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OHCA 2022 Oregon Long Term Care State Report

2022 OREGON LONG TERM CARE STATE REPORT Improving lives by advancing quality care in Oregon since 1950

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4 Long Term Care 101 5 A Continuum of Care 6 Oregon Leads the Nation in Providing High-Quality Long Term Care 8 Initial and Continuing Training Requirements 10 Oregon Care Partners Trainings 12 Impacts of COVID-19 14 Economic Impact, Affordablity, and Workforce 16 Oregonians in Need of Long Term Care 19 Nursing Facilities and Post-Acute Care 20 Long Term Care Financing 22 Oregon Medicaid LTSS Clients 24 2023 Policy Priorities 25 Endnotes TABLE OF CONTENTS

2022 Oregon Long Term Care State Report www.ohca.com 4 Long Term Care 101 Long term care is a continuum of services and supports, including health care, social services, and housing, provided to individuals living with chronic conditions or disabilities that affect their ability to perform activities of daily life. In Oregon, this continuum of care is provided through settings that allow Oregonians to maintain their dignity, independence, and autonomy within safe environments. The continuum includes inhome care; senior retirement housing; communitybased care communities (assisted living, residential care, and memory care); and skilled nursing facilities. The Continuum of Long Term Care Services and Supports In-Home Care fIn-home health supports and services fFamily supports fCommunity supports Independent Living/Senior Retirement Housing fRecreational activities fAmenities such as housekeeping and dining services Assisted Living/Residential Care fCommunity-based settings f Assistance with activities of daily living and instrumental activities of daily living such as bathing and medication management fMemory care Skilled Nursing fPost-acute rehabilitative care fIntensive, skilled nursing services fEnd of life care/hospice

www.ohca.com Oregon Health Care Association 5 A Continuum of Care Licensed facilities that provide 24-hour skilled nursing for post-acute rehabilitative care or long stay services that are needed due to ongoing and indefinite cognitive or physical impairment(s). Skilled Nursing Facility (SNF) Residential Care Facility (RCF) Licensed 24-hour home and community-based service settings that serve anywhere from six to more than 100 residents. Rooms can be shared by two individuals. Different types of residential care include 24-hour residential care for adults and specialty memory care communities. Registered nurse consultation services are required by regulation. Assisted Living Facility (ALF) Licensed 24-hour home and community-based service settings for six or more residents in individual, private apartments. Services are comparable to residential care communities. Registered nurse consultation services are required under state regulations. Adult Foster Home (AFH) Services are provided in single family home-like settings that are licensed for five or fewer individuals who are not related to the foster home provider. Adult foster homes provide a range of care and service needs. Memory Care Community (MCC) Environments where staff care for individuals with Alzheimer’s or dementia, who have needs that require a secure setting. Each setting is licensed by the state as a residential care, assisted living, or nursing facility. Memory care communities are required by the state to train staff to care for residents with dementia and provide specialized services. Independent Living (IL)/ Senior Retirement Housing (SRH) Communities organized to provide housing and services to senior households. In general, these communities do not provide health care or assistance with activities of daily living. Often, they offer recreational opportunities, dining, laundry service, and other similar amenities. In-Home Care Agency (IHC) Agencies that employ, assign, and schedule caregivers to provide personal care assistance for clients in their homes or in community settings. Home Health Agency (HHA) Agencies that provide skilled care services in individuals’ homes. These services are largely funded by Medicare. Foundational to the long term care system in Oregon is a commitment to community-based care, where care is provided to individuals in community settings such as assisted living, residential care communities, and adult foster homes. Community-Based Care (CBC) Housing with Services (HWS) An entity that coordinates two or more health and social services for older adults and people living with disabilities, who reside in publicly subsidized or private congregate settings.

