Agenda 07/11/2023 Item # 2E (May 25, 2023 BCC Workshop Minutes)07/ 11 /2023
2.E
COLLIER COUNTY
Board of County Commissioners
Item Number: 2.E
Doc ID: 25985
Item Summary: May 25, 2023 BCC Workshop Minutes
Meeting Date: 07/11/2023
Prepared by:
Title: Management Analyst II — County Manager's Office
Name: Geoffrey Willig
06/30/2023 3:21 PM
Submitted by:
Title: Deputy County Manager — County Manager's Office
Name: Amy Patterson
06/30/2023 3:21 PM
Approved By:
Review:
County Manager's Office Geoffrey Willig County Manager Review
Board of County Commissioners Geoffrey Willig Meeting Pending
Completed 06/30/2023 3:22 PM
07/11/2023 9:00 AM
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MINUTES OF THE COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
STATE VETERANS' NURSING HOME WORKSHOP
Naples, Florida, May 25, 2023
LET IT BE REMEMBERED that the Collier County Board of County
Commissioners, in and for the County of Collier, having conducted busin ss herein,
met on this date at 3 p.m. in REGULAR SESSION in Administ MNtuilding F, 3ra
Floor, Collier County Government Center, Naples, th ollowing members
present:
•
CHAIRMAN: �L r C N. oCast o
ris Hall
Dan Kowal
William L. McDaniel Sr.
Burt L. Saunders
CA
County Manager
w, County Attorney
lirector, Communications, Government & Public Affairs
Troy Miller, Communications & Customer Relations
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Anyone who needs a verbatim record of the meeting may request a video recording from the Collier
County Communications & Customer Relations Department or view it online.
Chairman LoCastro called the meeting to order at 3 p.m.
1. Pledge of Allegiance
Chairman LoCastro asked a veteran in the audience to lead the Pledge of Allegiance.
2. Workshop Topics
Chairman LoCastro said this is a very important topic and we're excited about o te- nded
veterans nursing home. So much work has gone on behind the scenes and this e o. 1
issue when we met with all the main players. This is a big project in Comm i e 1 aunders'
district and no one has done more on the inside, especially with his back �r so he's taking
the lead, but this is a Collier County project. Veterans from every distr' w be able to take
advantage of this wonderful opportunity, but we have a ways to go ed everyone for
taking the time to come. We have a lot to talk about.
Mr. Mullins outlined the four presentations.
2.A. Mike Kolejka and Neil Terry with Orcutt Winslow
renovated state veteran homes around the count)
currently being built. They also will discuA
(USDVA) requirements and expectations
additional services, such as outpatient e
rehabilitation.
w Mialize in designing new and
N, ovillscuss models of veteran homes
5� 'bepartment of Veterans Affairs
rties, with emphasis on designs with
adult day care and short-term
Mr. Terry told the BCC:
�y.
• He's been with Orcu=tiona
ow for over 37 years.
• Orcutt Winslow is a and international firm that recently merged with an
Orlando firm, * it ha#4 local presence.
• Our three roject types are healthcare, education and senior living.
• Mr. KolgiQ is rincipal in charge of senior living, which also focuses on veterans'
• W 've de ed over 50 veterans' homes and remodeled over 20 nationwide, as far as
Ha irginia.
• Our rst veterans' home was in 2009, when we worked for the state of Arizona in Tucson.
the first 120-bed veterans' home that followed the federal VA's guidelines for new
terans homes.
-4,• tate veterans' homes get about two-thirds of their funding from the federal VA, which has
guidelines to follow to receive the appropriation.
• Part of the guidelines is that they require a Small House concept, which divides veterans'
homes into pods, households of no more than 12 beds at a time. The idea is to center
bedrooms around living, dining and kitchen areas to create smaller units, so you have more
one-on-one care with caregivers, and it fosters social interactive action between residents.
• Studies have shown this is a better approach to care. The only problem is it can be very
inefficient and that's what he will discuss today.
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• Once a home has been built and occupied for a year, we go back to conduct a post -
occupancy evaluation. We interview staff and residents to understand what works well and
what doesn't. From that, we've evolved each of our designs to consider some of the things
that aren't working.
• We also work with each state to ensure we're designing a home that works within state
parameters, rules or guidelines.
• You're going to see how these evolved. Mike, our principal in charge of Senior Living,
which oversees veterans' homes, has been involved with all our veterans home projects to
ensure they have all the elements of good care and efficient designs.
• Mike is considered a national expert and has presented to the National AssoA4 of State
Directors of Veterans Affairs and the National Association of Veteran H� so he can
talk about the project types and good designs. 0
Mr. Kolejka detailed a PowerPoint presentation and reported that:
• We're working on our 15th veterans' home for the Utah De p ri Veteran Affairs, a
new replacement home for 105 beds in Salt Lake City.
• Part of our involvement today is to tell you about trend w re seeing in the industry
and where we see state veterans' homes going and wher ollier County can find the best
concepts to move forward for veterans.
• We have six offices and work from coast to c lso are working with Guam on a
veteran's home. •
• We're also building some adult day c're, 1 nursing, assisted living, and we
reposition existing veterans' homes a d v ans cemeteries.
