• A REPORT
TO THE
ARIZONA
• LEGISLATURE·
•
COMPR EHENSIVE
I l 0N·
GTE,:R'.· r.'. A} R"~ E~:~.~.";.
~~ t' I",",
• IN ARIZOf~A
• EXECUTIVE SUM ARY
AND RECO ME.I\~D TI()NS
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MARCH, 1982
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ABO U T T HIS SUM MAR Y I I I
House Bill 2081 was enacted by the 35th Arizona Legislature
as a blueprint for an improved system of long-term care.
The desired system calls for one level of nursing home care
within which each client or patient would receive nursing
and other needed services appropriate to the acuity of his
or her condition or health needs. In addition, House Bill
2081 formalizes the long-standing principle that people have
a right and should be assisted to reside in the least
restrictive environment.
As a part of the implementation strategy written into the
legislation, the Arizona Department of Health Services is
required to prepare a comprehensive report for the president
of the Senate, the speaker of the House of Representatives,
and the Governor. A preliminary report was submitted on
December 1, 1981.
This present document summarizes the Department's final
report, and includes the recommendations in that report.
In at least one respect, the Department's proposals go
somewhat beyond the precise mandates in House Bill 2081.
wnile the bill focuses primarily on the medically indigent,
the proposed strategies would serve all in need of longterm
care. The aging and the aged would make up the
majority of those served by the desired system; however,
these proposals would accommodate long-term care clients
and patients of all ages .
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SPECIFIC LEGISLATIVE CONCERNS
House Bill 2081 assigns to the Department a number of tasks
designed to promote implementation of the desired system.
These areas of exploration are set down verbatim as they
appear in the legislation:
1. The vo1tmtary certification of specialty services
offered by a nursing care institution including
acute care designation.
2. The estab1is1mJent of levels of required rnrsing
hours, based on patient acuity, at levels equivalent
to the rnrrsing hours that patients with similar acuity
levels would receive within the current three-level
system.
3. A IIEaIlS by which. the director, if a showing that an
insufficient number of rnrsing care institution beds
were available to serve patients of a certain acuity
level, could designate for certain limited geographic
areas, a number of vacant beds, if any, in rnrsing
care institutions in the geographic area for the care
of those patients needing beds at the designated
acuity levels.
4. Case rmnagement systems to be used by each nursing
care institution evaluating and reporting patient
acuity levels.
The legislation also assigns to the Department the development
of proposed regulations that would be used to implement the
conclusions of the report. These have been developed and are
included in the Appendix of the final full report.
1. Voluntary Certification of Specialty Services
As mentioned above, the Department has established proposed
standards for specialty certification for the areas of
re~abi1itation and behavioral care. These are included in
Appendix B of the full report.
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It should be understood that facilities now can and could
continue to provide specialty services without formal certification.
For example, facilities certified to accept Medicare
patients are already required. to be staffed and equipped to
provide post-hospital rehabilitation; and some facilities
have established specialty programs to meet special needs.
Examples of these programs are the sub-acute program established
to meet the needs of those who require more intensive nursing
care than is available in most nursing homes. Another example
is the young adult program more precisely t'a,il0red for the
disabled young.
A major advantage of certification, nonetheless, is that there
would be assurance that the facilities so certified meet
acceptable program standards. This assurance, which is not
currently available, would greatly aid the client or his
family or other concerned party in choosing a facility
appropriate to meet the client's needs.
It should be noted that despite the above descriptions of the
way things are, the experience in Arizona and elsewhere is
limited where specialty care is concerned, and this is a
relatively untested area in long-term care.
The reaso~s for the relative lack of specialty activity are
many and varied. The restrictions and disincentives imposed
by Title XIX regulations are only one such factor.
Before specialty certification programs are implemented
there are potential problems and issues which need to be
resolved; namely,
- What is the distinction between the services provided in
a special hospital as compared to specialty services provided
in a certified nursing care institution? Are these programs
compatible or duplicative?
- Is there rrore of a rmrket for specialization in rnJI"sing homes
than there appears to be for special hospital licensure?