2022 Oregon Long Term Care State Report www.ohca.com 6 Oregon Leads the Nation in Providing High-Quality Long Term Care For more than 40 years, Oregon has been a national leader in providing quality care and services to older adults and other Oregonians living in long term care settings. Oregon’s pioneering efforts to provide aging services in the home and in home-like settings and our commitment to fund these services for lowerincome Oregonians enable those in need of care, from all backgrounds, to receive some of the highestquality care in the country. Long term care is the continuum of services and supports that includes health care, social services, and housing for individuals living with illnesses or disabilities that affect the ability to perform activities of daily living. Today, more than 40,000 Oregonians reside in licensed long term care settings and nearly 9,500 Oregonians receive services and supports in their homes provided by licensed in-home care agencies. Long term care continues to face many challenges, including continued impacts from the COVID-19 pandemic and the resulting workforce and cost containment challenges that came with it. For more than two years, providers have been working tirelessly to keep their staff and residents safe, while continuing to promote independence, choice, and dignity for their residents. Due to unprecedented inflation within the global economy, the cost of providing care and services continues to skyrocket. Yet, on the horizon we can see increasingly rising demand for long term care services as the “baby boomer” generation ages. There has never been a more critical time for the state to renew and enhance its commitment to long term care services and supports. #3 AARP ranked Oregon 3rd highest in the support of family caregivers.2 #4 AARP ranked Oregon 4th highest in the nation for long term care.3 #1 Oregon continues to invest more in home and community-based services as a percentage of Medicaid long term care service spending than any other state. (83.3% of all LTSS dollars.)1 Oregon ranked 4th in the nation in successful transfers from skilled nursing facilities back to their homes and to the community.4 #4

www.ohca.com Oregon Health Care Association 7

2022 Oregon Long Term Care State Report www.ohca.com 8 Initial and Continuing Training Requirements Oregon boasts some of the most robust training requirements for caregivers, clinicians, staff, and leadership in long term care service settings. For many long term care positions, Oregon has some of the highest training requirements of any state. These requirements include pre-service trainings as well as continuing education that is required annually. For example, in the case of certified nursing assistants (CNAs) in Oregon’s skilled nursing facilities, 155 hours of initial training is required. This includes 80 hours of classroom instruction and 75 hours of supervised clinical experience and a competency exam and additional, continued training required on a quarterly basis. The initial training requirement is more than double the federal minimum requirement of 75 hours of initial training for CNAs in these settings. Assisted Living and Residential Care Communities All assisted living and residential care communities (which include memory care) must have a training program in place that includes methods to determine competency of direct care staff through evaluation, observation, or written testing as well as documentation of direct care staff’s demonstrated competency. Knowledge and performance that must be demonstrated within the first 30 days of hire by direct care staff that include: • The role of service plans in providing individualized resident care • Providing assistance with the activities of daily living • Changes associated with normal aging • Identification of changes in the resident’s physical, emotional, and mental functioning, and documentation and reporting on the resident’s changes of condition • Conditions that require assessment, treatment, observation, and reporting • General food safety, serving, and sanitation • If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised Further, pre-service dementia care training is required which must include the following subject areas:5 • The dementia disease process • Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including reducing the use of antipsychotic medications for non-standard uses • Strategies for addressing social needs of persons with dementia • Specific aspects of dementia care and ensuring the safety of residents with dementia, including: • Identify and address pain • Provide food and fluids • Prevent wandering and elopement • Use a person-centered approach All staff must also undergo a preservice orientation, which includes these topics: • Residents’ rights and the values of communitybased care • Abuse and reporting requirements • Infection control • Fire safety and emergency procedures

www.ohca.com Oregon Health Care Association 9 In addition, all staff must have:6 • 12 hours of annual continuing education in topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Beginning July 1, 2023, training in infectious disease outbreak and infection control will also be required In-Home Care Agencies All in-home care staff are required to participate in 4 hours of initial orientation that includes multiple care-related topics. In addition, all staff must have:7 • 8 hours of initial training • A further 4 hours of basic, non-injectable medication training for caregivers who provide medication services must be obtained prior to providing medication services • 6 hours of annual continuing education Additionally, a competency evaluation must be conducted and must include a combination of direct observation and written or oral testing. Skilled Nursing Facilities In addition to adhering to all regulatory, compliance, and training requirements set forth on a national level by the Centers for Medicare and Medicaid Services (CMS), Oregon nursing facilities have strict requirements at the state level, including the following training requirements. All staff must have: • An orientation to ensure the safety and comfort of all residents is assured in accordance with facility policies which is to be carried out by a registered nurse Certified nursing assistants (CNAs) in these settings must complete:8,9 • An Oregon State Board of Nursing OSBN approved nursing assistant training program (155 hours) • Pass an OSBN-administered examination that qualifies them to obtain certification as a nursing assistant in Oregon • 12 hours of annual continuing education (at least 3 per quarter) Sample of Care Training Requirements by Licensed Setting LICENSED SETTING INITIAL/ PRE SERVICE ANNUAL CONTINUING EDUCATION Nursing Facility (SNF) Certified Nursing Assistant (CNA) 155 hours and Exam 12 hours (3/quarter) Assisted Living/Residential Care (ALF/RCF) Direct care worker Demonstrate proficiency in multiple care topics 12 hours including 6 hours in dementia specific topics In-Home Care Direct care worker 4 hours orientation 8 hours training 4 hours medication (for staff providing medication) 6 hours Sources: Oregon Administrative Rules: OAR 333-536-0070; OAR 411-054-0070; OAR 411-086-0310.

