Вы находитесь на странице: 1из 13

Winter 2013

A publication for Wisconsins Long-Term Care Profession by

Elections Governing Over. Begins.

THE BUDGET ISSUE:

Including: Going for the Gold: Participating in the National Quality Award Process is a Win for Everyone Entitlement Reform, the Fiscal Cliff and their Effects on Long-Term Care Providers The Affordable Care Act Care Act is Here to Stay - Now What?

ECS - Electronic Chart & Financial System

Clinical Medication Mgmt. Physician Orders Pharmacy Formulary e-MAR / e-TAR Progress Notes & Assessments Nurse Charting CNA Picture Charting Patient Scheduling Therapy Ancillary Dept. Easy Access MDS & Care Plans MDS Best Reference RUG Forecaster Care Plans Quality Assurance QM /QI QA Status Changes Incomplete Record Care Continuum Service Plans Care Assist Flow Sheets Care Plans OASIS Face Sheets Diagnosis Financial Accounts Receivable Accounts Payable General Ledger Administration HL7 / CCHIT / HHS E-mail Alarms Reports Marketing Time Clock Human Resources

Wisconsin Health Care Association

Welcome
Happy New Year!
After a long election year in 2012, Wisconsins state and federal political leaders will be getting back to the business of governing in 2013. In February, Governor Scott Walker will release his version of the 2013-15 Biennial State Budget. In the subsequent months, the Wisconsin State Legislatures Joint Finance Committee, as well as the State Assembly and Senate will address several important matters impacting all facets of the long-term care continuum, notably the states Medicaid budget and the future of the Family Care program. In the Winter 2013 Continuum, we offer an edition filled with useful information on issues facing members of the long-term care provider community, including: The state and federal legislative landscape for long-term care providers in the coming session; The use of antipsychotic medications; The implications of the Affordable Care Act for long-term care providers; The importance of providers participating in the AHCA/NCAL National Quality Award process; The implications of the Wisconsin Supreme Courts Helen E.F. Decision for providers serving individuals with challenging behaviors. Thomas P. Moore Executive Director WHCA Brian Purtell Executive Director WiCAL Traditionally, Wisconsins long-term care provider community has been politically alert and active. But as we enter this legislative session, we must do so with intensified resolve and involvement. Members of the provider community that have, in the past, watched from the sidelines must enter the playing field to assure the legislative and regulatory process acknowledges, understands and responds to their needs and concerns. WHCA/WiCAL is truly proud to represent the individual and collective interests of Wisconsins skilled nursing and assisted living facilities. In the year ahead, major issues impacting our states entire long-term care continuum will garner greater attention in both in Washington and Madison. WHCA/WiCAL and its membership will be prepared to assure their voice and message ring loud and clear throughout the discussions in which these issues are addressed and resolved. Sincerely,

Wisconsin Center for Assisted Living

A Complete Financial Package Integrated within a Powerful EMR / EHR.


ECS - Do More with Less Maximize Profitability & Increase Reimbursements
Centralized Data Point of Care Point of Sale One Point Entry Improve Efficiency Improve Workflow Improve Morale Reduce Errors Improve Quality of Care

Why
Advocacy | Education | Excellence

The World of Assisted Living is Changing... Are YOU Ready for the Future?
The Wisconsin Center for Assisted Living is ready to help your community meet the challenges of 2013 and beyond: Experienced Staff Strong National Partnerships Unmatched Educational Offerings Effective Quality Improvement Resources JOIN WiCAL TODAY! Visit www.whcawical.org to learn about 2013 membership benefits.

ECS improves efficiency, eliminates errors and ensures a correct reimbursement for the care given. Helping the entire facility and staff to work in harmony to accomplish the same goals in less time. Resulting in greater care for the residents.

Let us show you the difference!

Advertise with us in a future issue. Reach your target audience for as little as 11 cents per person!
EMR / EHR & Financial System
WINTER 2013 | CONTINUUM 3

Visit us at www.american-data.com or email us at info@american-data.com

Empowering Healthcare Denes All We Do

Advertiser Index
2 4 4 7 9 15 15 15 15 20 20 21 21

Leading the industry with quality medical products, innovative technology and customer-driven services

21 21 22 22 23 24

800.328.8111 www.mckesson.com

American Data McKesson OConnel Pharmacy Boyer & Associates, LLC. Golden Living Centers - Continental Manor Navigator Group Purchasing Inc. Royal Construction Security Insurance Services Wipfli West Bend Insurance Morton LTC Pharmacy Gordon Flesch Company, Inc. Crown Commercial Specialized Medical Services, Inc. Infinity Rehab Badger Graphic Systems Marin Bros. Distributing Co. Inc. Aviv REIT, Inc. M3 Insurance Solutions

Contents
6
Continuum is published for the Wisconsin Health Care Association and the Wisconsin Center for Assisted Living 131 W. Wilson Street, Suite #1001 Madison, WI 53703 Phone: 608.257.0125 Fax: 608.257.0025 www.whcawical.org

Winter 2013

Clinical Corner Surveillance of Atypical Antipsychotic Drug Use is Coming


Recent surveys have increased concern regarding the use of antipsychotic medications. Are you ready for the implementation of CMS regulations? Find out the details.

Media Matters Going for the Gold: Participating in the National Quality Award Process is a Win for Everyone
The AHCA/NCAL National Quality Award process has a three-tiered system of participation that offers long-term care providers a series of measurable criteria to gauge their progress in providing quality long-term care. In 2012, Golden LivingCenters Continental Manor in Abbotsford, WI was one of two facilities in the country to be recognized with this impressive distinction. By participating in the National Quality Award process, facilities truly go for the gold making it a win for administrators, staff and, most importantly, the residents they care for.

Managing Editor John J. Vander Meer Publisher Dean Gille Editor Abbie McDowell Account Manager Kris Holden Creative Director Sara Rice

10

Capitol Connection At the Table or On the Menu Entitlement Reform, the Fiscal Cliff and their Effects on Long-Term Care Providers
As a profession, long-term care relies on federal and state governments for 80 percent of its reimbursement. Yet, even after all of the cuts long-term care providers sustained as a result of sequestration, bad debt, health care reform, state Medicaid cuts and more, Congress continues to look to the provider community to sacrifice. The head of AHCA/NCAL offers his perspective on how we must let our lawmakers know about the impact their decisions have on those we care for.

