providing quality care to America s seniors, individuals with disabilities and those who require post-acute care. Quality improvement is a journey involving an ongoing commitment to continually raising the bar on performance expectations. Skilled nursing care centers are no exception. We continue to look for new, better ways to enhance the lives of our residents and their experience in our facilities. This year the long term and post-acute care profession turned a new page on what it means to provide quality care. As the largest association representing our profession, the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) launched our own Quality Initiative. This bold, new effort is unlike any before. We have set specific, measurable targets for our members to meet over the course of the next three years. Our skilled nursing goals include: Safely Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a skilled nursing facility (SNF) stay by 15 percent. The Quality Initiative builds upon much of the work facilities are already doing, but we wanted to further encourage centers nationwide to demonstrate progress through quantifiable goals. There is no single definition of quality care, but one crucial way to look at quality is through data. This report contains the most comprehensive and current data available about the quality of care in skilled nursing care centers. It sets the current benchmarks for our profession and allows us to analyze how we can improve moving forward. While the 2012 Quality Report paints a clear picture of the state of care, it is important to remember that behind the numbers and the charts are real people: our parents or grandparents, our heroes from the Greatest Generation and our friends living with disabilities. They have turned to a skilled nursing care center because they had needs that neither a hospital, nor family and friends, nor home- and community-based service providers could meet. We are honored to serve them and we look forward to continuing to improve the quality of care they receive in our centers each and every day. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, and CNA) by 15 percent. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent. Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the offlabel use of antipsychotic drugs by 15 percent. Neil Pruitt, Jr. Chair, AHCA Board of Governors When we achieve the goals of the AHCA/NCAL Quality Initiative, hundreds of thousands of lives will have been improved residents will have more fulfilling experiences and staff will be more empowered in their professions.

5 TABLE OF CONTENTS Executive Summary 2 The Long Term Care Community 7 Who We Care For 8 Workforce 11 Nursing Facility Staffing 12 Staff Turnover and Retention 12 American Health Care Association Members 16 AHCA Quality Initiative and Activities 17 AHCA Quality Initiative 17 Safely Reduce Hospital Readmissions 17 Increase Staff Stability 19 Increase Customer Satisfaction 21 Safely Reduce the Off-Label Use of Antipsychotics 21 AHCA Programs that Advance Performance 22 Long Term Care Trend Tracker 22 The Advancing Excellence in America s Nursing Homes Campaign 24 AHCA/NCAL National Quality Award Program 25 Trends in Quality 28 Skilled Nursing Facility Quality Measures 28 Regulatory Compliance Measures 29 Five-Star Rating 32 Customer Satisfaction 32 Employee Satisfaction 33 Trends in Payment for Quality 36 State Value-Based Purchasing Programs 36 Value-Based Purchasing Measurement 37 Tying Measurement to Incentive Payments 38 Managed Care 38 Skilled Nursing Reimbursement in Medicaid Managed Care 38 Medicare Advantage Prescription Drug Plans 39 Medicare Value-Based Purchasing Demonstration 40 Patient Protection and Affordable Care Act 40 Accountable Care Organizations and Bundled Payments 40 Medicare-Medicaid Integration 41 Outlook 41 The Year Ahead 43 Appendix 44 References 51

6 EXECUTIVE SUMMARY As the nation s largest association of long term and post-acute care providers, the American Health Care Association (AHCA) represents a diverse group of providers that care for persons across the health care continuum. AHCA represents two-thirds of all for-profit facilities, one-third of not-for-profit facilities and one-third of government facilities in the country. AHCA members are committed to a quality-driven, innovative and efficient healthcare system that meets the needs and preferences of the individuals in our care. In that spirit and in an effort to keep members, policymakers and the public informed about the advancements in quality care, AHCA publishes the annual Quality Report. Compiled from both government reporting and AHCA research, the Quality Report offers an overview of the latest national trends in the profession (including comparing AHCA members to nonmembers), updated information on how skilled nursing facilities are performing on governmental quality measures, and information on current and forthcoming payment models connected to quality care. The Quality Report also highlights ongoing efforts in the long term and post-acute care profession to improve quality care and reports on the current status of those programs and initiatives. Three major trends are notable in this report: Growth of short-term skilled rehabilitation Improvements in quality across spectrum of measures Expansion of value-based purchasing programs Shift from Long-Term Care to Short-Term Rehabilitation Today s skilled nursing facilities care