2022 Oregon Long Term Care State Report www.ohca.com 10 Total number of caregivers trained 24,257 Total number of in-person and online classes 152,740 Caregivers Trained via Oregon Care Partners Oregon Care Partners Trainings Established in 2014 by the Oregon Legislature, Oregon Care Partners provides access to no-cost, high-quality trainings in all corners of the state. These trainings are offered in-person and online with timely, evidence-based curriculum, including Alzheimer’s and dementia care; medication management; challenging behaviors and communication; traumainformed care; diversity, equity, and inclusion in long term care; and specialized training on Alzheimer’s disease for public safety workers. From January 2021 to May 2022, 24,257 unique individual caregivers completed 152,740 Oregon Care Partners in-person and online classes and webinars.10 The COVID-19 pandemic required Oregon Care Partners to completely reimagine its curriculum delivery. All classes were conducted via webinar and online infection prevention training courses were developed in collaboration with the Oregon Department of Human Services (ODHS).

www.ohca.com Oregon Health Care Association 11

2022 Oregon Long Term Care State Report www.ohca.com 12 Impacts of COVID-19 Few sectors have been as heavily impacted by the COVID-19 pandemic as long term care. Early on in the pandemic, facilities were closed to all visitors in order to protect residents and staff from the spread of infection. Activities were curtailed and many essential services such as dining had to be restructured under the emergency regulations from the Oregon Department of Human Services (ODHS) and the Centers for Disease Control and Prevention (CDC). During those challenging times, the staff in Oregon’s long term care communities showed incredible resolve and continued to provide the services and supports needed by residents. Oregon fared better than much of the country for the first years of the pandemic, with lower rates of positive cases and fatalities from COVID-19 in our long term care settings compared to many other states. Vaccines, which were distributed initially in onsite clinics at Oregon long term care communities across the state between December 2020 and April 2021, were a lifeline for our sector and for all older Oregonians most at risk of serious complications from COVID-19. The vaccination rates of long term care residents and staff remain high compared to the general Oregon population for the initial vaccine doses; booster rates are relatively comparable. Overall, long term care residents are one of the highest vaccinated populations in the country. Long term care residents are at especially high-risk for complications and mortality from COVID-19 infection due to a high level of medical need and co-occurring chronic health conditions amongst this population. Oregon long term care staff and residents have higher rates of vaccination than the general Oregon population.11,12 Notably, Oregon requires the reporting of vaccination data for both communitybased care providers and nursing facilities, while federal reporting requirements only mandate data to be reported by nursing facilities. Because of COVID-19 Vaccination Rates, as of June 2022 Long Term Care Facilities – Oregon Rate of Vaccination Facility Staff – Initial Doses Facility Residents – Initial Doses General Population – Oregon Adults – Initial Doses 88% 89% 76.4% Source: Oregon Health Authority. Long-Term Care Facility COVID-19 Vaccination Data. June 6, 2022; Oregon Health Authority. (2022). COVID-19 Vaccination Metrics. June 6, 2022.