Blister Pack, OPUS cassette, Strip Packaging & Pre-filled syringes Printed MARs which can include photos of both the drug & resident In-service training for facility staff Facility consultations, on-site reviews & reports provided by pharmacists

Layout & Design David Cox Published by

12

Cover Story The Budget Issue: Elections Over. Governing Begins.


The conclusion of the November 2012 elections shifted the political power in Wisconsin State government back to the Republicans as they captured control of the State Senate, where half of the seats were up for re-election, and maintained their majority in the State Assembly. Now attention turns to the states biennial budget process and efforts to foster job creation, review the states mining laws, create a venture capital fund for entrepreneurs, and balance the Medicaid budget.

1155 Wilburn Road Sun Prairie, WI 53590 608.834.3400 www.bgsinc.com For more information in advertising in Continuum call 608.257.0125. If you are planning on moving and would wish to continue receiving Continuum, call 608.257.0125 and inform WHCA/WiCAL of your new address. 2012 Badger Graphic Systems. All rights reserved. The contents of this publication may not be reproduced by any means, in whole or in part, without prior written consent of the publisher. PUBLISHED DECEMBER 2012

16

Stakeholder Spotlight The Affordable Care Act is Here to Stay New Taxes and Fees Under Obamacare
On November 6, 2012, the American people re-elected Barack Obama as President of the United States for a second term, and with the re-election came the realization that the Affordable Care Act is here to stay. Are you ready for the implementation of CMS regulation?

Serving Facilities in South Central WI 125 S. Thompson Rd. | Sun Prairie, WI 53590 Phone: (608) 837-8002 | Fax: (608) 837-8005

18

LTC LEGAL LETTER Balancing Rights and Safety What the Helen E.F. Decision Means for Laws Governing Challenging Behaviors
The Wisconsin Supreme Courts decision in the Helen E.F. case relating to the treatment of Alzheimers Disease in Wisconsin Statutes presents important legislative challenges that are expected to be addressed in coming legislative session. What the Helen E.F. case and the Legislative Council Study Committee means for the future treatment of residents with challenging behaviors in long-term care.

www.oconnellpharmacylongtermcare.com
Going the extra mile is our way of doing business!

4 CONTINUUM | www.whcawical.org

WINTER 2013 | CONTINUUM 5

Clinical Corner

Surveillance of Atypical Antipsychotic Drug Use is Coming


By Patricia Boyer and Gail Robison

percent did not include comprehensive assessments, and 10 records lacked evidence of an RNs coordination of the RAP assessment. The study reported 33 percent of the foundational assessments (e.g. Braden, fall risk assessment, nutritional assessment) were out of compliance: records without documented psychotropic drug RAPs (now CAAs) and 46 percent of records indicated that an RN solely conducting the assessment. There was only one example of documented assessment by the appropriately qualified practitioner: psychiatrist, geriatrician and/or psychologist along with only two care plans involving such practitioners. Federal care plan requirements were not met in 99 percent of records reviewed. Care plans were not developed by the interdisciplinary team: 20 percent of records indicating an RN, social worker, or LPN was solely responsible for developing the care plan. Less than 5 percent of records contained care plans developed by at least a general physician and an RN. As required to the extent practicable, 91 percent of the records did not contain evidence that the resident, family/legal representative or physician participated in the plan of care process. The decision-making process identified confusion between resident assessments and care plans: 98 records indicated they did not intend to develop care-plan interventions for psychotropic drugs, but 54 percent of the 98 records staff had developed the interventions. However, 18 percent of the records that listed care plan interventions for antipsychotic drug use did not contain evidence of the interventions. Monitoring of psychotropic drug interventions in the care plans found blank or incomplete in several cases.

n July 2012, the U.S. Department of Health & Human Services Office of Inspector General (OIG) released results from a study indicating nearly all records reviewed 99 percent failed to meet one or more federal requirement for resident assessments and/or care plans. The sample was a total of 375 Medicare nursing facility records randomly selected from a previous OIG study of 640 nursing facility records from January-June 2007. A previous OIG study reported about half of the antipsychotic drugs being utilized by skilled nursing residents were not given for medically accepted indications and one-fifth of the drugs were not given in accordance with federal safeguards to protect residents from unnecessary antipsychotic drug use. In Wisconsin, there have been efforts to limit the utilization of antipsychotic medications in long-term care facilities. In 2010, legislation was signed into law requiring that skilled nursing facilities obtain written informed consent when an antipsychotic drug that has received a federal Food and Drug Administration black box warning is prescribed for a patient with a degenerative brain disorder. While the prevalence of antipsychotic medication prescriptions is well under the national average for shortand long-stay residents in Wisconsin, there is always room for improvement.

Percent of short-stay residents who newly received an antipsychotic medication. Lowerpercentages are better. WI Average 1.9% National Average 3.0%

Percent of long-stay residents who received an antipsychotic medication. Lowerpercentages are better. WI Average 19% National Average 23.7% Source: Medicare.gov

As a result of concerns about the utilization of antipsychotics, OIG recommend CMS: (1) improve the detection of non-compliance with federal requirements for resident assessments and care plans for residents receiving antipsychotic drugs, (2) take appropriate action to address non-compliance with the requirements, and (3) provide methods for nursing facilities to enhance the development and usefulness of resident assessments and care plans. CMS concurred with all OIG recommendations with some changes already in place through a multidimensional improvement approach. What specifics did the study identify that nursing homes can process for quality assurance and performance improvements? Related to the RAI MDS requirements compliance identified: 28 percent did not include quarterly MDS assessments, 12

The findings cross over many aspects of the antipsychotic drug use management care system in the nursing home practice. The response to the OIG issues included the following: National CMS initiative to improve behavioral health and dementia care and to reduce antipsychotic drugs in the nursing home by 15 percent. CMS plans to strengthen the State Operations Manual related to documentation of resident and family involvement in assessment and care planning. New surveyor guidance is expected to emphasize medical record compliance, and staff, resident or family interviews. CMS expanded the sampling of residents receiving antipsychotic medications in the Quality Improvement Survey process. Clarifying guidance/policy revisions related to deficiency determination, and enforcement remedies will be provided in mandatory surveyor training programs. Public-private partnerships including consumer awareness, development of consumer educational materials. A new quality indicator (QI) will be posted on the CMS Nursing Home Compare website. A short-stay incidence indicator will be posted (would indicate the number of residents who admit without an antipsychotic medication that are started on such medication after admission). Enlistment of qualified health professionals, technical assistance, tools, resources and research to advise and assist in improvement strategies. The OIG study can be reviewed on the website under the listing: Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs.