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- Should facilities which chose to provide specialized
services be required to obtain a certificate of need in
order to control over-specialization and increased costs?
- Will third-party payors including cotmties or private pay
patients be willing and able' to pay for the increased costs
associated with specialization?
RECOMMENDATION I
SPECIALTY CERTIFICATION
THE DEPARTMENT OF HFALTH SERVICES CONTrntJE TO EXPI.DRE
WHETHER IT mULD BE FEASIBLE, PRACTICAL, AND COST EFFECTIVE
TO CERTIFY SPECIALTY SERVICES WITHIN NURSING CARE
INSTITUTIONS.
2. Nursing Care Based on Patient Acuity
The University of Arizona conducted extensive studies of
patient acuity systems in other states. The report of findings
of this research is included in the full report. Based on
these explorations, the University recommended, and the
Advisory Committee endorsed, the Ohio Revised System deemed
capable of providing the most complete and reliable information
for determining nurse staffing needs based on a patient's
acuity. However, the system would require extensive developmental
work. The advisory committee strongly recommended
delaying the implementation of a patient acuity system until
a system relevant to Arizona's experience could be developed.
Introducing a complex system could have a significant impact
on a facility's operation and cost, thereby offsetting any
potential cost benefit which might be gained under an acuity
based system.
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RECOMMENDATION 2
PATIENT ACUITY SYSTEM
THE DEPARTMENT OF HEALTH SERVICES DEVELOP A SYSTEM OF
NURSE STAFFING BASED ON PATIENT AmITY BY JANUARY 1, 1983.
THE DESIRED SYSTEM SHOULD:
- BE COMPATIBLE WITH ANY SUBSEQUENT PROPOSAL 'ID INCLUDE
LONG-TERM CARE IN ARIZONA'S HEALTH CARE COST CONI'AINMENT
SYSTEM; AND
- BE BASED ON A CONSIDERATION OF REIMBr.JR.SEMENT FACTORS; AND
- BE COST EFFECTIVE
3. Designating Nursing Care Beds in Shortage Areas
In Arizona there is a maldistribution of available nursing
home beds. Among existing homes, occupancy rates are high.
This is particularly true in rural areas.
On the other hand, occupancy rates in rural hospitals are
often below fifty percent. It has been demonstrated in
several other states that the so-called "swing bed" concept
could help meet the need for long-term care beds while
increasing the use of hospital beds in rural areas.
Under the swing bed concept, vacant beds in hospitals which
provide acute care are simply used for patients who need longterm
care. Unfortunately, at present federal reimbursement
regulations present a major roadblock to the use of acute
care beds for long-term care. Although the 1980 Amendments
to the Social Security Act do allow reimbursement for the
swing bed program, the Department of Health and Human Services
has up to now delayed issuing the required implementing
regulations.
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RECOMMENDATION 3
DESIGNATING NURSING HOME BEDS IN SHORTAGE AREAS
'mE DEPARTMENl' OF HEALTH,SERVICES REQUEST A WAIVER
FROM 'mE DEPARTMENT OF HEALTH AND HUHAN SERVICES TO
FACILITATE JMPLEMENTATION OF THE sw:m; BED CONCEPT
IN HELPING MEET 'mE NEED FOR LONG-TERM CARE BEDS;
AND
'mE lli?LEMENTATION OF sw:m; BEDS n~ RURAL HOSPITALS
BE PROMJrED BY A CONSORTIUH WHICH IDULD INCLUDE 'mE
DEPARn1ENT OF HEALTH SERVICES, 'mE ARIZONA NURSING
ID1E ASSOCIATION, 'mE ARIZONA ASSOCIATION OF HOMES FOR
'mE AGED, THE ARIZONA HOSPITAL ASSOCIATION, 'mE
HEALTH SYSTEl1S AGENCIES AJ.'ID arHER CONCERNED GROUPS.
4. Case Management in Nursing Care Institutions
Traditionally, case management has usually meant the management
of community-based services, or combinations of services,
as needed by the client. Through this concept of case
management, the client or patient is assured of continuity
of care and other needed community support.