for two distinct populations. Facilities have long been known for providing care to individuals who need long term care because they can no longer live independently at home or in assisted living. However, in recent years, there has been a shift in the types of individuals served in this setting. Now, the majority of individuals served in skilled nursing facilities are people who need rehabilitation or skilled nursing care to complete their course of care following an acute illness. Of the 3.7 million individuals who received care in a nursing facility in 2009, only 854,000 resided in the facility for at least a year. Of the remaining 2.9 million, 80 percent were admitted for short-term rehabilitation covered by Medicare. Individuals with short-term admissions, on average, have greater needs for assistance with Activities for Daily Living and are less likely to have dementia compared to long-stay individuals. As a result of this shift, both the range of services provided by skilled nursing facilities and the acuity of illness of persons served has significantly increased over time. Chronic medical conditions are present in at least onequarter to one-third of all individuals receiving skilled nursing care, with most of these individuals living with multiple chronic conditions. The average case-mix index (a measure of severity of illness) has increased in nursing facilities each year. At the same time, AHCA members continue to be the leading providers of care and services for the nearly one million individuals who do reside in nursing facilities for the long term. For the majority of these individuals, Medicaid is the principal payer for their care. Compared to non-members, AHCA members serve a greater percentage of Medicaid beneficiaries people with very low incomes and minimal assets. Approximately 65 percent of the residents in AHCA-member facilities rely on Medicaid as the principal payer for their care, compared to 61 percent of residents in non-member facilities. Only 20 percent of individuals in member facilities pay for their care out-of-pocket, compared to 24 percent in non-member facilities. Improvements in Quality Quality in skilled nursing facilities is measured by the Centers for Medicare and Medicaid Services (CMS), states and research organizations on the basis of indicators including compliance with regulations, clinical outcomes, staffing levels and consumer satisfaction. Clinical outcome quality measures (QMs) are computed quarterly by CMS and publicly reported on its Nursing Home Compare website. In skilled nursing facilities nationwide, the average performance has improved in 12 of the 15 total QMs over the last five years. The most dramatic improvements were seen in QMs for post-acute care patients, with 29 percent improvement in the proportion of individuals with pressure ulcers and 12 percent improvement in those with pain. For long-stay residents, there has been a 56 percent reduction in the use of physical restraints. In 2010, AHCA members had better scores than non-members for nine of the 15 QMs.

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8 4 AHCA Quality Report Executive Summary Overall staffing trends also show a steady increase in the amount of direct care nursing time per resident day for all levels of nursing staff including Registered Nurses (RNs), Licensed Practical and Vocational Nurses (LPNs/LVNs) and Certified Nursing Assistants (CNAs). In addition, turnover has decreased for all nursing staff in direct care roles, as well as for nurses with administrative duties and for all nursing staff in the aggregate over the past several years. In order to take part in the Medicare and Medicaid programs, skilled nursing facilities must comply with federal regulations. Compliance is assessed by state surveyors contracted by CMS. All of the reported measures for regulatory compliance showed improvement over the last five years. The average number of deficiencies has steadily declined and the number of facilities cited for Substandard Quality of Care or Immediate Jeopardy also showed an overall downward trend. At the same time, the proportion of skilled nursing facilities with deficiency-free surveys has increased. CMS also rates skilled nursing facilities through its Five-Star Rating System, which is incorporated into the Nursing Home Compare website. Since the implementation of the rating system at the end of 2008, the percentage of facilities receiving an overall rating of four or five stars has steadily increased to 43 percent of facilities in these two categories combined. The proportion of facilities receiving a one or two star rating has correspondingly decreased. The improvement in overall ratings is attributable to increases in staffing levels and improvement in quality measure performance. Additional key measures of quality care include satisfaction rates among customers (both residents and family members) and nursing facility employees. Since 2008, customer satisfaction ratings for long-stay residents and their families have remained stable at 89 percent and 87 percent respectively. While short-stay patient satisfaction ratings have lagged behind those of their long-stay counterparts, short-stay customer ratings have increased nine percentage points since 2008, from 78 percent to 87 percent in Despite an improvement in employee satisfaction rates for nurses and nursing assistants since 2005, their rate of satisfaction only reached 67 