• We have several key partnership g HMR, a South Carolina -based company that
operates a lot of veteran's ho �,� i wide.
• In addition to our post- c valuations, we're creating a task force with HMR to
look at how we take t omes we've done and push them to the next level for
operational efficiency whi till maintaining the most important thing, resident
satisfaction, care and great place for caregivers, who workday and night to care for our
nation's her
• We want s e the latest designs for veteran homes. We've done two in Virginia that
were Ja
mp d — one in northern Virginia, about 30 miles west of Washington, D.C.,
and an in Virginia Beach. Both are open and operational, hold 128 vets and were
c pietea,9ast year.
• Th orKs use some of the key components of the Small House design concept, a
ma eable household size, but we've tried to adjust it based on the post -occupancy
ack to find out the sweet spot for the size of the household and how we can arrange
em in such a way that those households are able to be staffed.
• One of the challenges now is trying to find caregivers and facility staff administrators.
Ever since the pandemic, the population of available staff has continued to shrink, while
competition, particularly in the private sector, has continued to grow, so we work hard to
ensure that as these designs evolve, we make them as efficient as we can for staffing,
doing more with less but not compromising on the quality of design or the quality of
resident care.
• This is an outdoor therapy garden with half of a Chrysler 300 that we used as part of
outdoor training for residents, particularly with physical and occupational therapy.
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• There are a variety of different flooring surfaces, with ramps and steps that allow residents
to exercise, particularly those who may only be staying in a home short-term before
returning home to their families. Some are permanent.
• This is a simplified floor plan showing one of the iterations we developed about five years
ago, what the VA calls a community center, which is like a town center where a lot of
larger functions are performed, such as administrative offices, multi -purpose spac
physical therapy, kitchen, laundry, and all facility components, in addition to a cok bar,
canteen, movie theater, etc. They're equidistant from various residential househ s.
• What's on each side are neighborhoods. This design has four 16-bed househol s %g$ make
up a neighborhood. At the center of the neighborhoods, with a linear passa , is a
main -street promenade that's the entry into each of the individual houseolL. This
maintains a sense of community and a sense of house.
• Think of these as 16-bed homes with an extended family. Within �� kitchen and
living space accessible to all the residents and in the center are s a support spaces,
including caregiver workstations that provide visual access t h*seholds.
• Since then, we've continued to evolve that design sinc was eloped about six years
ago. The next veterans home evolution, which we finis eran's Day last year, is
in Post Falls, Idaho. It's a different layout.
• Unlike other senior living communities with predominantly female populations, most
veterans' homes are predominantly male, so fine and detailing are respectful and
appropriate for the population we're seiwin s 7Ve'rOfooking ahead to the future as the
populations evolve.
• [He detailed several photos showing e ee shop, main -street promenade, community
center, church, a multi -purpose s aft s bar/canteen, with a billiard table, poker
chairs, sports club features, an rr shop.]
• The design creates a sen�jjf iv , but still allows visual connection front to back.
• Within each of the Zo Ids, ne of the most important components for staff are the
carers, the frontline staff ii�pibers caring for veterans every day. They also act as a
concierge and welco visitors as they come into each household.
• We've even ' oduz fireplace elements. Residence hallways feature lounges at the end,
with conn s to daylight throughout, so you're never going down a long, circuitous
ay i ng is always very easy.
as a living room with a visual connection to outdoor courtyards and other
�enities. The kitchen and dining are the heart of the home. There are induction
et up so residents can sit in a household kitchen.
materials and finishes that are durable, long lasting and can take a lot of abuse is
because many residents are in scooters and wheelchairs.
'irginia facility, this 64-bed facility is designed to be expanded to up to 128 beds
another neighborhood on the other side. We decided in this iteration, as we
o evolve, to look at staffing. Northern Idaho has a staffing shortage when it
comes to caregivers, so rather than having dining at the end of each corridor, a decision
was made to have one dining venue that serves two households, so you can serve double
the number of residents with the same number of staff.
Within each one is a little prep kitchen that allows them to cook made -to -order food, such
as omelets, toast, cheeseburgers, etc., that residents are looking for.
We're looking at how we can consolidate things better without losing quality or care.
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• Our latest project, Salt Lake Veterans' Home, is a 105-bed home expected to be
completed in the first quarter of 2025. It has a distinct look that orients the entry to take
advantage of the Wasatch Mountains to the east of the Salt Lake City area, while also
creating a great open environment with a large front entry canopy and a multi -purpose
space that can be used for events. It opens onto a 6,000-square-foot event plaza, so the
space can spill out and accommodate motorbike rallies and food trucks. We've de igned
entry courtyards to take advantage of those functions so residents can go outside a njoy
them.
• Some of the earlier veteran's home concepts have a dedicated garden outdoorr e
house, but that also means you're maintaining 10-16 different courtyards, ws with
this concept, we're looking at how we can do more with less without co ismg
quality. We're sharing a courtyard between two households and thosypwkoom spaces
open up onto those. We've also introduced shading elements and ensure they're
used. That's part of the feedback we received. They need shade.