www.ohca.com Oregon Health Care Association 13 this, direct comparisons between the Oregon and national data should be made with caution. Vaccine Mandates As of July 2022, Oregon continues to be one of a handful of states that requires COVID-19 vaccinations for all long term care facility staff, allowing only for medical and religious exceptions that meet certain criteria. All nursing facility staff nationwide are subject to vaccine requirements via federal mandate. Residents are in no way required to be vaccinated, though Oregon facilities have worked hard to provide a variety of avenues (onsite and offsite) for their residents to easily receive initial doses and booster shots if desired. Longer Term Impacts Clinical The pandemic required many changes to the provision of care in Oregon’s long term care communities. For example, infection prevention efforts were enhanced significantly and regular testing of staff and residents continues to be required when new COVID-19 cases are detected. Additionally, the use of telehealth to provide remote services to residents have been implemented across long term care providers in Oregon with great succes, along with the advancement of other technologies to improve care. Many of these innovative changes, including the wider use of telehealth, were already beginning to take place prior to the pandemic; however, their adoption took place at light speed as the pandemic upended the sector. Policy Many regulatory policies were put in place during the course of the pandemic in order to protect residents and staff from the spread of COVID-19. These ever changing—and sometimes contradictory— requirements at the local, state, and federal levels often challenged Oregon’s provider community to keep pace and remain in compliance. The establishment of new regulatory measures has slowed in recent months. However, the importance of clear guidance and uniform enforcement of regulations is essential for providing care safely. Over the course of the pandemic, many investments have been made by state and federal policymakers to enhance access to personal protective equipment (PPE) and increase worker wages including a onetime bonus incentive for Oregon nursing facility staff at certain income levels. These investments have been a lifeline to workers and providers during the pandemic. Workforce While the pandemic has roiled the economy and workforce worldwide, the long term care sector has experienced some of the most challenging workforce issues of any industry. In spite of a critical need for a larger caregiving workforce to meet the care needs of our aging society, nursing facilities, assisted living, and residential care have seen more than a five percent drop in total workers since 2019.13 The reasons for the decline are complicated, and the accumulated burdens of the pandemic have led many to leave the sector. These changes point to the increased need to invest and support a welltrained workforce that can meet the demand for an increasingly aged society.

2022 Oregon Long Term Care State Report www.ohca.com 14 Economic Impact, Affordability, and Workforce The long term care sector provides significant employment opportunities in Oregon, especially for women, who make up a majority of the long term care workforce. Yet, recruiting and retaining the large number of professionals required to provide highquality care for aging Oregonians is a major challenge. The sector must cultivate a pipeline of talent as demand for long term care services and supports grows. Providers in rural Oregon face particularly acute challenges as populations in these areas have, sometimes significantly, proportionately more older adults than in urban and suburban areas of the state. However, the number of workers is not increasing in these areas making it difficult for long term care facilities to find enough qualified caregivers and medical staff. More than 65,000 Oregonians are employed in the long term care sector. This includes approximately 49,600 Oregonians employed in assisted living, residential care, and nursing facilities—a slight decline from a peak of just over 52,000 in 2019.14 The decline is due to COVID-19’s impact on the workforce. Despite the nearterm decline, Oregon’s long-term care workforce will increase rapidly in the years ahead to serve our aging population; however, significant efforts will need to be made to ensure the workforce is trained and available to support care needs. In particular, the demand for home health aides and personal care aides will both increase by 29% while the demand for registered nurses will increase by 15% by 2028.15 Women make up a majority of the long term care workforce (81% female versus 19% male) in Oregon. Very little variation exists in the gender distribution of the workforce across nursing facilities, community-based care, and in-home care sectors. The high proportion of women employed in long term care communities in Oregon is comparable to that of the overall long term care workforce in the United States. Oregon’s long term care workforce is growing increasingly diverse. People of color make up a slightly larger share of the workforce than of the general population in Oregon. Approximately 31% of Oregon’s long term care workforce are people of color, compared with approximately 25% of the general population. There is some variation in workforce demographics across long term care settings in Oregon. The age of the long term care workforce is another important issue to consider. More than 29% of Oregon’s home care workforce is 55 years of age or older, while 11% of the workforce is over the age of 65. As many of Oregon’s nursing professionals approach retirement, this may add additional pressure on filling these important positions in the years ahead. At the same time, the U.S. Bureau of Labor Statistics projects that the need for nurses will grow by as much as 15% by 2028.16 Affordability of Care The affordability of long term care is an important equity issue. Most people who need long term care services and supports will require Medicaid at some point to help them pay for their care needs. As Oregon approaches one million adults 65 years of age and older, this raises many questions about access to care. Fortunately, Oregon offers robust Medicaid long term care services and supports access compared to many other states. However, stringent standards of eligibility mean that many middle-income Oregonians do not have adequate coverage or savings to fund their long term care needs and must spend down their savings to Medicaid eligibility. 38,000 40,000 42,000 44,000 46,000 48,000 50,000 52,000 54,000 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Employment in Oregon Nursing Facilities and Residential Care: 2011-2021 Source: Oregon Employment Department, 2022. Source: Oregon Employment Department (2022).