percent in 2011, demonstrating significant room for improvement. Tying Reimbursement to Quality The historic method of purchasing skilled nursing facility care using fee-for-service payment structures rewards providers with higher costs and higher volume, regardless of the quality of outcomes. However, in recent years, reimbursement trends across health care settings for both Medicare and Medicaid have begun to shift from payments based on volume and type of services provided to payments based on outcomes and quality. Payment methods intended to foster specific provider behaviors and better outcomes are often referred to as pay-for-performance or value-based purchasing (VBP) arrangements. In an effort to provide additional resources to skilled nursing facilities and further emphasize quality care for Medicaid beneficiaries, many states are exploring VBP programs. In 2012, 12 states with AHCA affiliates were operating these arrangements. So far, states have tested a variety of approaches to VBP with mixed results. Both Medicare and Medicaid managed care are rapidly replacing traditional fee-for-service arrangements as the dominant payment and service delivery systems. Many states with existing managed care programs are aggressively pursuing managed long term care expansions. Eleven states were operating some form of Medicaid managed long term care statewide or regionally in By 2014, approximately 26 states will have some form of Medicaid managed long term care. However, it is unclear at this point if and how managed care will incorporate VBP models. The Patient Protection and Affordable Care Act (ACA) established three national efforts with implications for quality incentive payments: Accountable Care Organizations (ACOs), bundled payments and Medicare-Medicaid integration efforts. All three of these initiatives are still unfolding and little detail is available on how or whether quality incentives for skilled nursing facilities may be included. However, all three seek to facilitate and encourage coordinated and integrated care and reward providers who improve quality while lowering cost, very likely impacting long term and post-acute care. Through two new entities established within CMS the Medicare-Medicaid Coordination Office (MMCO) and the Center for Medicare and Medicaid Innovation the ACA aims to better integrate the two programs for individuals who are eligible for both. Currently, 28 states are working with MMCO on some form of Medicare- Medicaid integration initiative.

9 AHCA Quality Report Executive Summary 5 Through improvements in a majority of quality measures, declines in citations, increases in staffing levels and improvements in customer satisfaction rates, skilled nursing facilities have demonstrated their commitment to improving quality of care. Conclusions People who receive care in skilled nursing facilities and their families have increasingly higher expectations for the quality of services provided. They are rightfully demanding excellent outcomes and maximum value. Skilled nursing facilities are well on their way to transforming their operations to meet the quality and value demands of their customers and of government payers. Through improvements in a majority of quality measures, declines in citations, increases in staffing levels and improvements in customer satisfaction rates, skilled nursing facilities have demonstrated their commitment to improving quality of care. This commitment has been accelerated by new collaborative efforts of the profession in partnership with government and other stakeholders. The Advancing Excellence in America s Nursing Homes (AE) campaign brings together a variety of the profession s stakeholders to activate and support skilled nursing facilities as they improve their performance in key clinical and organizational areas. Through AHCA s software tool LTC Trend Tracker SM, independent and small regional providers now have easy access to the kinds of key quality and operational information needed to examine and benchmark performance that were previously only available to larger skilled nursing care center chains. Additionally, AHCA is driving quality improvement through the AHCA/NCAL Quality Awards Program which establishes criteria and pathways and provides peer recognition for providers on their journey toward performance excellence. Finally, earlier in 2012, AHCA/NCAL launched the Quality Initiative, a member-wide challenge to meet specific, measurable targets in hospital readmissions, staff stability, customer satisfaction and the off-label use of antipsychotics. Taken together, the Quality Initiative offers the potential to dramatically improve outcomes and satisfaction for hundreds of thousands of individuals in long term and postacute care, all the while reducing health care costs. Medicare and Medicaid budgetary pressure will continue to drive policymakers and skilled nursing care providers to explore payment methodologies which offer the promise of greater accountability and efficiency. The quality efforts already underway by the profession are preparing skilled nursing care providers for payment reforms that are currently being evaluated by government entities. By continuing to expand their capacity to effectively manage, measure and monitor specific areas of care, providers will be better equipped to adjust to payment models based on quality of services and new organizational structures within the health care system.