• Within the community center, the promenade features reside e * s throughout and
brings in more daylight and connections to outdoor gai n p . T e more we can
connect with the outdoor environment, even for resident/ yAiV ni not be able to get
outside, it's really important.
• [He detailed the plan of the Salt Lake City home a� its ameniti
• There's a sports bar, coffee shop and connect' s eater, therapy and outdoor therapy
ar s garden, a multi -purpose space, retail sales t, hop and other amenities.
• The design continues to evolve, and tea[Ciii
c uses two dining venues served by one
common kitchen, which helps reduce . Rather than including the living room and
den in one space, we've moved thand den spaces farther down to create activity
centers along the way as resideMt Ne "aveling through.
• We also introduced a couaectfo
when it's too hot or it',ftaidlni
�ridor, which is mostly glass, and allows residents
have a walking path around the shared households.
• Another feature we've ind is a lot of outdoor covered porches. Being able to get
outside in a safe way im ortant.
• We've conti d to Folve resident rooms over the last 13 years, and this represents the
latest and st iteration, where resident rooms are treated like a junior suite, like you
would e in a -end hotel, where a caregiver can, in one glance, see the entire room
and s o ensure residents are safe.
• T e's clpd, a nightstand and headwall that provides medical gases, reading lights and
co r lighting, TV and everything else in the room, as you would typically see in a
skil -nursing facility. There's a recliner and we've also introduced either a sofa bed or
tended couch, which is important, particularly at end -of -life, when family members
\ ay need to spend a night with a resident during difficult moments.
JThere's also an armoire, a desk with a TV over it for ease of view, and a hand -washing
sink in each room, which is important for proper hygiene. There's a spot for residents to
park a wheelchair or scooter for charging purposes with cabinetry above.
• With bathrooms, we've looked at how to make them safe and ensure there's a direct line
of sight from the bed to the toilet, which is important, especially for those with dementia
and Alzheimer's care. There's also a large shower that allows for ample service for
residents to be taken care of, particularly if they have mobility issues.
• Another of our latest and greatest projects is the 126-bed Tennessee Veterans' Home
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under construction outside Memphis, which is due to be completed next year. We're
introducing a living and dining space for each household but doing it in a way that we can
share staff and resources between two households due to staffing challenges.
• It's designed for future expansion and features the promenade/main street and a large
outdoor event space for veterans to play pickleball, putt -putt golf, bocce, etc., in a secure
way and allow the public to come out for special events.
• Two -wing neighborhoods utilize a shared kitchen between dining and living space .
• What's on our boards moving forward? Our Hawaii veterans' home is due to be
completed next year, but we're working now on a Maui veterans' home, whic to ome
of the same concepts we developed for the Salt Lake project, but doing it 60-bed
home due to the smaller population.
• What's unique is that it has an adult day healthcare program include s of the
building and the VA is looking to move adult day healthcare forty �ey're providing
funding, so you can get two-thirds of the funding that you'd no ly et for an inpatient
veteran's home for every participant.
• You can serve a larger population of veterans within a ur w o may not yet be
ready to live in a skilled nursing facility, but because o e y-onset dementia, frailty
or other physical impairments, can't be left at home whi heir adult children work or go
to school.
• The adult day program is something many st s0al xpressed interest in. A resident
usually comes in around 8 a.m. and usuall 3 p.m., so sometimes breakfast is
provided, and lunch is definitely proAe , ILS 11 as a variety of activities. There's a large
influx of people in the morning and 1 zv t the same time, so there are special design
constraints. A
• We're also assisting the state o aka on its grant application for a new 128-bed home,
with the same concept o g Tot of amenities you've seen in the previous examples,
a shared kitchen, dinino
n li g spaces, but shortening corridors to make shorter travel
distances so residents don ve to go far down the corridor to get to the dining room,
living room or other curty rd spaces. It also locates the caregiver to provide a direct line
of sight to al ajor l�lousehold components so they can do their job as efficiently as
possible t excess staff.
is o ther feature for soiled linen and trash, which can be held here and then
kith a buggy and wheeled to a central laundry or trash, so you're not taking
it offensive materials through the building and public areas. That population is
ve to that.
iealthcare could potentially be a component for Collier County. We completed
in the Phoenix area, a 99-participant adult day health program. Three
, are being served — early onset dementia, young adults with traumatic brain
seniors who potentially are a fall risk if they're left at home by themselves
and children or other family members are away.
ti xcy uvinponent is that a large number of people arriving in the morning and leaving in
the afternoon, so we're designing it for bus or vehicle drop-off with a large gathering
space at the building entry, where you check people in and out.
There's also a theater, a large activity space, dining venues and separate activity spaces for
each of those populations, as well as a therapy component. It could be a freestanding
building, attached to a veteran's home or potentially be retrofitted into an existing veterans
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home.
We've heard from some states that there may be an interest in taking underutilized areas in
existing skilled -nursing facilities, including a veteran's home, and converting them to
outpatient or inpatient rehabilitation.
A project we did in Scottsdale, Arizona, called Pueblo Norte, was a traditional double -
occupancy, skilled nursing facility where you have two people in a room who shar a
bathroom and there's a shower room down the hall, an old -school, traditional skil e
nursing facility that was prevalent in the 1960s-1980s. The client realized there' r
unserved need for rehabilitation, so they asked us to renovate the building int r ate
rooms with full bathrooms. There's also a large activity space and a dedicaaec -in
area for residents and visiting family members, as well as a large physicrapy space.