The case management mandated in House Bill 2081 refers to
the evaluation of the acuity level of each patient within a
nursing care institution in order to determine the numbers
and types of nursing staff needed to serve adequately the
total population within that institution.
As can be seen, a major yardstick of this kind of case
management is the patient acuity system. Thus the development
of the patient acuity system called for in House Bill 2081
must precede the fashioning of the case management system.
Ideally, the two mandates should be developed as dovetailing
parts of a more comprehensive strategy for improving longterm
care.
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RECOMMENDATION 4
CASE MANAGEMENT SYSTEMS
TIlE DEPAR'IMENT OF HEALlli SERVICES DEVELOP A CASE
MANAGEMENT SYSTEM COMPATIBLE WIlli TIlE PATIENT
ACUITY SYSTEM BY JANUARY 1, 1983; AND
TIlE DEPAR'IMENI' OF HEALlli SERVICES IN COOPERATION WITH
TIlE DEPAR'IMENT OF ECONCMrC SECURITY \-DRK WITH aI'HER
CONCERNED GROUPS TO FACTI..rrA-m THE DEVELOPHENr OF A
CASE M\NAGEMENT SYSl'EM DESIG.:TED 10 HANAGE COMMUNITYBASED
SERVICES IN BEHALF OF THE AGED AND AGING AND
OIHERS BESET WIlli DISABLING CONDITIONS; AND
TIlE ASSESSMENT AND CASE MANAGEMENT SYSTEN BE PROVIDED
ON A COUNTY-WIDE OR AREA-WIDE BASIS \-JIlli THE FOLLOWING
SERVICES AVAILABLE ON REQUEST:
• •. AN ASSESSMENT OF TIlE CLIENT'S PHYSICAL, MENTAL AND
SOCIAL FUNCTION
... AN EVALUATION OF TIlE CLIENT'S NEEDS FOR SERVICE
· .. DEVELOPMENl' OF AN ORGANIZED PLAN 10 MEET TIlE CLIENT'S
NEEDS
· .. ASSISTANCE IN OBTAINING NEEDED SERVICES
EVALUATION FOILOW UP OR CON'I'INUm; CASE MANAGEMENT,
WHEN APPROPRIATE
COUNSELING SERVICES FOR FAMILIES
AVATIABTI..ITY OF CASE MANAGEMENT IN EACH COUNI'Y TO
AIL AGED AND OTHER POPULATIONS ON A FEE FOR SERVICE
OR SLIDING SCALE BASIS.
ADDITIONAL CONCERNS AND RECOMMENDATIONS
FOR IMPLEMENTING HOUSE BILL 2081
5. Nursing Home Licensure
House Bill 2081 calls for " implementation of a system,
based on one level of care " but within which a strategy
would be developed and put in place to assure that even within
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the single-license structure, each patient would receive a
level and amount of nursing care required and justified by the
patient's condition. The Department's proposals for meeting
this mandate are described in-the section of this report
entitled "2. Nursing Care Based on Patient Acuity".
Carrying out those proposals and recommendations would lead to
a single level of nursing care licensure. At present--since
1977--nursing facilities in Arizona have been licensed for
three levels of care: skilled, intermediate and personal care.
The majority of facilities are licensed as skilled nursing
facilities: 86 percent of the 79 licensed facilities are
licensed in whole or'in part as skilled nursing facilities.
Of the total licensed beds, 75 percent are licensed as skilled
nursing beds; 11 percent as intermediate and 14 percent as
personal care. Despite such class distinctions in licensing,
there are wide variations in the types of patients in any given
facility, and variations in the amount of nursing care they
require. But at the same time, most facilities licensed for
only one level of care presently charge the same rate to all
patients regardless of the acuity of their conditions.
There are exceptions. Twelve facilities currently licensed as
skilled care have established two rate structures to reflect
somewhat more precisely the amount of care and nursing staff
the patient requires.