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11 THE LONG TERM CARE COMMUNITY As the baby boomers age, demands for long term care services are expected to grow. While home- and communitybased services have expanded nationally to help meet this growing demand, many individuals will still need long term care in a skilled nursing facility. Simultaneously, the need for short-term rehabilitation following acute illness and hospitalization is growing as the elderly live longer and are hospitalized for a wide range of illnesses. This section of the report examines trends in nursing facilities in light of these circumstances. The total number of nursing facilities and the total number of beds has essentially remained static over the past five years at approximately 15,700 facilities and 1.7 million total beds. The number of not-for-profit facilities has decreased 9.5 percent while there has been a 2.9 percent increase in the number of for-profit facilities. While a majority of facilities are classified as Table 1.1 for-profit, publicly traded companies 1 control only 6.8 percent of skilled nursing facilities nationally. Detailed trends from 2007 to 2012 in the number and types of facilities nationally are reported in Table 1.1 and Table A1. Overall, 69 percent of skilled nursing facilities serve urban communities, while only 31 percent are located in rural areas. For-profit and not-for-profit facilities are largely located in urban areas. Of urban facilities, approximately two-thirds are classified as for-profit and onequarter are classified as not-for-profit. Government facilities are more evenly divided between urban and rural locations with 42 percent of government facilities in urban areas while 58 percent are located in rural areas. Approximately 72 percent of for-profit facilities are located in urban areas, while 28 percent are in rural areas. In not-for-profit facilities, 68 percent are in urban locations while 32 percent are in rural locations (Table A2). The number of Medicare-certified beds has remained essentially unchanged over the last six years, but the number of Medicaid-only certified beds has declined by 44 percent (Table A1). This trend likely represents the payment levels associated with the Medicare and Medicaid programs. The Medicare Payment Advisory Commission s (Med- PAC) annual reports have consistently shown positive Medicare margins for skilled nursing facilities while Medicaid margins are negative (MedPAC, 2012). Given the average $19.95 per Medicaid 1 There are nine publicly traded companies among the top 50 chains in the country and include Ensign Group, Extendicare, Kindred Healthcare, National Healthcare Corp, Skilled Healthcare, Sun Healthcare Group, Advocat Inc., Brookdale Senior Living and Five Star Quality Care, Inc. (Provider, 2012) Long Term Care Community National Overview Number of Facilities (Total) 15,866 15,772 15,718 15,694 15,693 15,690 For-Profit 10,521 10,581 10,607 10,641 10,758 10,832 Not-for-Profit 4,382 4,244 4,199 4,145 4,030 3,968 Government Total Beds 1,717,691 1,713,059 1,709,468 1,708,355 1,705,921 1,705,165 Average Number of Beds (All) Occupancy Rate 89.0% 88.6% 88.0% 87.5% 87.0% 86.6% Number of Persons Served at Any Given Time 1,431,134 1,420,735 1,411,054 1,400,484 1,395,832 1,387,727 AHCA Analysis, CMS CASPER Data, various years

12 8 AHCA Quality Report The Long Term Care Community While home- and community-based services have expanded nationally to help meet this growing demand, many individuals will still need long term care in a skilled nursing facility. patient day shortfall in Medicaid skilled nursing care payment rates (Eljay, 2011), the declining trend in Medicaid-only beds is of little surprise. The average number of beds per facility has remained unchanged at 108. Forprofits on average have more beds per facility than not-for-profits (Table 1.1). Approximately 20 percent of facilities are small, with less than 60 total beds, while 20 percent have more than 140 beds (CMS CASPER data, March 2012). There is essentially no difference in average beds per facility when comparing multi-facility ownership with independently-owned facilities. On any given day, the number of individuals in skilled nursing facilities averages 1.4 million (Table A1). That number has declined by three percent since This translates into a steady decline in occupancy rates over a six-year period, from 89 percent in 2007 to 86.6 percent in This decline may reflect the shift to greater use and financing of home- and community-based services and