On September 27, 2012, CMS followed through on these recommendations by publishing S&C: 12-45-NH Interim Guidance and revisions to State Operations Manual, Appendix P Traditional Survey Protocol for LTC. These rules were effective December 1, 2012. The changes in the survey process has a lot of focus on use of psychoactive drugs. The areas impacted include: Education of staff in care of dementia residents and how to address behavioral and psychological symptoms of dementia (BPSD). How the facility monitors the use of psychopharmacological medications, specifically antipsychotic medications. Administrator will be asked for a list of residents who are receiving or have received antipsychotic medications over the past 30 days. This increased focus on use of antipsychotic drugs allows the surveyors to work toward meeting the objective CMS has to reduce the percent of drugs utilized. How does this all apply to the Assisted Living environment?

Regulations may not be in place as they are in Skilled Nursing Facilities; however, the focus is the same. This is played out in the bill that is before U.S. Congress. The introduction of a bipartisan bill that would charge HHS to require informed consent before prescribing antipsychotic drugs to nursing home and assisted living residents. The bill (S. 3604) would also establish monthly report cards on each homes use of the drugs. So, no matter what area in which you work, use of antipsychotic drugs is an issue you need to be aware of and take steps to prevent inappropriate use of antipsychotic drugs in your facility.

Patricia Boyer is the President of Boyer and Associates. Gail Robinson is a long-term care consultant. Ms. Boyer can be reached at pboyer@boyerandassociates.com. Gail Robinson can be reached at gail.robinson@gmail.com.

Our Nation-Wide Healthcare Consulting Services: Medical Review Operational Assessment Web Training Phone/Email Consultation Mock Survey Traditional/QIS Corporate Compliance Medicare/Medicaid Audit Assisted Living training Assisted Living Assessments

CONtaCt uS tOday! 262-754-0525 boyerandassociates.com


Our consultants will be there immediately and leave you with lasting solutions! Patricia J. Boyer

6 CONTINUUM | www.whcawical.org

WINTER 2013 | CONTINUUM 7

Media Matters

Going for the Gold:


By John J. Vander Meer

Participating in the National Quality Award Process is a Win for Everyone

For more information on how to apply for the National Quality Award go to: qa.ahcancal.org Application Deadlines: January 31: Bronze Quality Award February 28: Silver and Gold

Do the difficult things while they are easy and do the great things while they are small. A journey of a thousand miles must begin with a single step.

Lao Tzu

Center Continental Manor (GLCM). The process keeps you so focused on quality year after year that it eventually leads to the kind of quality that youre aiming for. Erickson said GLCM won the Bronze Award in 2000 and the Silver Award in 2005, and began applying for the Gold Award in 2009. We knew all along that our staff had the ability to provide that level of quality care to our residents, said Erickson, who said she included GLCM staff in almost every aspect of the Quality Award process. Ultimately, Erickson said it was the work of the staff that made attainment of the Gold National Quality Award possible. Theres always room for improvement no matter where you work, she said. Its about ensuring the staff that you employ is made up of people who put their hearts and souls into caring for people. By participating in the National Quality Award process, facilities can truly go for the gold making it a win for the facility all the way around administrators, staff and, most importantly, the residents they care for. Theres an old saying nothing succeeds like success. And, by participating in the National Quality

Award Process, facilities can improve the quality of care their residents receive and administrators and staff develop their facilitys reputation as the community to be in if/when the time comes. It will be a great marketing opportunity for us, Erickson said. Since the award, Erickson said the facility has been the subject of several articles in local and national publications, and theres been a buzz about it in Abbotsford, a community of about 2,500 people. What advice does Erickson offer facilities looking to go for the Gold? WHCA/WiCAL and AHCA/ NCAL notifications we stay on top of that information, she said. On behalf of WHCA/WiCAL, I say thats good advice and congratulations to Golden LivingCenters Continental Manors clinical and administrative staff on this well-deserved award.
John J. Vander Meer is the Director of Communications for the Wisconsin Health Care Association and the Wisconsin Center for Assisted Living. He can be reached at: john@whca.com

ach year, the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) receive applications from hundreds of facilities from across the country applying for recognition as a skilled nursing facility or assisted living community that provides highquality care for their residents. Crafted after the prestigious Baldrige Performance Excellence Program, the AHCA/NCAL National Quality Awards are organized into three categories Bronze, Silver and Gold. In order to be considered for the next award category, one must complete the previous level. Consequently, the road to receiving a Gold National Quality Award can be a long journey. In 2012, Golden LivingCenter Continental Manor in Abbotsford, WI was one of only two facilities in the country to be recognized with the impressive distinction of being a Gold National Quality Award recipient. It has been a long journey that we started back in 1999, said Trudy Erickson, Nursing Home Administrator for Golden Living

Congratulations to Golden LivingCenter Continental Manor in Abbotsford, Wisconsin for receiving the Gold AHCA/NCAL National Quality Award!
From the dedication of leaders and staff, to the processes built on quality care, to the family environment created through customer and community focus, our goal is to achieve clinical results and exceed expectations. The minute you walk in the door, you know you have stepped into a center where people care so deeply about one another that they have become family. Golden LivingCenter Continental Manor is sharing our passion for improving quality of life through innovative healthcare one person, one family and one community at a time.

WHCA/WiCAL is pleased to announce the re-launch of the member information services on www.whcawical.org, and our new weekly electronic newsletter, CareConnection. For more information on benefits of membership call (608) 257-0125.

Golden LivingCenter - Continental Manor 600 East Elm Street Abbotsford, WI 54405 715-223-2359 www.GoldenLivingCenters.com/ContinentalManor

8 CONTINUUM | www.whcawical.org

Qualied applicants considered without regard to race, color, religion, gender, sexual orientation /gender identity, veteran status, national origin or disability; Drug-Free Workplace GLS-00-0000

Capitol Connection

At the Table or On the Menu


Entitlement Reform, the Fiscal Cliff and their Effects on Long-Term Care Providers
By Gov. Mark Parkinson

ve said it many times: I truly believe we are in a time of extraordinary opportunities and remarkable challenges. Today, 10,000 Americans turned 65. By 2030, there will be 72 million older persons in this country. We have the opportunity to care for millions of Baby Boomers in our assisted living and skilled nursing centers. Even though many centers are already seeing increased demand for our services, it is only beginning.

these difficult times. My answer is always the same: I am confident that we will survive and thrive. The dedication of the people who work in this profession is amazing. As individuals, as companies and as a profession we can emerge from this stronger than ever. But it wont be easy. We will have difficult choices to make. We will have to commit to the hard work that is needed to succeed. The first thing we must do is become the cost and quality solution. We are already making great strides in quality. The number of centers recognized by CMS as a four- or five-star has increased 30 percent since 2009. Nearly half of all skilled nursing centers nationwide are participating in Advancing Excellence and 22 percent of our members have earned a Bronze, Silver or Gold National Quality Award. We know that providing quality care is the right thing to do. But we also know that future payment models will require us to continuously improve quality. The Quality Initiative we launched in February 2012 will help us reach new heights in quality of care. We have set aggressive, measurable goals to safely reduce hospital re-admissions, reach higher levels of customer satisfaction, retain more employees and reduce the offlabel use of antipsychotic medications. When we get every member on the path to showing better health outcomes at a lower cost, we will thrive.

