Study committee field proposals for legislation aimed at improving long-term, community-based care

Oct. 20—PIERRE, S.D. — If all goes according to plan, the South Dakota Legislature will see nearly a dozen proposals for legislation addressing gaps and needs in the long-term care industry this coming session.

Legislators in the Study Committee on Sustainable Models for Long-Term Care discussed a wide range of solutions over the summer, including opportunities to merge existing healthcare resources and facilities, increased reimbursement rates for community-based care services and to bolster South Dakota's pathways to healthcare workforce opportunities.

On Wednesday, they picked through those ideas, and voted on which they would move forward with as legislative recommendations this law-making season.

Currently, these recommended legislative proposals are just recommendations. But they offer a glimpse into the ideas that have been circulating this summer, and will be presented officially during the legislative session this coming January.

* Recommend the creation of a healthcare workforce coalition.

There is a Board of Nursing through the South Dakota Department of Health, but no general coalition representing the diverse non-nurse workforce and program needs of South Dakota's healthcare system.

Committee members said such a coalition, if formed through legislation this winter, should address barriers to education, clinical skills training and entry into the healthcare workforce in the state.

"I think this is a topic that is going to keep coming up for the next decade, and we need to keep it on the front burner and not the back," said Sen. Erin Tobin from Sioux Falls, who motioned for this idea to move forward through the committee. Legislators agreed that being proactive in forming such a workforce coalition is crucial.

Six other proposals addressing healthcare workforce needs were deemed not as crucial, or not fully defined, and voted against by the committee.

* Recommend that the larger group supports legislation to join interstate compacts for advanced practice registered nurses, social workers, counselors and psychologists.

Interstate workforce compacts make it easier for specialists to move from one state to another to find work.

The committee moved forward with a proposal to introduce legislation that would have South Dakota join interstate compacts licensing APRNs, social workers, counselors and psychologists.

Three states have already enacted compact legislation for advanced practice registered nurses, including North Dakota, Delaware and Utah.

South Dakota already participates in the Registered Nurse and Licensed Practicing Nurse Licensure Compact (NLC). Forty-one states and territories already participate in this compact.

* Recommends an elderly waiver in long-term care for adult daycare in other licensed healthcare facilities.

This recommendation would allow all licensed facilities to take on up to 5 adult daycare recipients. The goal: diversify revenue streams for the smaller facilities in the state, that otherwise are not licensed to provide these services but have the required number of skilled nursing staff.

Legislation that incentivizes increased use of adult day services may mean more funds would be needed per facility that participates. Expenses paid for increased use of waiver-style adult day services would come from both state general funds and federal funds.

* Recommends the state study and support a state program of all-inclusive care for the elderly (PACE) program.

Organizations with a PACE program cover all Medicare and Medicaid-covered care and services, and anything else the health care professionals in the PACE team decide the patient needs to improve and maintain their health, including prescription drugs and medically necessary care.

There are 32 states in the U.S. that have PACE-offering organizations.

Some members of the committee, like Rep. Brian Mulder from Sioux Falls, said the decision for a PACE program to come to the state was more of a private entity business decision.

The proposal is merely to study and support a state program for a potential PACE program.

* Recommends increasing the amount permitted for the personal needs allowance (PNA).

Medicaid recipients in South Dakota get an allowance of $60 per month. The allowance can be used for a number of household expenses, including bills, clothing and personal care items.

This recommendation, supporters argue, would open up the conversation about how much more recipients should be receiving as allowance, given the rising impact of inflation since the allowance rate was first set in 2004.

"We're not picking a number, but I do think it needs to be increased," Rep. Chris Karr from Sioux Falls said.

* Recommends DHS provide greater reimbursement for remote patient monitoring services.

A number of devices are used to monitor patient health from a distance, like glucose monitors, heart rate monitors and wearable activity tracker bracelets.

This is a proposal to amend the state Medicaid plan to provide increased reimbursement rates for those remote patient monitoring services and vital readings, and provide education to providers on what telehealth and home modifications they are already using can be reimbursed.

This reimbursement would cost the state $21,152, and the federal government $24,385.