assisted living during this time period. At any single point in time, Medicaid is the major payer for care in a skilled nursing facility, with an average of 64 percent of individuals being Medicaid beneficiaries. Private pay individuals constitute 22 percent of the payer mix and Medicare is 14 percent (Figure 1.1). However, these percentages do not reflect the payer mix of all residents receiving services over time as they only reflect individuals in a facility on any given day rather than all individuals being admitted to a facility over time. For-profit facilities are more likely than not-for-profit facilities to provide services to Medicaid beneficiaries. In for-profit facilities, 59 percent of individuals are Medicaid beneficiaries, compared to 46 percent in not-for-profit facilities. Government facilities have the highest percentage of residents who are Medicaid beneficiaries, at 65 percent. For-profit facilities are also more likely to provide services to individuals whose stay is covered by Medicare. In for-profit facilities, 13.7 percent of individuals use Medicare as the primary payer compared to 11.3 percent of residents in not-forprofit facilities. For-profit facilities are significantly less likely to have individuals paying privately. In not-for-profit facilities, 25 percent of residents are classified as private pay compared with only 17 percent in for-profit facilities (Figure 1.1). Medicare covers up to a maximum of 100 days of skilled nursing facility care as long as the person continues to demonstrate improvement from Medicare covered services. Approximately 67 percent of individuals have Medicare coverage for less than 30 days (MedPAC, 2010). To qualify for this benefit, the individual must have had a three-day inpatient hospital stay within the last 30 days and require daily skilled nursing care, such as wound care or intravenous therapy, or rehabilitation services, such as physical, occupational or speech therapy. On average, about 25 percent of all individuals admitted to a skilled nursing facility for rehabilitation services are discharged to home. The remaining individuals stay in the facility and either pay for services privately or through Medicaid coverage (MedPAC, 2012). Since Medicare pays only for short-term, post-acute care, Medicaid often pays for long-term stays in skilled nursing facilities. This explains why, on any given day, only 14 percent of individuals in skilled nursing facilities have their stay paid for by Medicare while 64 percent are paid by Medicaid. However, when examining all 2.9 million admissions to skilled nursing facilities, 80 percent had Medicare reimburse some or all of their stay (Table 1.2). This demonstrates that facilities have high turnover of individuals covered by Medicare as compared to individuals covered by Medicaid, who are staying for longer periods of time. In fact, only 854,000 individuals remain in a facility for at least one year despite nearly 2.9 million individuals being admitted to skilled nursing facilities each year (Table 1.2). WHO WE CARE FOR In the past, skilled nursing facilities cared primarily for individuals who could no longer live at home independently (e.g., long-stay residents). However, with greater pressure to shorten

13 AHCA Quality Report The Long Term Care Community 9 Figure 1.1 Primary Payer of Services For-Profit Principal Payer of Services Not-for-Profit Principal Payer of Services Government Principal Payer of Services 17% 14% 25% 11% 24% 8% 59% 46% 65% AHCA Analysis, CMS CASPER Data, March 2012 Medicare Medicaid Other Figure 1.2 Age Distribution Medicare Admissions Non-Medicare Admissions Long Stay Residents ( >12 Months) 33.4% 10.4% 29.0% 29.6% 44.4% 14.9% 56.2% 41.4% 40.7% AHCA Analysis, CMS MDS 2.0 data, 2009 Less than 64 years Between 65 and 84 years Greater than 85 years

14 10 AHCA Quality Report The Long Term Care Community hospital lengths of stay as well as the development of assisted living and the expansion of home- and communitybased service options, the types of individuals cared for in skilled nursing facilities has changed. There are now two distinct populations cared for in America s skilled nursing facilities: (1) individuals who need rehabilitation or skilled nursing care to complete their course of care following an acute illness (2) individuals who need long term care because they can no longer live independently at home or in assisted living As a result of the changing populations in skilled nursing facilities, both the range of services provided by these facilities