Continuous improvement in quality care is critical, but that alone is not enough. We also must be a political powerhouse from coast to coast. In our state capitols and in Washington, D.C., we must become a powerful lobbying voice that cannot be ignored. From fiscal cliff negotiations to oneoff pieces of legislation, we must let our lawmakers know about the impact their decisions have on those we care for, those we employee and those we support in our communities. Long-term and post-acute care faces an ongoing threat of additional budget cuts as the federal government attempts to reduce the deficit and debt. Even after sequestration, bad debt, health care reform, state Medicaid cuts and more, Congress continues to look to our profession to sacrifice. We are doing everything possible to combat the current proposals. We launched a multi-week media campaign inside Washington, D.C. including radio, television and print advertisements designed to reach members of Congress and their staff. We hosted several fly-ins, so our state leaders can meet personally with policymakers on Capitol Hill. And well continue to leverage the relationships we have built on the Hill. But sometimes the best messenger is the one in the trenches. To ensure we reach our goals, we need your help. There are many ways you can get involved. Become a part of our Quality Initiative. You can find more information about the goals, resources for individual facilities and more online at qualityinitative.ahcancal.org. Sign up for Advancing Excellence at www.nhqualitycampaign.org.

Apply for an AHCA/NCAL Quality Award at qa.ahcancal.org. Sign up for our grassroots efforts to contact your Members of Congress. You can register in CapWiz online at www.ahcancal.org/advocacy. Contact your Member of Congress. Set up a meeting when they are in your state, or come to Washington for a fly-in and meet with them on Capitol Hill. And then tell us about it: advocacy@ahca.org. This summer, AHCA/NCAL created a new mission statement for our organization: improving lives by delivering solutions for quality care. Our mission statement signals a new direction for our profession. We have a renewed focus on quality. We bring solutions to the table. We are a political and lobbying powerhouse. The patients and residents we care for every year, their families and our employees are counting on us. Our mission is much more than just words on paper. Its a signal to our audiences state, federal and everywhere in between that we are truly committed to surviving and thriving in these extraordinary times. Thank you for the work you do every day. I look forward to working with you to improve lives in 2013.
Governor Mark Parkinson is the President and CEO of the American Health Care Association and the National Center for Assisted Living. Before leading AHCA/NCAL, the native Kansan was a successful businessman, state legislator, and most recently served as the 45th Governor of the State of Kansas. He can be reached at mark@ahca.org.

Wisconsin Congressional Delegation


LEGEND
US Senate US House of Representatives

7 8 3 2
Ron Johnson (R) Tammy Baldwin (D)

District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 202.224.5323 202.224.5653

6 5 4 1

ronjohnson.senate.gov baldwin.senate.gov

Wisconsin Congressional District 1. Counties served: All of Racine and Kenosha; portions of Walworth, Waukesha, Milwaukee and Rock
Paul Ryan (R) paulryan.house.gov 202.225.3031

Wisconsin Congressional District 2. Counties served: All of Dane, Green, Iowa, Sauk and LaFayette, portions of Rock and Richland.
Mark Pocan (D) pocan.house.gov 202.225.2906

In our state capitols and in Washington, D.C., we must become a powerful lobbying voice that cannot be ignored.
At the same time, we face some daunting challenges. We rely on federal and state governments for 80 percent of our reimbursement. In a healthy economy with productive state and federal governments, this reimbursement system has protected us from the periodic economic fluctuations. Unfortunately, the federal government is broken, and our national and state economies are slowly recovering from the worst recession since the 1930s. Everyone from governments to individuals is looking for ways to cut back spending. We are admonished to do more with less. I have been asked time and time again whether our profession can survive

Wisconsin Congressional District 3. Counties served: All of Adams, Buffalo, Crawford, Dunn, Eau Claire, Grant, La Crosse, Pepin, Pierce, Portage, Trempealeau and Vernon. Portions of Chippewa, Jackson, Juneau, Monroe, Richland and Wood.
Ron Kind (D) kind.house.gov 202.225.5506

Wisconsin Congressional District 4. Counties served: Milwaukee County, including 1) that part of the city of Milwaukee located in the county, and 2) the village of West Milwaukee and the cities of Cudahy, St. Francis and South Milwaukee. Bayside, Brown Deer, Fox Point, Glendale, Shorewood and Whitefish Bay.
Gwen Moore (D) gwenmoore.house.gov 202.225.4572

Wisconsin Congressional District 5. Counties served: All of Jefferson and Washington; portions of Dodge, Milwaukee and Waukesha.
F. James Sensenbrenner, Jr. (R) sensenbrenner.house.gov 202.225.5101

Wisconsin Congressional District 6. Counties served: All of Columbia, Fond du Lac, Green Lake, Manitowoc, Marquette, Ozaukee, Sheboygan and Waushara. Portions of Dodge and Winnebago.
Thomas E. Petri (R) petri.house.gov 202.225.2906

Wisconsin Congressional District 7. Counties served: All of Ashland, Barron, Bayfield, Burnett, Clark, Douglas, Florence, Forrest, Iron, Langlade, Lincoln, Marathon, Oneida, Polk, Price, Rusk, Sawyer, St. Croix, Taylor, Vilas and Washburn; portions of Chippewa, Jackson, Juneau, Monroe and Wood.
Sean Duffy (R) duffy.house.gov 202.225.3365

Wisconsin Congressional District 8. Counties served: All of Calumet, Brown, Door, Kewaunee, Marinette, Menominee, Oconto, Outagamie, Shawano and Waupaca; portions of Winnebago.
Reid Ribble (R) ribble.house.gov 202.225.5665

10 CONTINUUM | www.whcawical.org

WINTER 2013 | CONTINUUM 11

Cover Story

The Budget Issue:

Elections Over. Governing Begins.