www.ohca.com Oregon Health Care Association 15 Direct Care Worker Profile–Oregon NURSING FACILITIES COMMUNITY-BASED CARE IN-HOME CARE ACROSS ALL SETTINGS17 % Female 83% 80% 83% 81% Median Age 43 28 32 37 % w/ Children Under 18 20% 35% 34% 26% % Identify as a Person of Color 23% 35% 31% 31% % w/ Associates Degree or Higher 17% 16% 20% 19% Source: 2022 Paraprofessional Health Institute, 2022. Workforce Projections 29% Growth by 2030 HOME HEALTH AIDES 29% Growth by 2030 PERSONAL CARE WORKERS 15% Growth by 2030 REGISTERED NURSES Home Care and In-Home Care Workforce Nursing Facility Workforce Assisted Living and Residential Care Facility Workforce 17% Men 17% Men 20% Men 83% Women 83% Women 80% Women Medicaid/Medicare Eligibility Payment for long term care services is increasingly covered by public sources—namely Medicaid and Medicare. Medicaid eligibility can be a complicated process. Eligibility for Medicaid-funded long term care services in Oregon is based on a combination of income and asset levels as well as the level of support that one needs to carry out their activities of daily living (ADLs) such as bathing, eating, or dressing or their instrumental activities of daily living (IADLs), including laundry, shopping, and meal preparation. Income and asset thresholds also depend on whether an individual has a spouse, and whether that spouse is also applying for Medicaid services. Eligibility requirements also vary slightly by the type of Medicaid-funded long term care services used by an individual e.g., institutional/nursing home or home and community-based services. Medicare also pays for short duration long term care services provided in skilled nursing facilities under limited circumstances. Specifically, for individuals enrolled in Medicare, the program will pay for up to 100 days of post-acute care following a qualified in-patient hospital stay. Days 1–20 are covered in full. From day 21 to 100, there is a co-payment required. Medicare provides no skilled nursing coverage after 100 days. The costs of care continue to increase especially with record inflation over the past year. This makes access to care far more difficult for thousands of Oregonians just at the time the number of people who may need support is nearing peak levels. The State of Oregon must continue to invest in its Medicaid program and older adults living with long term care services and supports needs to ensure the system can provide care and support to those who need it, when they need it. Source: Paraprofessional Health Institute, 2022.

2022 Oregon Long Term Care State Report www.ohca.com 16 Long Term Care Providers & Oregonians Served Sources: Estimates based on data from the Oregon Department of Human Services. 2021–2023 Legislatively Adopted Budget; Oregon Health Authority, Licensed In-Home Care Agencies. April 27, 2022. Tunalilar et al (2022a) Portland State University; Tunalilar et al (2022b) Portland State University; NCAL / AHCA Research (2022). Nursing Facility Patient Characteristics Report. July 2022. PROVIDER TYPE NUMBER OF SERVICE PROVIDERS OREGONIANS SERVED (IN 2021) Adult Foster Homes19 1,354 5,180 Nursing Facilities20 131 6,758 Assisted Living/ Residential Care21 336 15,146 Memory Care22 224 6,023 Independent Living 200 12,000+ In-Home Care Agencies23 186 9,300+ Home Care Commission Workers24 17,000+ 20,000+ TOTAL 19,441+ 74,407+ Oregon 65+ Population— Current & Future Projections 834,769 19.4% OF THE OREGON POPULATION 976,925 21.3% OF THE OREGON POPULATION Oregonians in Need of Long Term Care More than 70,000 Oregonians receive long term care services across the state each day, and that number will grow as Oregon’s population continues to age. Oregon’s population is aging steadily. In 2022, an estimated 834,769 Oregonians were 65 years of age or older, and, of that, 88,718 were 85 or older—the age group most likely to need some form of care and support.18 By 2030, there will be an estimated 111,894 Oregonians over the age of 85, a 26% increase over the next eight years. Source: Population Research Center, Portland State University, 2021a. 2022 2030

www.ohca.com Oregon Health Care Association 17 POPULATION BY AGE 2022 2030 Oregon Demographics—Current & Future Projections 4,296,300 4,580,700 Oregon Population Growth: 2022–2030 6.6% Total Population Growth 17% (Growth: 2022–2030) 26.1% (Growth: 2022–2030) AGE 85+ AGE 65–84 YEAR Source: Population Research Center, Portland State University, 2021a. TOTAL POPULATION 65–84 85+ 834,769 88,718 976,925 111,894 25