* Recommends DHS amend and expand in-home services and establish new reimbursement rates.

The big idea of this proposal is regionalization. Sen. Bryan Breitling of Miller described a number of efforts to combine or regionalize services to reduce costs to providers.

Some examples include hosting bathing assistance and nail care services in a centralized location, and establishing an aide rate for nail care services so non-RN or non-LPN providers can offer that service.

This proposal, if executed, could also save the state money, Breitling said, by amending the state Medicaid plan to allow virtual supervision of medication aides, so providers don't have to pay higher rates for registered nurses or licensed practicing nurses to provide the same treatment.

This proposal also includes an amendment to the state Medicaid plan to double the mileage reimbursement for home care providers, RNs and LPNs. A doubling of this rate would cost the state $258,391.

* Recommends DHS establish new eligibility for community support provider services for traumatic brain injury (TBI) patients over age 22.

Community support providers fulfill healthcare and personal care duties to individuals in their homes. But due to federal regulation, a person who suffered a traumatic brain injury before they were 22 years old is not eligible for community support provider services in South Dakota.

With only 11 TBI beds in the state of South Dakota, community support provider services could give patients the option to stay in the state instead of having to find appropriate care elsewhere.

The solution brought forward in this proposal is to establish a new Home and Community-Based Services waiver for adult TBI patients. If TBI patients became eligible for those community support provider services, Breitling said, more of those services could be provided in-state.

"There's a huge gap in TBI," Tobin said. "If there were some issues ironed out it could provide help for the entire state."

If community support provider services were offered to TBI patients through Medicaid, Breitling said it would save the state money by billing more than half of the cost of care to Medicaid, instead of entirely through state general funds.

Even so, he said there is a lot to figure out about what is possible, and more discussions would be needed during the session.

* Recommends DHS update Dakota@Home processes.

Legislators agreed that the Dakota@Home system, that connects healthcare providers and agencies with clients in need of community or home-based care services, needs to be updated. Not just to make it easier for the clients to use effectively, but so providers can best connect them with the services they need.

* Recommends draft legislation regarding palliative care.

People living with long-term, painful or terminal illnesses sometimes receive palliative care, which is a form of medical care that focuses on increasing quality of life for the patient.

Currently, community-based palliative care is not reimbursed under South Dakota Medicaid.

Breitling said by making palliative care a more viable option for Medicaid, institutional care and community-based services recipients in the state, overall Medicaid expenditures from hospitalizations and ER visits could go down.

Since community-based palliative care is not included in South Dakota Medicaid, the financial impact on the state wouldn't be insignificant. If only 10% of patients at skilled nursing facilities utilized palliative care services, legislators estimated it would cost the state about $2,651,401.

On the request of the committee, staff members from each of the three delegates from South Dakota to the U.S. House and Senate called into the meeting.

Nurses are already working for eight hours for seven days, Study Committee Chair Sen. Jean Hunhoff from Yankton said. The new rules from the Centers for Medicare and Medicaid, the federal agency that partners with healthcare programs to provide Medicaid and Medicare services, would require RNs to be on staff 24/7, a requirement that healthcare providers currently can't meet.

That is a huge concern for the committee, Hunhoff said, as well as the ratios they are pushing forward on licensed practical nurses.

Hunhoff asked the staff if the U.S. delegation from South Dakota was working with other states with significant rural healthcare systems to prioritize keeping facilities open.

Katie Murray, staff for Rep. Dusty Johnson, said the office is keeping the rule changes on their radar. Early in October, Johnson met with the South Dakota Association of Healthcare Organizations (SDAHO), which is actively lobbying against the changes proposed by CMS.

Because these are proposed rule changes, Sarah Schmidt, staff for Sen. John Thune, said those direct conversations with CMS are the extent of what the delegation can do.

"CMS is going to do what CMS is going to do," Schmidt said. "They're not going to listen to us."

Hunhoff asked if the staff members could gauge whether the federal agency fully understands that rural communities across the country simply can't meet these new requirements.

Schmidt said regardless of how much they understand, they are going to keep asking them.