By James McGinn

which included analysis.

the

following

he November 6, 2012 elections shifted the political power in Wisconsin State Government back to the Republicans as they captured control of the State Senate and maintained the majority in the State Assembly. In the 33-member State Senate, the Republicans regained the majority and will control the chamber, 18 to 15. The Senate Republicans will be led by Majority Leader Scott Fitzgerald (R-Juneau), while the Democrats will be led by Minority Leader Chris Larson (D-Milwaukee). In the 99-member State Assembly, Republicans maintained their majority and will control the Chamber 60 to 39. The Assembly Republicans will be led by Speaker Robin Vos (R-Rochester), while the Assembly Democrats will be led by Minority Leader Peter Barca (D-Kenosha). It is important to note that 25 of the 99 members of the Assembly are freshman Legislators and 29 members will be serving in just their second term.

government, and investing transportation infrastructure.

in

As Governor Walker prepares his budget, fiscal information will be constantly revised and updated as revenues and expenditures change. Legislators and most observers of the budget process will rely on the Legislative Fiscal Bureaus January 2013 report on revenue estimates and state agency budget requests to accurately reflect and project the states fiscal condition. The LFB is a nonpartisan service agency of the Wisconsin Legislature. The Bureau provides fiscal and program information and analyses to the Wisconsin Legislature, its committees, and individual legislators.

The Bureau also serves as staff to the Joint Finance Committee the 16-member committee which reviews and deliberates on legislation affecting state revenues and appropriations. The primary focus of the Committees work, and thus, that of the Bureau, in each legislative session is the states biennial budget. While the Governor will also consider the Fiscal Bureaus analysis, the Department of Administration submitted its own revenue estimates and agency budget request to his office late last year

In a November 20, 2012 letter to Governor Walker and the Legislature, Department of Administration Secretary Mike Huebsch noted that Wisconsins budget is in a much stronger position than two years ago and we are on track to end the 201113 biennium with a $348 million gross ending balance. This is good news as just 2 years ago the 201112 Legislature was faced with a $3.6 billion structural deficit and was called into session immediately to address the deficit and fix our states fiscal problems. With respect to the next two fiscal years, Secretary Huebsch expects revenue to increase by $518 million in fiscal year 2013-14, and an additional $502 million in fiscal year 2014-15. Again, this is good news, but Secretary Huebsch cautions that revenue estimates cover more than a two and

one-half year period, from now until June 30, 2015, and there is great uncertainty with the federal budget and payments to states. All state agencies were instructed by Governor Walker to submit their budget requests to Secretary Huebsch maintaining spending at, or below, state fiscal year 2012-13 levels. Secretary Huebsch reported that state agencies have requested an additional $529 million in state general purpose revenue (GPR-or state tax dollars) in fiscal year 201314 and $540 million (GPR) in 201415, or $1.7 billion for the biennium.

While the $410 million cost to continue request is substantial, the Department explained that one important factor is the ongoing demand for long-term care services for seniors and people with disabilities. In state fiscal year 2011, long-term care expenditures reached nearly $2.9 billion and accounted for 43 percent of total Medicaid expenditures. It should be noted the Departments funding request for Family Care and other programs (PACE/Partnership/ IRIS) assumes these programs remain in existing service areas with no further expansion into new counties.

DHS BUDGET PICTURE


A review of the Department of Health Services budget includes a request for an additional $658 million (GPR) for the Medicaid program alone. The Departments request includes $248 million due to a decline in federal Medicaid matching rates from the current 60.32 percent to 59.02 percent in fiscal year 2014 and 58.79 percent in fiscal year 2015. The Department also requested $410 million to reflect the cost to continue the Medicaid program based on enrollment projections and estimated expenditures per enrollee.

In state fiscal year 2011, long-term care expenditures reached nearly $2.9 billion and accounted for 43 percent of total Medicaid expenditures.
Per past instructions, the Department did not include in its request any additional dollars for rate increases for Medicaid providers. That decision is made by the Governor and Administration staff.

Me d i c a i d

Joint Fi nance

Fa

12 CONTINUUM | www.whcawical.org

Asse

mbl

ble

Ca

re

Ac

As the Legislative session begins, most of the attention will be focused on Governor Scott Walkers proposed 2013-15 biennial budget bill to be introduced in February. The Governor has indicated that his top 5 priorities for inclusion in his proposed budget bill will be job creation, tax cuts, transforming education and workforce development, reforming

da

THE BUDGET

Af

for

Co mm itt eA ss ign Elec me tion nts s

et udg 5B 3-1 201

WHCA/WiCAL PRIORITIES
The top priority for WHCA/WiCAL in the 2013-15 biennial budget is to include a provision that directs all of the funding derived from the nursing home bed tax to support improvement in nursing home resident care. In the current fiscal year, 2012-13, approximately $45 million have been skimmed from the nursing home bed tax and used for other purposes. Our message is to eliminate the skim and return and rededicate all of the nursing home bed tax revenue to its original purpose, supporting
WINTER 2013 | CONTINUUM 13

m i l y C a re

WISCONSIN LEGISLATIVE LEADERSHIP

MANY ISSUES FACING LEGISLATURE


Other issues expected to be discussed and debated in the Legislature include revisiting mining legislation that failed to pass the Senate by a single vote last year. Mining companies have expressed a strong interest in revising state laws, they believe prevent the opening of an iron-ore mine in Iron and Ashland counties. Another initiative that failed to pass last session and is a priority of legislative leadership is to advance a venture capital bill to encourage economic development and job creation. Also, since the courts have blocked a requirement for photo identification for voting purposes, Legislators have expressed a desire to modify the photo ID law to comply with possible legal problems with the law. WHCA/WiCAL expects the Wisconsin Legislature to have a busy session with a focus on a balanced budget bill, job creation efforts, and a watchful eye on Washington D.C. We will again be requesting the membership to assist us to ensure the concerns of all long-term care providers are considered in Madison. The WHCA/WiCAL Legislative Day will be held on March 26, 2013 at the Inn on the Park, located on the Capitol Square. We encourage all members to attend this important event. Please stay tuned to Care Connection, WHCA/WiCALs weekly electronic newsletter, as details on this event will be forthcoming.
James McGinn is WHCA/ WiCALs Director of Government Relations. He can be reached at jim@whca.com.