2022 Oregon Long Term Care State Report www.ohca.com 18 Oregon County Level Population Estimate and Percentage of Total County Population, 2021—Age 65+ Baker 4,716 28.00% Benton 12,723 13.50% Clackamas 83,724 19.70% Clatsop 10,247 24.70% Columbia 11,004 20.80% Coos 18,223 28.00% Crook 6,722 26.40% Curry 8,591 36.30% Deschutes 43,864 21.60% Douglas 30,629 27.40% Gilliam 508 24.90% Grant 1,899 26.30% Harney 1,633 21.70% Hood River 4,102 17.20% Jackson 52,932 23.60% Jefferson 5,164 20.70% Josephine 24,293 27.40% Klamath 15,874 22.70% Lake 1,965 24.00% Lane 80,401 21.00% Lincoln 15,970 31.40% Linn 25,920 19.90% Malheur 5,526 17.30% Marion 58,9377 16.80% Morrow 2,210 17.50% Multnomah 120,255 14.70% Polk 16,999 19.10% Sherman 480 25.80% Tillamook 7,748 28.00% Umatilla 13,504 16.80% Union 5,843 22.20% Wallowa 2,297 30.90% Wasco 5,725 21.50% Washington 88,382 14.60% Wheeler 473 32.50% Yamhill 20,421 18.90% Source: Population Research Center, Portland State University (2021b)  10–15%  16–20%  21–25%  26–30%  31–36% PERCENT OF POPULATION AGE 65+ 26

www.ohca.com Oregon Health Care Association 19 Source: Oregon State University Nursing Facilities and Post-Acute Care Nursing facilities typically provide care for individuals in need of rehabilitation following a serious health complication or hospital stay. While some individuals reside in nursing facilities for a very long period of time due to ongoing care needs, often their stays are short in comparison to those receiving care and services in other long term care settings. Therefore, length of stay in Oregon nursing facilities is highly compressed. In 2021, the median length of stay was 20 days.27 2020 saw the first increase in the median length of stay in several years, which is likely reflective of the COVID-19 pandemic’s continued impacts on our long term care system. While some individuals have intensive care needs that necessitate longer stays, the compressed length of stay reflects a shift toward nursing facilities acting as providers of short-term post-acute rehabilitative care. This helps keep costs down for the state, as nursing facility care is much more costly than community-based options. Median Length of Stay: Oregon Nursing Facilities 25 18 19 21 22 23 24 20 17 16 15 2016 2017 2018 2019 2020 2021 NUMBER OF DAYS

2022 Oregon Long Term Care State Report www.ohca.com 20 Assisted Living Residential Care 54% Private Pay 45% Medicaid 1% Other Source: Tunalilar et al 2022b. Long Term Care Financing Payer Sources Public funds, primarily Medicare and Medicaid, are the main sources of long term care financing in the United States, including in Oregon. However, the level of public investment varies by program and care setting. For instance, nursing facilities see higher rates of Medicare and Medicaid funding than community-based care facilities, where private pay remains the largest payer source statewide. However, Medicaid is increasing as a payer source in community-based care communities with more lower income Oregonians requiring services. The growing differential between private pay rates and Medicaid rates is putting tremendous financial stress on providers who primarily serve Medicaid clients. This differential must be addressed with continued investments for access to be maintained for those needing care across the state. Memory Care Source: Tunalilar et al 2022b. Skilled Nursing Facilities Source: Luck et al 2022. & 52% Private Pay 47% Medicaid 1% Other 11% Private Pay 62% Medicaid 24% Medicare 3% Other 54% Private Pay 45% Medicaid 1% Other 52% Private Pay 47 Medicaid 1% Other

www.ohca.com Oregon Health Care Association 21 Private Pay vs. Medicaid Rates 2020 2022 *PRIVATE PAY MEDICAID RATE PRIVATE PAY MEDICAID RATE28 MEDICAID ADD ON ALF **$4,49929 Level 1 - $1,370 **$5,045 Level 1 - $1,511 Level 1 - $1,663 Level 2 - $1,699 Level 2 - $1,873 Level 2 - $2,061 Level 3 - $2,132 Level 3 - $2,351 Level 3 - $2,587 Level 4 - $2,678 Level 4 - $2,953 Level 4 - $3,249 Level 5 - $3,221 Level 5 - $3,551 Level 1 - $3,907 MCC **$5,801 $4,480 **$5,99530 $4,939 $5,433 IHC **$28/hr $27.12/hr **$32.00/hr $29.90/hr $32.92/hr *Private pay and Medicaid rates are monthly rates for assisted living/residential care facilities. The rate for in-home care is hourly. **The private pay rate for MCC from 2020 is an average monthly rate. The private pay rate for assisted living/residential care facility and in-home care is a median monthly rate. Sources: Genworth Financial 2021; Tunalilar et al 2022b; Oregon Department of Human Services, 2022. Assisted Living/ Residential Care Memory Care In-Home Care