In addition, in the absence of established acuity standards,
22 skilled nursing facilities in Maricopa County accept Countyestablished
differential rates for skilled and intermediate
care. These, of course, are the nursing facilities with which
the county contracts for the prov~s~on of nursing home services
for medically indigent patients.
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It is clear that single level nursing care licensure cannot be
put in effect until the Patient Acuity System has been
developed and implemented. This is because the total legal
mandate calls also for assurances that nursing care staffing
will be appropriate to true patient needs. The return to a
single level licensure should be postponed until the patient
acuity system and other implementing strategies are developed
and in place.
RECOMMENDATION 5
NURSING CARE INSTITUTIONAL LICENSURE
THE DEPAR'IMENT OF HEALTH SERVICES CONTINUE 'ill LICENSE
THREE SUBCLASSES OF NURSUlG CARE n~STI'lUITONS IN
ACCORDANCE WITH A.R.S. 36 § 405.B.
6. Developing Least Restrictive Alternatives to Institutionalization
House Bill 2081 includes a clear mandate that strategies be
developed to place persons in the least restrictive health care
environment possible. While the mandate applies specifically
to the indigent, the movement toward deinstitutionalization
is a wider one affecting all who might be spared full
institutional domicile. The following discussions and
recommendations would promote development of new or expanded
opportunities for placement in the least restrictive alterna-tives.
Supervisory Care Homes
Supervisory care homes are a new class of residential care
institution created through enactment of A.R.S. § 36-401
in 1977. With enactment of this legislation, personal care
homes became classified as a sub-class of nursing care
institutions.
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The intent of this legislation was to enable boarding homes to
be licensed if they had been or would provide health related
services. This resulted in upgrading standards of care. Most
of the supervisory care homes'had provided services to the
chronic mentally ill and elderly.
The legislation defined a supervisory care home as a
residential care institution which provided only
supervisory care services to five or more ambulatory persons
unrelated to the administrator or owner of such home.
Supervisory care services were defined as board and general
supervision, including assistance to persons in the selfadministration
of prescribed medications.
Many of the persons receiving services in supervisory care
homes require services above those such a facility can provide.
Some of the residents are not capable of self-administration
of medications, and they need help with bathing, feeding
and dressing. These are the aged and those who have mental
or physical impairments. Such persons are imperfectly served
by present classifications of homes: they need more care
than is available in a supervisory care home, but less than is
available in a nursing care institution. Clearly, there is
need for further refinements in present legal definitions.
RECOMMENDATION 6
SUPERVISORY CARE HOMES
THE STA'IDIES AND REGULATIONS GOVERNING SUPERVISORY
CARE HCMES BE IDDIFIED 'IO ALLOW PERSONAL CARE
SERVICES 'IO BE PROVIDED BY THESE FACTI..ITIES; AND
LICENSED NURSES AND HOME HEALTH AGENCILS BE PERMI1TED
TO ADMINISTER MEDICATIONS AND TREA'IMENTS 'IO RESIDENTS
ill THESE FACILITIES; AND
THE PRESENT DEFINITION OF 'AMBULATORY PERSON' BE
RETAll1ED ill THE STA'IDIE TO ASSURE PATIENT SAFETY; AND
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PERSONS WHO MAY BE MORE MENTALLY ll1PAIRED AND UNABLE
1D FlliD THEIR TiJAY 1D SAFElY WITIIOUT ASSISTANCE BE
PLACED m A CERTIFIED ADULT FOSTER CARE HCl1E WHERE
THE NUMBER OF RESIDENTS IS RESTRICTED 1D FOUR OR LESS.
Home Health Services
With implementation of Medicare in July, 1966, home health
services were formalized and minimum standards were developed
to assure adequate care for the homebound aged sick.
Despite the obvious potential of home health services for
reducing the more costly inpatient care, the development of
home health agencies in Arizona has lagged, particularly
outside Maricopa and.Pima Counties. In seven of Arizona's
fourteen counties there are no home health agencies at all.