and the acuity of illness of persons served has significantly increased over time. Tables 1.2 and A3 compare 2009 Medicare, non-medicare and longstay admissions. Medicare admissions include those that were admitted from an acute care hospital. Non-Medicare admissions may be admitted from the community or after a non-qualifying Medicare hospital stay. Long-stay residents include individuals that reside in the facility for at least one year. Short-stay individuals admitted on Medicare are significantly older at admission than non-medicare admissions and are more likely to be female. Short-stay individuals on Medicare are, on average, 78.5 years old at admission compared to non-medicare individuals who are 73.4 years old. Long-stay individuals residing in a facility for at least one year averaged 79.5 years old at admission. Individuals under the age of 65 are more likely to be non-medicare admissions, and only 15 percent of long-stay individuals are on under age 65. More than three-quarters of residents are classified as Caucasian in both short- and long-stay populations. This reflects the demographic characteristics of this age cohort in the United States (U.S. Census, 2010). A large proportion of individuals in skilled nursing facilities for both short- and long-stays have impaired functional status (Table 1.2). Dementia and incontinence are the leading reasons for needing long term care in a skilled nursing facility. Nearly one-third of short-stay admissions are living with a cognitive impairment like dementia but, as expected, nearly two-thirds of those who stay in a facility long-term have dementia. Similarly, persons admitted for rehabilitation are far less likely to be incontinent compared to long-stay residents. Those without dementia or incontinence are more likely to be discharged home following their post-acute stay. Table 1.2 Characteristics of Individuals Receiving Services in Nursing Facilities Medicare Admissions Non-Medicare Admissions Long-stay Residents ( >12 months) Total # Individuals 2,329, , ,358 Age Category Age (Average) Gender Male 36.6% 39.5% 29.3% Female 63.3% 60.4% 70.7% Functional Status Dementia 29.5% 38.0% 63.7% ADL Dependence 4.4% 4.2% 4.1% Require Assistance with Walking 90.9% 80.6% 76.0% Incontinence of Bladder 35.8% 39.6% 66.4% Require Assistance with Eating 28.3% 28.0% 35.6% AHCA Analysis, CMS MDS 2.0 data, 2009

15 AHCA Quality Report The Long Term Care Community 11 Individuals admitted to a skilled nursing facility for a short-stay have higher levels of activities of daily living (ADL) dependence than long-stay residents. Activities of daily living include five activities: getting in and out of bed, bathing, eating, dressing and using the bathroom. Long-stay residents, on average, are dependent in 4.1 out of the five ADLs while short-stay, on average, are dependent in 4.4 at admission. Shortstay residents also require more assistance with walking in the hallways. While 76 percent of long-stay residents require assistance to walk, more than 90 percent of short-stay residents need assistance. This is consistent with what would be expected. Short-stay individuals are often admitted to skilled nursing facilities for rehabilitation services to improve ambulation following treatment for an acute illness in a hospital. The average degree of assistance needed with ADLs for individuals in skilled nursing facilities has steadily increased each year (Figure 1.3), as has the average case mix, a measure of severity of illness (Figure 1.4). This reflects the changing population in skilled nursing facilities and the increasing care needs of this population. Chronic medical conditions are common in skilled nursing facilities. At least one of these conditions is present in onequarter to one-third of all individuals in skilled nursing facilities (Table A3). However, most individuals are living with multiple chronic conditions. Reflecting the functional limitations discussed above, most individuals admitted to skilled nursing facilities from the hospital receive speech, occupational or physical therapy (Table 1.3). Figure 1.3 Average ADL Dependence Trends in Resident ADL Dependence Computed by AHCA using CMS Nursing Facility CASPER standard health survey data. This measure for ADLs is obtained by taking the sum of residents that are somewhat (assisted and dependent combined) or fully dependent on staff for the five ADLs (dressing, bathing, transferring, toileting and eating) divided by the total number of residents. Figure 1.4 Average case mix index Average Case Mix