2022 Oregon Long Term Care State Report www.ohca.com 22 Medicaid Long Term Care Clients by Care Setting Source: Oregon DHS | OHA Office of Forecasting, Research & Analysis (2022). Monthly Caseload Variance Report. Department of Human Services, Adults and People with Disabilities. May 2022. 4,127 Assisted Living 760 Residential Care 599 Contract Residential Care 1,683 PACE 2,457 Memory Care 3,728 Nursing Facilities 2,299 Adult Foster Homes 17,357 In-Home Care Oregon Medicaid LTSS Clients 31

www.ohca.com Oregon Health Care Association 23 Total Oregonians Enrolled in Medicaid Utilizing Long Term Care Services and Supports 33,010 Source: Oregon DHS | OHA Office of Forecasting, Research & Analysis (2022). Monthly Caseload Variance Report. Department of Human Services, Adults and People with Disabilities. May 2022.

2022 Oregon Long Term Care State Report www.ohca.com 24 2023 Policy Priorities Stabilize and Grow the Long Term Care Workforce As Oregon’s aging population grows, the caregiving workforce must also grow to meet the demand for care. Providers are doing everything they can to recruit and retain direct care staff, certified nurse assistants, registered nurses, and other essential workers. Workers’ wages and benefits have increased significantly over the past few years. Nevertheless, an acute scarcity of trained and qualified workers is the single biggest challenge facing the long term care sector today and is limiting access to long term care services and supports for Oregonians. Oregon must expand investments in the caregiving workforce in 2023: fRenew the MedicaidWage Add-On Program that offers additional funding to providers who meet specified wage thresholds through Medicaid reimbursement. fContinue the Oregon Essential Workforce Health Care Fund, providing high quality health insurance benefits for employees of participating long term care employers. fDeliver wraparound support services for essential caregivers that allow them to stay in their jobs, including childcare, workforce housing, health services, and transportation supports. Support Access to Care Ensuring all Oregonians have access to long term care, especially for those who are low-income or live in rural communities, depends on Medicaid reimbursement rates meeting the true cost of care. fNursing Facilities: Continue to fully rebase Medicaid reimbursement rates fCommunity-Based Care and In-Home Care Agencies: Revamp Medicaid reimbursement rates to cover the true cost of quality care Ease Overly Restrictive Regulatory Burdens Causing Staff Departures Oregon has one of the most highly regulated long term care systems in the nation. The COVID-19 pandemic required significant and costly enhancements such as infection prevention and control, vaccinations, personal protective equipment, and caregiver supports. Most long term care providers continue to operate under a vast array of pandemic-related restrictions and oversight, in addition to implementing new regulations adopted over the last few biennia. While many recent regulations and requirements are intended to protect the health of residents, the cost of care is rising dramatically and caregivers are leaving the sector to avoid working under restrictive and challenging conditions. Now is the time to pause any new regulatory requirements, analyze existing requirements to assess whether they are causing staff to leave, and allow time for recently adopted laws to be fully implemented by the Department and providers.