In several ways, the home health agencies playa mandated
role in implementing House Bill 2081. For example, the bill
calls for extension of home health services to the aged
and physically and mentally disabled in supervisory care
homes and adult foster care homes. In addition, the bill
mandates that there be preadmission and annual screening
of indigent persons placed in Long-Term Care settings and
that the counties certify adult foster care providers which
meet sanitation, nutrition and medication administration
standards. Home health agencies could perform many, if not
all of these functions.
RECOMMENDATION 7
HOME HEALTH
FUNDlliG BE PROVIDED FOR ESTABLISHMENT OF A HCME HEALTH
AGENCY lli EACH COUNTY; AND
FUNDING FOR ESTABLISHMENT OF OTHER ALTEaNATIVES 1D
INPATIENT CARE AND REIMBURSEMENT SYSID1S 1D PAY FOR
ALTERNATIVE SERVICES BE EXPLORED.
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Shortages in Rural Areas
Traditionally in Arizona, the rural areas have suffered most
from shortages of health manpower and services. In the rural
areas in particular, every health-related resource must be
fully exploited.
RECOMMENDATION 8
EXP_~DED UTILIZATION OF HEALTH CARE FACILITIES
'TIill DEPA.~THENr OF HEALTH SERVICES COlLABORATE WITH OTHER
PUBLIC AND PRIVATE AGENCIES 1D PRCMOTE MJRE APPROPRIATE
AND EXPANDED UTILIZATION OF EXISTING HOSPITALS AND NURSING
CARE INSTITUTIONS IN RURAL AREAS.
Need for Reliable Data
A major and significant feature of House Bill 2081 is the
built-in mandate to promote and develop alternatives to total
inSitutional care. At present there is a scarcity of
reliable data concerning the costs of alternatives to
institutional placement.
RECOMMENDATION 9
COST STUDY
A COST S'l1IDY BE CONDUCTED 1D DETERMINE COSTS ASSOCIATED
WITH:
- ESTABLISHING A CENTRALIZED CASE MANAGEMENT SYSTEM IN FACH
COUNI'Y OR AREA OF 'IRE STATE.
- ESTABLISHING OTHER ALTERNATIVE PROGRAHS SUCH AS DAY CARE,
RESPITE CARE, Ha1E HEALTH PROGRAMS BOTH INSTITUTION-BASED
AND CQ:.1MlJNITY-:M.SED .
- IMPLEMENTING SPECIALIZED CERTIFICATION PROGRAMS IN
NURSm; CARE INSTITUTIONS.
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7. Organizational Format to Implement House Bill 2081
To fully implement House Bill 2081 will require development of
both statewide and local entities with collaborative power
beyond the several organizational prescriptions in this report.
While such synergetic influence would properly begin at
the state level, perhaps the most effective promotional effort
is to be expected at the county or areawide levels of
promotional activity.
RECOMMENDATION 10
INTERAGENCY COLLABORATION
THE GOVERNOR'S COUN:::IL ON AClliG TAKEi ON A LEADERSHIP
ROLE m COORDINATmG THE HEALTH, SOCIAL SERVICES AND
OI'HER RESOURCES NEEDED TO KEEP AS MANY AGED, PHYSICAILY
AND MENTAILY IMPAIRED AND OTHER DEVELOPMENTAlLY
DISABLED PERSONS m THE LEAST RESTRICTNE ENVIRONMENT
POSSIBLE; AND
ORGANIZED CONSORTIUMS BE ESTABLISHED m EACH COUNTY OR
AREA TO COORDINATE EXISTlliG CClMUNITY RESOURCES AND 'ID
PROMJI'E THE ESTABLISHMENT OR EXPANSION OF OTHERS. THE
CONSORTIUM PARTICIPANrS SHOULD mCLUDE RESPRESENTATNES
OF AREA AGENCIES ON ACll-r;; REPRESENTATNES OF STA'IE AND
COUNI'Y GOVERNMENTS, INCLUDn~G BOARDS OF SUPERVISORS AND
BOARDS OF HEALTH; CONSUMER ADVOCATE GROUPS; HEALTH
SYSTEMS AGENCIES AND OTHER CONCERNED ORCANIZATIONS AND
INDIVIDUAL CITIZENS.
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