[He showed photos of the main entry, reception area, corridor, privat e t rooms and
large therapy space, which features a skylight to bring in daylight �pws and outdoor
access for an outdoor therapy garden.]
This may be another option for veterans and others. He askee ere any questions.
Chairman LoCastro asked about the recently opened Virginia Beac a96 facilities. Are they
occupied and do you have staff? If so, what's the percentage? We've h rd!that of the nine facilities in
Florida, many aren't fully staffed. He was the chief operating gfficer o Physicians Regional Medical
Center and it was hard to get staff. There's a patient-to-staf atio Y� must maintain, so if you don't
have the staff, even if you have a waiting list of 500 voter s, u9![n't bring them into a recently
opened facility. For the facilities that opened recen you set up and are the homes suffering
due to staffing problems? Is it staff first and residend?
;:/c
Mr. Kolejka responded:
• You must hire all your e p ees before you can admit residents.
• With veterans' home , e inimum number of residents you need, and the VA will
come in with a survey to o a full survey assessment, which allows the state to ramp
up and complete the
cc ancy of the building.
• In northern ho, beds, the total current capacity, they're taking on four to six
residents month. That's their ramp up period, so you don't have to hire all the
caregi staf ediately. You can add caregivers as the resident population increases.
• Bec the design of that facility and the evolution of the design, it's easier to bring
staf er than we would with a facility designed under the previous Small House
didelines.
•t
econd veterans' home, in Radcliff, Kentucky, which is adjacent to Fort Knox, has
open since 2017, and it's never been able to exceed 50% occupancy, yet they have a
ly 300-veteran waiting list. The reason is that they can't get the staff because they
want to move there due to its relatively rural location.
's really hindering it is that it was a 12-bed household with kitchens in each and that
requires excessive staffing in each household, so they've never been able to open half the
building.
Chairman LoCastro asked if they didn't realize there was a staffing challenge in rural Kentucky. Why
was it such a blindside, that you built such a beautiful facility that's basically sitting half empty because
it's nearly impossible to bring people there? Why build it there? Build it where the employees are is
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what we always say, even if veterans have to travel. Is that a lesson learned or were there people who
promised you that the staff would be there? What happened? We want to learn those lessons since we're
in a very advantageous position here. We have hospitals that have challenges, as well, but we have some
other positives that other communities don't.
Mr. Kolejka responded.
• Part of it dealt with the fact that we were working under very rigorous Small Ho
design guidelines that were mandated by the VA that you could not exceed a ce?NW,
household size. You had to provide all of these dedicated amenities to each hapTqVId, so
in some ways the designs were shackled to those Small House design guidA4.
• However, in 2017 there was a change in VA rules, when the Secretary oeran Affairs,
Secretary Shulkin, allowed states to no longer be required to follow rbatik the Small -
House design guidelines and allowed them to either completely f eir own state
health department regulations or some type of a hybrid that all d s as architects to be
able to have more flexibility and more freedom to design fa s at weren't so staff
intensive.
• We could develop them with shared dining venues tha would never have been
allowed and allowing larger household sizes so we cou rovide for those.
• There was some flexibility that allowed us to n7 o those things. We did require some
staff and, as a result, are now seeing higher cup s, even in rural veterans' homes
because of those changes. •
Chairman LoCastro asked if those changes
faring now? It's almost a sin to have this bea
travel to a rural area. What's the prognosis in
cruky and if so, how is the Kentucky home
y and veterans in need, but staff doesn't want to
now? What's the occupancy?
Mr. Kolejka said it's about 50% an 's eTWperating for about six years. We've been talking with
Mark Bowman, executive director of tNing
ntucky Department of Veteran Affairs, about potentially
taking one of the household wings and it into adult day healthcare or rehabilitation because
there's a demand for that a the sAing ratios, particularly for adult day healthcare, are a fraction of
what they would be for s d nursing, so that's their hope. They are increasing pay and providing
incentives to get care rs t ve from Louisville to Radcliffe or to commute. There's a commuter
subsidy that they'v put n place that's helped to increase staffing, so they're hoping to get to
about 75% occ ied i the next year or two. They may look at repurposing the remaining 25% into
adult daycare olr�,
Aaro asked if that rural location was selected because they thought there was a large
ins there, or was the land cheap and available? What was the reason for that location,
. it in Lexington, where land is very expensive, and it could have had a different
were the factors in selecting that location?
Mr. Kolejka said 125 acres was given for the project at no charge.
Chairman LoCastro said that makes sense. And the difference between Idaho's 64 beds and Virginia
Beach's 128 beds, was it basically land acreage that was available? Are the different sizes of the homes
based on what you think the population might be in the area and the footprint of the size you'd get?