Index AHCA analysis of CMS SNF PPS claims data, various years. Nearly one in four individuals receives all three services. Most individuals admitted to a skilled nursing facility following a hospital admission also have recently received or are receiving an intravenous (IV) medication. Both rehabilitation services and IV services are rarely required for long-stay residents (Table A3). WORKFORCE According to data from the U.S. Bureau of Labor Statistics (BLS), approximately 1.7 million workers were employed at skilled nursing facilities across the United States in 2010 (this does not include other types of long term care facilities, such as assisted living and other residential care facilities). Approximately one million people, including Registered

16 12 AHCA Quality Report The Long Term Care Community Table 1.3 Therapies Therapies received during stay Any Therapy (Speech, OT, or PT) Nurses (RNs), Licensed Practical and Vocational Nurses (LPNs/LVNs) and Certified Nursing Assistants (CNAs), provided nursing care to residents. Of these workers, the majority were CNAs. From 2005 to 2010, nursing facilities have provided a growing source of employment nationwide in all labor categories (Table A4). Nursing Facility Staffing Often cited as a key indicator of quality of nursing facility care, staffing is typically expressed in terms of hours of staff time per resident day. Over the past five years, as shown in data from CMS in Table A5 and Figure 1.5, the overall staffing trend shows a steady increase in the amount of direct care nursing time per resident for all levels of nursing staff. Overall nursing staff time per resident day across all three categories is up almost nine percent from 2007 to Medicare Admissions Non-Medicare Admissions Long-stay Residents ( >12 months) 92.4% 61.6% 8.9% Speech Therapy 24.9% 14.8% 1.9% Occupational Therapy 86.4% 54.4% 4.2% Physical Therapy 89.6% 58.5% 5.2% Combination of therapies received Speech & OT 23.5% 13.1% 0.5% Speech & PT 23.6% 13.3% 0.5% OT & PT 84.4% 52.2% 1.8% Speech, OT & PT 23.0% 12.6% 0.3% AHCA Analysis, CMS MDS 2.0 data, 2009 As part of the CMS Five-Star Quality Rating System - which has been available on since the end of 2008, allowing consumers to access and compare information about nursing facilities - a rating of between one and five stars is assigned to each facility for their staffing levels. The ratings are determined based on the overall number of nursing staff as well as the number of RN staff per resident day. These staffing levels are adjusted to take into account the acuity of individuals served in each facility. As shown in Figure 1.6, from 2009 to 2011 there has been a 19 percent increase in the proportion of facilities receiving a staffing rating of four or five stars. In 2011, 47.9 percent of facilities received either a four or five star rating, compared to 40.3 percent in Correspondingly, 22 percent fewer facilities were rated as one or two stars, with 39.5 percent receiving one or two stars in 2009 and 31 percent receiving the same in Staff Turnover and Retention AHCA conducts periodic nationwide staffing surveys available to all Medicare and/or Medicaid-certified nursing facilities, collecting annual retention and turnover information for all employees (except temporary and contract staff) who work(ed) in skilled nursing facilities. In 2010, more than 3,700 nursing facilities from across the country (both AHCA members and non-members) participated in this survey. AHCA defines retention as the number of employees who have worked in a nursing facility for 12 months or longer divided by the number of current employees at the end of the calendar year. Turnover is defined as the number of terminations (voluntary and involuntary) in a given year divided by the total number of current employees at the end of the calendar year. From 2008 to 2010, turnover decreased for all nursing staff in direct care roles, as well as nurses with administrative duties and for all nursing staff in the aggregate (Figure 1.7). Nursing staff in direct care roles include CNAs, LPNs/LVNs and staff RNs. The retention rates in these same job categories increased slightly or remained relatively stable between 2008 and 2010 (Figure 1.8). Turnover rates for staff in administrative, food services and housekeeping positions improved from 2008 to 2010, while turnover increased for those working in therapy and social services roles (Figure 1.9). Retention shows positive trends in all of the non-nursing job categories over this same time period (Figure 1.10).