Sen. Scott Alberta Fitzgerald Darling Co-Chair, Senate Majority Joint Finance Committe Leader

Rep. Chris John Nygren Larson Co-Chair, Senate Minority Joint Finance Leader

Rep. RobinVukmir Vos Sen. Leah Assembly Speaker Chair Senate Health and Human Services

Rep. Peter Mike Endsley Barca Chair Assembly Assembly Minority Aging and Long-Term Care Leader

The Experienced Leader in Group Purchasing


No Cost Membership, No Commitment Level Maximize Savings Opportunities and Choice with the Industries Top Vendors Volume Discount Pricing and Price Protection Fully Transparent Cost Reporting, Managed Order Guides, and Analytic Tools A Focused Portfolio of Products and Services Call Navigator Today!
Sara Gregorich, Regional Account Representative Phone: 414-588-0447 | Sara.Gregorich@navigatorgpo.com www.navigator gpo.co m

Sen. Alberta Darling Co-Chair, Joint Finance Committee

Rep. John Nygren Co-Chair, Joint Finance Committee

Sen. Leah Vukmir Chair Senate Health and Human Services

Rep. Mike Endsley Chair Assembly Aging and Long-Term Care

and improving the care for the elderly and disabled who reside in Wisconsins nursing facilities. The same biennial budget process has been followed for years. Governor Walker will introduce his proposed budget bill in February, the bill will be referred to the Joint Finance Committee for review and approval by Memorial Day, and both Houses typically debate the measure in June and pass it by July 1. Both Majority Leader Fitzgerald and Speaker Vos have stated that timely passage of a balanced budget is the top priority of the Legislature. The biennial budget bill is the most important bill during the first 6 months of session. While the Department of Health Services $8 billion annual budget is the longterm care provider communitys top priority, the budget also includes funding for K-12 public schools, the University of Wisconsin System, Corrections, Shared Revenues, state employee compensation and fringe benefits, transportation funding and road construction, possible changes
14 CONTINUUM | www.whcawical.org

in income tax and other tax policy, all with the goal of balancing the budget and limiting state debt. In addition to the return and rededication of the nursing home bed tax skim in the budget bill, WHCA/WiCAL will be advancing legislation that: Permits the use of formularies by skilled nursing facilities and other qualified practitioners; Allows a nursing home to transfer licensed beds to another facility located anywhere in Wisconsin if the transferring and receiving nursing homes notify the Department of the proposed transfer within 30 days before the transfer occurs and the Department reviews and approves the transfer; Requires the Medicaid program to recognize and fund its share of the additional costs all long-term care providers will incur as required by the Affordable Care Act; Addresses provider concerns with Family Care program, including: provider contracts, rate changes, operational inefficiencies, and an enforcement/appeals process.

Specializing in Health Care Development and Award Winning Nursing Homes

HOW CAN OUR DEVELOPMENT TEAM HELP?


Construction Experience - Award Winning Adult Healthcare Projects Financing Specialist - Healthcare Finance Expertise Forecasting Expertise - Lender Relationships Operational Assistance - Licensed Nursing Home Administrator on staff
3653 Greenway Street | Eau Claire, WI 715-832-1986 PH | www.royalbuilt.com

From Concept to Keys...

WINTER 2013 | CONTINUUM 15

Stakeholder Spotlight

The Affordable Care Act is Here to Stay


New Taxes and Fees Under Obamacare
By Karen J. W. Breitnauer, J.D.

The penalty in this situation would be either $2,000 per fulltime employee minus the first 30 or $3,000 per subsidized full-time employee, whichever is less. Penalties are not paid on part-time employees.

coverage in the individual market for individuals with higher cost needs to obtain coverage during the first three years of exchange operation (2014-2016). All health insurance carriers (fully insured plans) and Third Party Administrators (TPAs for self-funded plans) will make payments to support the reinsurance payments to individual carriers. This applies only to major medical plans. States will have the option to establish the reinsurance program. If the state does not establish a reinsurance program, the U.S. Department of Health and Human Services will establish the program and perform the functions for that state. HHS has proposed initial payments of $5.25 per covered life per month (or $63 annually) in 2014.

ACA PROJECTED HEALTH INSURANCE PROVIDER FEES


(IN BILLIONS $)
16 14 12 10 8 6 4 2014 2015 2016 2017 2018

$13.9B $11.3B $8B $11.3B

$14.3B

PCORI FEES FOR HEALTH INSURANCE PLANS


(30+ hours per week) or pay a penalty. In order to hit the threshold of 50 or more full-time equivalent employees, employers should include full-time employees (30+ hours per week) and part-time employees (total monthly hours/120). Seasonal employees working 120 days or less are excluded. Based on current information, employers are subject to the penalty if at least one full-time employee in their population qualifies for subsidized coverage in an exchange. If an employer offers no health plan coverage (or offers coverage, but such coverage is not minimum essential coverage), the penalty is $2,000 per full-time employee minus the first 30 employees. If the employer continues to offer coverage the coverage must meet a minimum value standard (coverage of 60 percent of the costs which has not been further defined) and be affordable. Employers would determine affordability by comparing 9.5 percent of the fulltime employees W2 income to the contribution amount required for the lowest-cost single coverage which provides minimum value. Health insurance plans will be required to pay fees to help fund the PatientCentered Outcomes Research Institute (PCORI). The PCORI is a private, non-profit corporation that will assist patients, clinicians, purchasers and policymakers in making informed health decisions by advancing the quality and relevance of evidencebased medicine through research. The fees are effective for plan years ending on or after October 1, 2012. For example, for calendar year policies and plans the fee is applicable for the plan year starting January 1, 2012 and ending December 31, 2012. The fee is $1 per average number of covered lives for plan years ending before October 1, 2013. The fee increases to $2 in 2014 and will be increased thereafter based on a projected per capita rate. The fees will be treated like taxes and will be due on July 31 of every year for the preceding plan year. The fees are imposed on the insurance carriers (fully insured plans) or plan sponsors/employers (self-funded plans).

n November 6, 2012, the American people re-elected Barack Obama as President of the United States for a second term, and with his re-election came the realization that the Affordable Care Act is here to stay. The initial wave of changes brought about by the legislation included reimbursements, tax credits and mandates intended to bring more robust health care to the nations insured. The second wave is set to hit in 2014 with the dawn of exchanges, the individual mandate and employer play or pay penalties requires a different set of changes designed to pay for this massive piece of legislation, its coverage, subsidies, premium credits and enhanced benefits. This article will discuss the various taxes and fees that will be imposed to achieve the full realization of this law, including: Employer Pay or Play Penalties PCORI (Patient-Centered Outcomes Research Institute) Fees Reinsurance Fees Annual Fee on Health Insurance Providers Miscellaneous other taxes

ADDITIONAL TAXES
Under the ACA the following additional taxes will be imposed: Medical device excise tax on the sale of certain medical devices by the manufacturer, producer or importer of the device. The tax applies to sales after December 31, 2012. The tax is 2-3 percent of the price for which the manufacturer or importer sells the taxable medical device. Individual mandate tax of $95 annually to person who fails to maintain minimum essential coverage. The cost rises to $695 per uninsured person in 2016. Increase of Medicare payroll tax of .09 percent on individuals who earn $200,000 or more per year or families that earn more than $250,000 per year. Increase of unearned income tax to 3.9 percent on individuals who earn $200,000 or more per year or families that earn more than $250,000 per year.