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Mr. Kolejka said it's a bit of both, but predominantly the size of a veteran's home is based on the
veteran population in the area where you're going to build the home. In the case of northern Idaho, there
isn't a large enough veteran population to justify a home of 120-128 beds. However, we know the
population is continuing to grow. It's also utilizing some of the population from nearby Washington
state, the Spokane metropolitan area, so we looked at trying to "right -size" the facility for this initial
development. However, as that population grows, we've designed the building so it can be expakd in
the future, maybe not to 128 beds, but maybe 90 beds or something similar. We try to provide tUat
flexibility. Because we could increase the household size, we could decrease the staffing recVji
compared to some of the former homes where we weren't given the flexibility to do that_an icipate
they'll be about 90% occupied within the first 18 months. O
Chairman LoCastro said he was stationed out of Hawaii and was surprised to 1awaii has two
homes and 180 beds, especially with the cost of land there. Obviously, there a a I 6f active duty and
retired veterans there. Was the land there gifted or was there a sweet deal O seems that would be
a high -dollar value. We have nine homes in Florida, but Florida is mUch 1 a awaii and for
Hawaii to have 180 beds, there must be some reason, such as a waitirirrms1'000 people. At Kaiser
Permanente, the main hospital in Honolulu, they couldn't throw enou money at the staff there to staff
that hospital, so they had a lot of traveling staff who would co n an enjoy Hawaii for six months
and get top dollar, but they couldn't keep them. Tell us about We want to learn. We've made
some decisions here after hearing these kinds of storied. nt the next veterans nursing home;
we want the best one. You've said how you would v�h�d
the layout, size and structure. What
was special about Hawaii that got them two homes 1�nd and staff are expensive?
Mr. Kolejka responded:
• We've been working with H ce 2014, helping them with their original grant
application for the O t ome in Kapolei, on the southwest side of Oahu.
• Prior to that, Hawaii ha e veteran home located in Hilo, a 60-bed home with an adult
day health program. Why ey put it on Hilo, where the population of veterans is a
fraction of w at it ivn Oahu, was because, at the time, they couldn't get any Oahu land
donated t e state, but they did on Hilo, so that's where the first home went. It has
mainta a 0-85% occupancy level, but, unfortunately, had a bad outbreak of
CO ,Xhich ook the lives of many veterans.
• Since 01#&Jand was transferred from the Hawaii Department of Residential Services, 7
a to the Office of Veteran Services to build a 120-bed home, so we were hired
in 1 to design that home. Ideally, we'd love it to have been a single -story facility but
be use we only had 7 acres, we couldn't fit 120 beds, so we had to go to a two-story
configuration.
• That home is currently under construction and is due to be completed next year.
• Now Hawaii is shifting. They still have 53 beds allocated to them because they have a
fairly large veteran population, partly because of the large number of active military
bases on Hawaii.
• But they want to build a 60-bed home, so they're going to kick in the extra cost to round
up to 60 beds, so that's the X-shaped design you saw earlier. That would then max out
their bed count and they will then be able to serve the vast majority of veterans who
primarily live on Oahu, Maui and the Big Island.
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• There's a small population in Kauai, but not large enough to justify a home of that size.
Chairman LoCastro asked if they did something unique with the two-story facility because we kicked
that around here, trying to figure out how we can maximize our footprint and the number of beds. On the
second story, did you make it all administrative because you worried about veterans going up and down
elevators? Do you have residents on both floors? Is it a mix? So that's doable, but maybe not a
preference?
Mr. Kolejka responded.
• It's definitely not the preference to go with two stories because you have ;:4
eneck, an
elevator that residents have to come down. Particularly during the pan that was a
concern because that's a choke point where you have a potential for ' -control
issues.,
• What we did in Hawaii is similar to Virginia, 15-bed househol to ed on top of each
other so they each had dining and living spaces, a lanai or 1 a y with outdoor
garden spaces.
• The community center was compressed and extruded i t c d floor, allowing for the
pharmacy and therapy to be on the upper floor, with the st of the functions, like the
kitchen, laundry and administrative on the grou oor. It was because we were limited
to 7 acres.
• For 120 beds, we've built them in suclna can be done on 12-14 acres, but 7
acres is too small to be able to get a t layout.
Commissioner Saunders said the preseutat as helpful and asked to focus on the north Las
Vegas facility and the Collier County si 1�'1 acres of buildable space with water management
to be handled off -site. The Las o that's going to be completed in 2026 seems to have a
really efficient design. One e is s that all of us have had is that you'd have the 120 beds
on the first floor because that's a , and the ancillary services, such as adult day health care,
rehabilitative services, and other rvices, would be on the second floor because then you don't
have to worry abou e bot?eneck at the elevator with residents. Is that something that makes
sense, and woul acres fit the bill, recognizing that it's all buildable space?
Mr. Kolej X the orth Las Vegas home is situated on about 12 acres, so it's conceivable
that the 'c-tac- ayout could work on something that size. The only time we've ever done
another and story was our 120-bed Tucson home, which was built on 8 acres and very
ti t
had to go with two stories at the community center and on that floor we had the
phadministration and other ancillary functions, and then all the resident -focused areas,
1' ewe, barber shop, library, breakroom, bistro, coffee shop, were all on the ground floor. So yes,
y *uld take some of those non -resident -facing spaces and put them upstairs and pull in the
gs to consolidate that and provide a smaller footprint, which ultimately is great for residents
and staff because they don't have to travel as far.