17 AHCA Quality Report The Long Term Care Community 13 Figure 1.5 Direct Care Nursing Hours per Resident Day CMS-CASPER/OSCAR Data, March various years RN LPN CNA TOTAL Figure 1.6 Trends in Five-Star Staffing Ratings 7.5% 32.8% Percent of Facilities 8.4% 37.0% 8.9% 39.0% The overall staffing trend shows a steady increase in the amount of direct care nursing time per resident for all levels of nursing staff. Figure 1.7 Trends in Nursing Staff Turnover from % 20.8% 21.1% Percent of Nurse Turnover 18.9% 20.6% Oct % 15.9% Oct % 13.6% Oct % 25.9% 26.0% 34.2% 36.3% 28.9% 42.8% 46.7% 41.0% 43.0% 41.8% 34.7% 53.5% 46.6% 42.6% 48.7% 45.2% 39.5% 5 Stars 4 Stars 3 Stars 2 Stars 1 Stars DONs ARNs RNs LPNs/LVNs CNAs All Nursing Source: Abt-Associates., 2012 AHCA Reports on staffing turnover surveys, various years. Available at

18 14 AHCA Quality Report The Long Term Care Community According to data from the U.S. Bureau of Labor Statistics, approximately 1.7 million workers were employed at skilled nursing facilities across the United States in Figure 1.8 Trends in Nursing Retention from Figure 1.9 Turnover Other Job Categories Percent Turnover Percent of Nurse Retention 20.5% 20.3% 18% 16.7% 30.8% 25.7% 45.7% 37.7% 33.7% 28.5% 28.0% 24.3% 19.5% 24.7% 22.5% Administrative Therapy Food Services Housekeeping Social Services & Activities AHCA Reports on staffing turnover surveys, various years. Available at Figure % 74.3% 75.4% 66.3% 70.0% 69.9% Retention Other Job Categories Percent Retention 82.1% 85.6% 84.8% 73.9% 77.9% 82.5% 69.6% 75.0% 73.9% 77.7% 81.4% 81.1% 77.9% 82.4% 81.4% 79.8% 82.2% 67.2% 71.7% 80.8% 71.7% 73.5% 72.5% 68.9% 69.7% 69.7% DONs ARNs RNs 71.7% LPNs/LVNs CNAs All Nursing Administrative Therapy Food Services Housekeeping Social Services & Activities AHCA analysis on 2008, 2009 and 2010 nursing facility staffing survey data AHCA analysis on 2008, 2009 and 2010 nursing facility staffing survey data

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20 AMERICAN HEALTH CARE ASSOCIATION MEMBERS AHCA represents 55 percent of the more than 15,000 skilled nursing facilities in the United States today. AHCA members provide essential care to individuals in 8,690 not-for-profit, proprietary and government facilities. As of 2012, at any point in time, more than 770,000 individuals are receiving care in an AHCA member facility. As the nation s largest association of long term and post-acute care providers, the American Health Care Association (AHCA) represents a diverse group of providers that care for individuals across the long term and post-acute care continuum. AHCA represents 55 percent of the more than 15,000 skilled nursing facilities in the United States today. AHCA members provide essential care to individuals in 8,690 not-for-profit, proprietary and government facilities. As of 2012, at any point in time, more than 770,000 individuals are receiving care in an AHCA member facility. are part of smaller, regional multi-facility groups. Less than 12 percent of AHCA s members are part of a publicly traded company. Independently-owned and operated facilities account for 37 percent of AHCA s membership. Table 2.1 compares 2012 statistics on the number of facilities and facility types for AHCA members and non-members. AHCA member facilities comprise 930,011, or 55 percent, of all skilled Table 2.1 nursing facility beds in the United States. With the average bed size of an AHCA member facility 107 beds, member facilities are slightly smaller compared to the national average, 108 beds, as well as non-members, 110 beds. At an average of 93.5 beds, AHCA not-for-profit facilities also tend to have fewer beds than the national average, while proprietary member facilities average slightly higher at 110 beds. AHCA members tend to be slightly smaller when comparing bed count in government facilities as well. However, at 87.5 percent, the AHCA member occupancy rate is greater than the national average of 85 percent. As with the nation, AHCA members are more likely to be situated in urban areas than rural areas. However, when compared to non-members, AHCA members are less likely to be urban and more likely to be rural. Approximately 68 percent of AHCA members are located in urban areas, compared to 71 percent of non-members. At the same time, 33 percent of AHCA members are in rural locations while 29 percent of nonmembers are rural (Table A2). AHCA represents 64 percent of the nation s for-profit facilities, 36 percent of its not-for-profit facilities and 39 percent of its government facilities. AHCA member facilities include both those owned by multi-facility corporations and independently-operated facilities. Nearly two-thirds of AHCA s membership is comprised of facilities that are part of a multi-facility operation. Approximately half of these facilities are part of a large national chain and the remaining half Number of Facilities and Ownership Type Member Non-Member Total Total Number of Facilities 8,690 7,000 15,690 For-Profit Facilities 6,917 3,915 10,832 Not-for-Profit Facilities 1,428 2,540 3,968 Government Facilities Facility Type Multi-Owned Facilities 5,463 3,134 8,597 Independent Facilities 3,227 3,886 7,093 AHCA Analysis, CMS-CASPER data, March 2012

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