Cadillac Tax on High-Cost plans in 2018 40 percent excise tax on high cost plans currently defined as $10,200 annual limit on individual plans and $27,500 annual limit on other than individual plans. The Affordable Care Act is here to stay. Understanding the various fees, taxes penalties and other costs associated with it will be crucial as the provisions of this law continue to unwind.
Karen Breitnauer leads M3s Governmental Compliance Unit, which researches and reports on regulatory and legislative issues to clients and M3 staff. She is licensed to practice law in Wisconsin and is a member of the State Bar of Wisconsin, Health Law Section. She can be reached at Karen.Breitnauer@m3ins.com.

ANNUAL FEE ON HEALTH INSURANCE PROVIDERS


The ACA imposes an annual fee on health insurance providers effective with respect to premiums written in 2013. Fees are based on the total amount of premiums each insurer writes compared to other insurers. These fees are imposed only on health insurance carriers and not on employers that provide self-funded benefits to employees. The total amount payable by health insurance providers subject to the tax will equal $8 billion in 2014, $11.3 billion in 2015 and 2016, $13.9 billion in 2017 and $14.3 billion in 2018. After 2018, the amount of excise tax is indexed to the rate of growth of the premiums. Health insurance providers will owe a percentage of the annual dollar amount based on the providers net premiums written for the preceding year and divided by the net premiums written by all of the health insurance providers subject to the tax for the preceding year.

REINSURANCE FEES

EMPLOYER PAY OR PLAY PENALTIES


In 2014, all employers, including long-term care facilities and nursing homes, with 50 or more full-time equivalent employees will be required to provide minimum value health insurance coverage that is considered affordable to full-time employees
16 CONTINUUM | www.whcawical.org

The ACA establishes a transitional reinsurance program in each state to assist in stabilizing premiums for

WHCA/WiCAL AFFORDABLE CARE ACT PREPARATION SEMINARS


WHO: WHEN: WHERE: Robert Semandel, ESQ. of Jackson-Hewitt and Sean LaBorde, RHU of M3 Insurance Solutions for Business. February 6, 7 and 8, 2013 Appleton: Holiday Inn, 150 Nicolet Road - 920-735-9955 Eau Claire: Holiday Inn, 2703 Craig Road - 715-835-2211 Brookfield: Midway Hotel Brookfield, 1005 S. Moorland Road 262-786-9540

Pay or Play Penalty Example


No Health Plan Offered Employer Continues to Provide Plan

Penalty = $2,000/FTE 30 employees Penalty = Lesser of $2,000/FTE 30 employees OR $3,000/subsidized employee

REGISTER: www.whcawical.org

WINTER 2013 | CONTINUUM 17

LTC Legal Letter

Balancing Rights and Safety


What the Helen E.F. Decision Means for Laws Governing Challenging Behaviors
By Brian Purtell

under emergency detention pursuant to Section 51.15. Fond du Lac County then initiated a proceeding under Chapter 51 to have Helen involuntarily committed for treatment. A commitment was ordered and the court issued an involuntary commitment order in a locked psychiatric unit, which was appealed. The Court of Appeals determined that Helen was not the proper subject for commitment or treatment under Chapter 51 because Alzheimers disease was not a qualifying mental condition. Notably, the Court of Appeals also stated that since rehabilitation is the purpose of Chapter 51, the treatment of an Alzheimers disease patient under this Chapter is inappropriate because individuals with Alzheimers disease cannot be rehabilitated. The Court of Appeals decision was heard by the Supreme Court and the Court stated that because Helen was not medically capable of being rehabilitated, she could not be involuntarily committed under Chapter

51. Since her disability was likely to be permanent, she was therefore a proper subject for protective placement and services under Chapter 55. The Court also analyzed the purpose of the statutes and found Chapter 55 presented a better balance of Helens interest in liberty and the Countys interest in protecting the public and providing Helen with care. Three specific features of Chapter 55, not found in Chapter 51 include: placement options, the involvement of a Guardian ad Litem, and the need for long-term care versus short-term treatment and rehabilitation. The Court concluded that the features of Chapter 55 are more appropriate for individuals with Alzheimers or related dementias, and that Chapter 51 be reserved for individuals with mental illness for purposes of treatment. Of particular note, however, was that the Court did not rule on whether an individual who has a dual diagnosis of both mental illness and dementia could be involuntarily committed under Chapter 51. Instead, the Court left this issue for another day.
Brian Purtell, WHCA/WiCALs Legal Council, listens to testimony before the Legislative Council Study Committee on Legal Interventions for Persons with Alzheimers Disease and Related Dementias.

isconsins long-term care provider community provides tremendous care and services to a wide variety of individuals, in various settings, throughout the state. A very small but important subset of individuals served present unique challenges, particularly when, due to underlying conditions or progressive deterioration, causes an individual to create a danger to themselves or others. Historically, the avenue of last resort may have been a Chapter 51 emergency detention or involuntary commitment when the provider was unable to address the needs of the individual. While this process was sparingly used for individuals with Alzheimers or related dementias, it was an option prior to the Helen E.F. case.