Commissioner Saunders noted that the VA accepted that design and asked if we added a
second floor for other ancillary services, would there be a problem with the VA and the federal
government providing funding, as long as the 35% local match is provided? Would there be an
ability to get funding for a larger facility with a second floor that provides adult daycare services,
10
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rehabilitative services and others for non-resident veterans? Is it doable at the federal level?
Mr. Kolejka responded:
• Adult day healthcare is an interesting situation because under current rules, which the VA
is considering modifying, the VA will provide 65% of the typical per diem that they
would offer for inpatient skilled nursing care for every veteran who participates i adult
day care, as long as they come at least three days a week, six hours a day for no le than
18 hours a week.
• However, the VA currently does not provide any construction funding for an nbuilt
adult -day healthcare.
• They will only fund construction if it's a renovation of an existing comnt of an
existing state veterans' home.
• What most states, such as Boise, Idaho, are doing is they're prow' under -designed
project and now they can construct that component of the veter 's home at a 100% cost
to the state, but they would then be able to realize all the pe a the participants
who are part of that.
• Although you may build an adult -day healthcare progr ig d for 40-50 participants
at a time, realistically you probably will have 150-200 icipants in the general area
who are part of that program that you can realize 41at per diem because they're not all
coming daily. You may have one group Mory�s�T/jCc inesdays and Fridays and another
group Tuesdays, Thursdays, and Satur4a
• The VA will not contribute to the c 'ol'cost of a new veteran's home, unless you
establish a veteran adult day progra . i� my applies to an existing home. If you can
W part of a wing or conference room and renovate
admit three participants, you can
it for adult day care, and nowx�
65% of the construction�st(�f a
Commissioner Saunders responded: AV
• That works well, so we co Id theoretically do the Las Vegas type home, which takes a
smaller foo *nt, aim 11.7 acres would probably work with that and on a second floor,
the feder vernment could pay for some ancillary services that are not day healthcare
servic ut t ortion of that construction that's the adult daycare would be a 100%
loca 4h?
• ateviat delta would be between the cost with and without that would be borne by
t .*These are the questions we want to address.
• O vision is to build a model veterans home for the country. The Las Vegas model is
1 because it's much more efficient to operate and it would be easy to go to the second
floor for other important services.
• We have a community here that is very philanthropic and we're going to be able to raise
funds to assist all that we're trying to do, but we also have people who will volunteer. We
have senior centers all over the county with tremendous volunteers who provide a lot of
those services, retirees who are qualified to provide daycare -type services, but we also
have a couple of hospital systems that are very philanthropic.
• We can staff these facilities, but he understands there have been problems in other parts
of the country and we'll have some problems here, but not to that extent.
• We may be able to increase our 11.7 acres a bit, but that's the site we know we have. If
11
s an existing program. At that point they will pay
adult day healthcare, provided it's on the same site
Packet Pg. 27
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we can fit that Las Vegas -type of facility and work with the Florida Department of
Veterans Affairs on that, with services on the second floor, that would be ideal.
He knows Mike isn't officially onboard, but some funds will be available after July Pt for
some preliminary architectural and design work. When can Mike or someone from his
team look at our site?
• John Mullins, who has been integral to working on the details, has all the information
about the site and can provide it.
• When can we jumpstart the evaluation of the site from an architectural standpoi
make sure that 11.7 acres and this location will work?
Mr. Kolejka said he'd have to defer to Bob. O
Commissioner Saunders said he expected that and thanked him for the inform e Las Vegas site
plan looks like a nice, efficient facility that will fit nicely here. _
Commissioner Hall noted that some of his questions were answeredolLe as what we can learn about
why staffing is short. Are there pay guidelines, standards or pay scale to be adhered to? Or is
it for the market to determine? Are you finding staff shortages because the skill level in certain areas?
What can we learn from that?
Mr. Kolejka responded: 0
• Bob can speak about pay levels.
• When it comes to our national exper' n d where we've seen veterans' homes
struggle, the ones that are struggl* ost in terms of occupancy, despite a large
veteran demand, are typically i a reas because it's harder to attract staff there.
• Some states have found i re t g way of addressing that by contracting the operation
of their home to a third pa y.
• In Utah, all four of the v n homes, including the new one we're now designing, are
operated by a third-pjM g1roup, Avalon. There are several companies. Our Houston
veteran ho s run�6y Touchstone, the Hawaii homes are run by Avalon and others, and
HMR op many in the southeast.
• They e a ent pay structure than what a state may have, but that varies by state.
Sonifq4LAs operate their homes and others subcontract that out to a third party.
• 1%jargeA
#ban areas, such as Collier County and Naples, it's easier to attract staff than
places like Radcliffe, Kentucky.
said it's hard to imagine people not flocking to Big Spring, Texas.
A0%KoIdjki said Big Spring is one where we helped with renovations. Their occupancy is roughly less
than hat the capacity of the facility is.
Commissioner Kowal noted that Virginia Beach and Virginia are similar to Florida, with a large
veteran population, and that 128-bed facility was completed in 2022. How is it doing and where is it at
with staffing?