www.ohca.com Oregon Health Care Association 25 Endnotes 1. Murray, C., Tourtellotte, A., Lipson D., & Wysocki A. (2021). Medicaid Long Term Services and Supports Annual Expenditures Report: Federal Fiscal Year 2019. Chicago, IL: Mathematica, December 9, 2021. Available from: https://www.medicaid.gov/medicaid/ long-term-services-supports/reports-evaluations/index.html. 2. Reinhard, S., Houser, A., Ujvari, K., Gualtieri, C., Harrell, R., Lingamfelter, P., & Alexis, J. (2020). Advancing Action, 2020: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. Washington, DC: AARP Public Policy Institute, The Commonwealth Fund, and The SCAN Foundation. Available from: www.longtermscorecard.org/2020-scorecard/preface. 3. Reinhard et al., 2020. 4. Reinhard et al., 2020. 5. Oregon Administrative Rule. OAR 411-054-0070. 6. OAR 411-054-0070. 7. Oregon Administrative Rule. OAR 333-536-0070. 8. Oregon State Board of Nursing (n.d.). Oregon Nurse Practice Act. Available from: https://www.oregon.gov/osbn/Pages/laws-rules.aspx. 9. Oregon Administrative Rule. OAR 411-086-0310. 10. Oregon Care Partners (2022). Project Report. June 1, 2022. 11. Centers for Medicare & Medicaid Services (2022). COVID-19 Nursing Home Data. Data.CMS.gov. Updated May 22, 2022. Available from: https://data.cms.gov/covid-19/ covid-19-nursing-home-data. 12. Oregon Health Authority (2022). Long-Term Care Facility COVID-19 Vaccination Data. June 3, 2022. Available from: https://public.tableau.com/app/profile/oregon.health. authority.covid.19/viz/LTCFCOVID-19VaccinationData/WeeklyTrend. 13. Oregon Employment Department (2022). Current Employment Estimates (CES) Industry History Data. Nursing and Residential Care Facilities. www.qualityInfo.org. 14. Oregon Employment Department, 2022. 15. U.S. Bureau of Labor Statistics (2022). Long Term Occupational Projections (20182028). Projections Central. “State Occupational Projections.” Available from: https:// projectionscentral.org/Projections/LongTerm. 16. U.S. Bureau of Labor Statistics, 2022. 17. Paraprofessional Health Institute (2022). Workforce Data Center. Available from: https://www.phinational.org/policy-research/workforce-data-center/. 18. Population Research Center (2021a). “Estimates of Population Age Groups (under 18, 18-64, 65 and over) For Oregon and Its Counties, July 1, 2021.” Portland State University. April 2022. Available from: https://www.pdx.edu/population-research/populationestimate-reports. 19. Tunalilar, O., Carder, P.C., Winfree, J., Elliott S., Kim, M., Jacoby, D., Albalawi, W. (2022a). 2022 Resident and Community Characteristics Report: Adult Foster Homes. Portland, OR: Portland State University. Institute on Aging. Available from: https://www. pdx.edu/institute-on-aging/oregon-community-based-care-project-cbc. 20. NCAL/AHCA Research Division (2022). Nursing Facility Patient Characteristics Report. Washington, DC: American Health Care Association. June 2022. 21. Tunalilar, O., Carder, P.C., Winfree, J., Elliott S., Kim, M., Jacoby, D., Albalawi, W. (2022b). 2022 Community-Based Care Resident and Community Characteristics Report on Assisted Living, Residential Care, Memory Care. Portland, OR: Portland State University. Available from: https://www.pdx.edu/institute-on-aging/cbc-annual-reports. 22. Tunalilar et al., 2022b. 23. Oregon Health Authority (2022). Health Facility Licensing & Certification. In-Home Care Agencies. Available from: https://www.oregon.gov/oha/PH/ PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/ HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/ IHCList.pdf. 24. Oregon Department of Human Services (2021). 2021-2023 Legislatively Adopted Budget. Salem, OR: Oregon Department of Human Services. Available from: https:// www.oregon.gov/dhs/ABOUTDHS/DHSBUDGET/Pages/2021-2023-Budget.aspx. 25. Population Research Center (2021a). “Estimates of Population Age Groups (under 18, 18-64, 65 and over) For Oregon and Its Counties, July 1, 2021.” Portland State University. April 2022. Available from: https://www.pdx.edu/population-research/populationestimate-reports. 26. Population Research Center (2021b). “Population by Age and Sex for Oregon and Its Counties: July 1, 2021.” Portland State University. April 2022. Available from: https:// www.pdx.edu/population-research/population-estimate-reports. 27. Luck, J., Zhang, W., Scarborough, N., Kaiser, A., Bahl, C., & Mendez-Luck, C. (2022). The State of Nursing Facilities in Oregon, 2021.Corvallis, OR: OSU College of Public Health and Human Sciences. 28. Oregon Department of Human Services (2022). Rate Schedule – Effective January 1, 2022. 29. Genworth Financial (2021). Monthly & Hourly Median Costs Oregon – State 2021. Available from: https://www.genworth.com/aging-and-you/finances/cost-of-care.html 30. Tunalilar et al., 2022b. 31. Oregon Health Authority (OHA) | Oregon Department of Human Services (ODHS) Office of Forecasting, Research and Analysis (2022). Monthly Caseload Forecast Variance Report. Oregon Department of Human Services. Adults and People with Disabilities. May 2022.

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