Court in the Spring of 2012, which held that a person with Alzheimers disease does not have a Chapter 51 qualifying illness, and is more appropriately treated under the provisions of Chapter 55. This decision has created much confusion and discussion about the most appropriate way to address situations when individuals with Alzheimers or related dementias present acute situations in which they pose a risk to themselves or others. Helen was an 85-year-old woman suffering from Alzheimers disease, with symptoms including progressive dementia and memory lags. She lived in a nursing home in Fond du Lac for six years and began to exhibit agitated and aggressive behavior. She was transported to a hospital emergency room where the behavior persisted and was placed in the hospitals behavioral health unit

Fallout
Following the Helen E.F. decision, most counties have modified their procedures in the area of situations involving aggressive or dangerous individuals with Alzheimers or related dementias. Providers are increasingly confronted with information from county officials that law enforcement or others are not authorized to initiate an emergency detention for an individual who clearly has dementia. The application of these decisions varies slightly throughout the state with some counties using a more expansive interpretation, particularly when an individual may have both some underlying mental illness and dementia.

Background
Fond du Lac County v. Helen E.F. was decided by the Wisconsin Supreme

of the issues raised in the Helen E.F. decision. This Committee explored the development of modifications that would address the inadequacies of Chapter 55 for acute emergency situations. Those familiar with Chapter 55 recognize that while the Chapter provides additional protections and procedures for individuals in need of protective placement or services, this also comes at a cost of time which may be crucial for acute situations. If Chapter 55 is a more appropriate avenue for individuals exclusively with Alzheimers or related dementias given the additional protections afforded, modifications are necessary in order to shorten the timeframes to allow this to be a viable option when an emergency exists. Additional stumbling blocks exist with regard to the definition of an inpatient health care facility where a protective placement would be made. While Committee members generally agreed that it may be better for individuals with Alzheimers and dementia to be placed in a setting exclusive to this client population, the realities of hospitals or other similar providers creating dedicated and separate units to provide such services and treatment may be impractical or cost-prohibitive. It is hoped that the Committee will advance recommendations for legislation to be considered during the next legislative session. Whether this

ultimately results in modifications to Chapters 51 and 55 remain to be seen, but it is imperative that the provider community communicate their issues to their legislators. While it is only a small subset of individuals that present significant behavioral challenges, providers familiar with such instances will certainly share that they consume a disproportionate amount of time, energy and resources to protect the resident and others. It is hoped that the legislative changes will afford a safe and effective option for individuals with Alzheimers and dementia to receive the necessary care and treatment so as to protect them and others around them. For more information, or to keep abreast of developments in this area visit the Legislative Council webpage located at legis.wisconsin.gov/lc/committees/ study/2012/alz, or write me using the contact information listed below.
Brian Purtell is WHCA/WiCALs Legal Counsel, Executive Director of the Wisconsin Center for Assisted Living, and is a member of the Legislative Council Study Committee on Legal Interventions for Persons with Alzheimers Disease and Related Dementias. He can be reached at brian@whca.com.

This decision has created much confusion and discussion about the most appropriate way to address situations when individuals with Alzheimers or related dementias present acute situations in which they pose a risk to themselves or others.
18 CONTINUUM | www.whcawical.org

Legislative Council Committee


A Joint Legislative Council Committee reviewed the options and possible legislative changes to address some

WINTER 2013 | CONTINUUM 19

Great reasons to choose West Bend

g n i l e e F ? n I d e k c Lo
Make Your One Phone Call to Morton LTC Pharmacy.
Expert Medication Management with No Long Term Contracts.

We Can Help You Plan Your Future Growth


NEW CONSTRUCTION | REMODELING

The Ridges Assisted Living/Memory Care Facility


LODI, WI

Scope Planning/Budgeting Design-Build Site Selection

Financial Analysis Build to Suite/Lease Turn-Key Construction

William Nebel Co-Owner


Office: 608.831.2618 | Cell: 608.669.4546 6629 University Avenue, Suite 102 | Middleton, WI 53562 crowncommercialredev.com | bill.a.nebel@gmail.com

West Bends Specialty Lines division is staffed by claims and legal professionals who, for more than 20 years, have handled the most difficult situations facing long term care businesses. And our experienced loss prevention and risk management professionals are dedicated to providing our clients with the most up-to-date safety information. There are many great reasons to choose West Bend to protect your valuable business great pricing; exceptional coverages; convenient payment options; and experienced loss prevention, claim, and legal professionals who will help protect your business! To find an independent insurance agent in your area that represents West Bend, visit www.thesilverlining.com.
Twice Daily Deliveries e-MAR Options Multiple Cycle Options 24/7 Pharmacist Availability Pharmacist/Nurse Consultants Customized Compounding

Check your contract. Then call us.

mortonLTC.com
(920) 727-3853

An independent family-owned Wisconsin pharmacy since 1932.

20 CONTINUUM | www.whcawical.org

WINTER 2013 | CONTINUUM 21

WE FOCUS ON YOUR NEEDS.

PROVIDING COST EFFECTIVE SOLUTIONS, WITH PROVEN RESULTS.

www.avivreit.com
INVESTING WITH NURSING HOME OPERATORS FOR MORE THAN 30 YEARS

Digital/Commercial Print Direct Mail Web to Print/E-commerce Promotional Products

Creative Design Large Format Printing Corporate Apparel Fulfillment/Distribution Dean Gille 608.318.1967 dean@bgsinc.com Call us Today for a FREE Marketing Consultation

Acquisitions Sale Leasebacks Triple-net Leases

Foodservice

Full-Line

Family Owned & Operated Broadline Foodservice Distributor Free Web-Based Menu Program 6 Registered Dietitians Culinary Specialists Innovative Educational Programs Theme Meal Events

Distribution

Difference

with a

Duluth

Aviv REIT, Inc. proudly announces its recent acquisition of Seven Oaks Nursing & Rehabilitation Center, a 94-bed Skilled Nursing Facility located in Glendale, WI FOR MORE INFORMATION ON AVIV REIT PLEASE CONTACT: David Fasano dfasano@avivreit.com 312-855-0930
303 West Madison, Suite 2400, Chicago, IL 60606

Aberdeen

St. Cloud Wausau Minneapolis Green Bay

Sioux Falls Milwaukee Cedar Falls Sioux City Davenport Omaha Grand Island Des Moines Peoria Sheldon

Serving The Midwest 1-800-847-2404 MartinsNet.com


406 Viking Road, Cedar Falls, IA 50613

Cost Control Resources Dining Program Consultation Services Customized To Meet Your Needs

Salina

Topeka

Kansas City

Rosiclare

22 CONTINUUM | www.whcawical.org

Wisconsin Health Care Association

Wisconsin Center for Assisted Living

131 W. Wilson Street, Suite #1001 Madison, Wisconsin 53703

Any agent can place your business insurance, but not every agent can be your trusted business advisor.

Wed like to be yours.

www.m3ins.com

800.272.2443

Вам также может понравиться