Mr. Kolejka said it admitted its first resident in February after a ramp -up for staffing. They first had to
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complete some Virginia Health Department surveys, so that took time, but they opened on February 1 Oth
with three veterans, and they've been adding six to eight veterans per month. They anticipate being at
full or close to full occupancy within about 12 months, in February 2024, but believe they may beat that.
That's partly because Virginia Beach is a large municipality and doesn't have the same staffing
challenges as Radcliffe and other more rural locations.
Commissioner Kowal noted that many young veterans here travel to Tampa for surgery, such AAnee
replacement, and we just finished our longest war and many people served for many years. Coulvt
second story be occupied by a physical therapy facility? Are they allowed to use outpatient' ,
such as physical therapy treatment areas? Would that be available? They have a hard timlng
follow-up treatment here after traveling to Tampa. It's kind of a barren area here. INC)
Mr. Kolejka responded.
• The VA requirement is that they're only providing per diem fo a ' nt physical
therapy and that can include a short-term stay under 90 day t 're working to
change that to allow for outpatient care.
• We're designing all our therapy spaces in our homes t outside dedicated access
and other things we'd like to add in the future, but only patient therapy is permitted
now under the current VA per diem for state ve s h mes.
• The National Association of State Veterans o obbying hard to try to change that
so we can have outpatient care. That's wh9ttN aTT-04 day healthcare program comes in,
as a way to not so much get around t, but elp mitigate that, because you could offer
therapy as part of adult day healthca
• If you have a group of veterans w need to be in a skilled nursing facility but need
therapy services, you can add a t healthcare and leverage staffing between the
home and adult day care o getting the most bang for the buck in terms of both
per diem, income to st e, minimizing the number of additional staffing.
• Adult day healthcare wo e the way to potentially address outpatient therapy, while
inpatient care would e d e for residents who live there.
Mr. Aszatalos said Co sioner Kowal is right. Veterans who need rehab services must drive to
Tampa or across Alli r A now, so this would fill a hole if we were able to do outpatient therapy.
But this nursing ho i all going to be built for the post -Vietnam and post-911 veterans. If you look
at the time fra by t e we get this built, there won't be any World War II or Korean War veterans
here. There will Vietnam War veterans, but we're really building it for post -Vietnam veterans
who have L
a on , prosthetics and need rehab and wound care, so even inpatient -wise, we have to
look at them, too.
2X,ILStel4arrie Wallace, senior vice president of programs for Easter Seals Florida, and Jill
Gen , ce president of programs, will discuss Easter Seals' experience operating adult day cares
in Flo0fda and contracting with the USDVA for adult day health care services.
Ms. Wallace told the BCC:
Easter Seals Florida is part of a larger national network and Easter Seals Florida has 40 of
the 67 counties in Florida as our territory.
We offer services statewide that span the lifespan, providing services for individuals and
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their families and those disabilities.
• We offer early intervention, child development centers, workforce development, short
skills training with certifications, life skills, adult day training and adult day healthcare.
• Veterans hold a special place in her heart because her husband was an Army combat
engineer; she was a military spouse for many years; her daughter is a Navy veteran, an
astrophysicist who did great things with her GI Bill; and her son is an active -duty Marine
stationed at Camp Pendleton. Jill also has connections to veterans.
• Jill Gentry, our VP of programs, oversees our two adult daycare and healthcare to ,
in Winter Park and Gainesville. She'll share information that's pertinent to a t ings
we've heard today, and she'll be happy to answer your questions.
Ms. Gentry told the BCC. O
• Sometimes the biggest question about adult day healthcare is whoosomeone bring
their loved one or choose to come to an adult day healthcare fIt's the desire to
stay in your home and do it safely. That's always the best o'A tion here are times
when loved ones need more support than the caregiv n p de, so adult day
healthcare fits a good part of what's needed.
• Adult day healthcare is a secure, safe environment for s eone to spend the day with us
and receive medical support, social interaction, wit any cognitive decline and
simple tasks. It fills an important role and ker,& ne in the least -restrictive
environment as long as possible. •
• It can be a nice bridge for someone
caretaker with an opportunity to pre r
basis in their home and allows a �Me
F1716ally will be in a residence. It provides a
he loved one to not be in their life on a daily
build camaraderie with others outside their
spouse or adult child, who ha ying the role of a caregiver.
• As you're looking at blQuiAiki cture with both a residence and adult day healthcare,
there's a natural flowif e at could build, as well as eliminate, some potentially
trauma -based interaction ' someone who is now leaving their home for the first time
after they've been wig a aretaker, their sole support. It will make the transition a lot
easier.
• The best n do is support someone in a time of transition.
• Her hu�nd in the Army for 17 years and he misses it terribly. Nothing has ever
comp o his military career. Her stepson also was an Army medic at the time he died,
s�e,eStvare extremely important to us, and we enjoy our time with them, personally
a ssionany.
• [S presented a slideshow of Easter Seals' clients to show the BCC what their properties
clients look like, and the joy and energy Easter Seals gets from working with them.]
From 2018 to 2022, our two adult day healthcare centers served over 200 veterans.
Younger veterans were the smaller percentage served; veterans under 60 were only
served at 1%; from age 61-70, that jumps to 12%; from 71-80, it jumps to 27%; and from
80- 90, that jumps to 34%.
• What's impressive is that over 25% of our veterans were in their 90s. What a gift to be 90
and to have someone in your life who is your caregiver, who cares enough and advocates
enough to get you to services and supports you, but also ensures you're still in your
home.
• We've learned so much from these individuals. There's a richness in that.
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• It's very forward -thinking to be considering the veterans you will be serving once the
building is constructed. It's a sad idea that we are losing our veterans, so we appreciate
the time that we have with them.
• In terms of Easter Seals' involvement with the VA, Easter Seals national has been
serving veterans and their families, whether it's through education or training or just in
general wellness through health and emotional support, since World War II. ,,��
• Easter Seals Florida has been serving veterans for over 20 years and we work with`two
ADHCs (Adult Day Healthcare). One is Winter Park, a program called Daybret, and the
other is in Gainesville, Altrusa House. Both work with the local medical cent , and
Orlando VA Medical Center is our primary support. We also work with th colm
Randall Medical Center and Lake City Medical Center.
• We receive veteran referrals. Self -referral is often something that w ee, t the vast
majority are veteran referrals from the VA and the social work to he VA are
essential in that process. Whenever we receive a referral, the v an and caregivers are
invited to our facilities and given a comprehensive tour. Th e r ee other veterans,
our spaces and staff. It's full transparency.
• We want that initial agreement to participate to be don ence, and to alleviate
some of the stressors for the caregiver, who may be fee g a bit guilty about asking for
help.
• She's often asked if she'd put her parents in m. The answer should always be
yes. Sue Ventura, our CEO, had a father s o arly, and he was a veteran who
started having cognitive decline and e be his caretaker. She realized very
quickly that it wasn't something she o o on her own, so her father participated in the
Winter Park Daybreak program. that's exactly what her father and she needed,
so we really do believe in our c and are willing to put our loved ones in our
services.
• The relationship of a e n caregiver is important. If it's your spouse or adult child,
that's a big shift in dyna , so we try our best to serve the caretaker as much as the
veteran. We're buildipg a much normalcy back into that relationship as possible while
the veteran wins n their home.
• During admis ion, we do a series of intakes and surveys to understand what the veteran's
level �ci LI erminants of health are. Are they positive, are they fractioned, what can
we ild upon those strengths? We do that both with the client and caretaker. With
t care r and client, we revisit that in six months to see what impact we've made, but
se that data to understand what modifications we might need to make within our
ve learned interesting data that aligns with what we believe we knew about our
ommunity, but further supports and drives decision making.
• In North Florida, where we have two centers, these are extremely different communities.
When we do caregiver surveys, what we've learned has illustrated some of these key
differences. We asked caregivers what does your loved one coming to our ADHC mean
to you, what does it allow you to do that you previously could not do? In Gainesville,
70% said it allowed them to either re-enter the workforce or stay in the workforce. That's
almost the exact opposite of the response in Winter Park, where they say they can now
make their appointments, take care of themselves, have social connections, do more for
themselves and their well-being.
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What that does is it drives some of our decision making around hours of operation. It tells
us that if we have 70% of our workforce in Gainesville dropping their clients off to us
and the caregiver is going to work as well, then we need to be sure to open a bit earlier or
stay open a little later. Those are the modifications we'll make. They don't seem like a
big deal, but they're incredibly important to someone who's trying to stay in the
workforce and keep their loved ones safe.
Transportation is not something we do in-house. We rely on and work with local
transportation companies. Yours is CAT. We have Lynx, so we've become well -versed in
coordinating and helping families secure and set up the transportation they'r 00
need.
Caregivers in Winter Park rely on public transportation, while caregiverOINGainesville
are picking up and dropping off veterans, so those nuances of the in4ACVtQAaregivers
add up and tell us something about how we can change, modify amain the
operational decisions that we make.
Caregivers are the ones who have our clients in the evenin ar ends, so
communication lines are extremely important. We oft%hobserve things a family member
doesn't see, and sometimes family members tell us so ttKt happened on Sunday
that we really need to know on Monday, so our nurse a center director are very active
participants in those conversations. Both ensure re are no missed moments for
improvement or clients' protection and safety
• For outpatient therapies, we coordinataDwiA oT d6fntities that want to come in and do
OT, PT and speech therapy as much a , so that's one less stressor for the family
and one less appointment a client ne tend to elsewhere.
• We follow all AHCA (Florida A c Health Care Administration) regulations,
which are very clear and ensu u ve a safe and secure environment for your client,
whether it's the qualic f]p ployees, ratios, or the number of rooms you need. We
always try to go beyon atWequired.
• When we look at ratios, qVlways hold out key positions from ratios, so we're
concurrent planningjpd ofi a day when staff are out, we have more staff than we could
need. Size c makeor break you, whether it's their temperament or their demeanor.
We're sh up and being consistently on time. These things will make or break a
facili we appy with the teams we've developed.
• We' very careful to never understaff and to always be concurrent planning so
w&'re a s within the ratio.
• " ed push morale for our staff is we've invested in our staff who don't have
ce i ications. Most staff are required to have certifications. You have to have an LP, a
sulting RN and CNAs. You have to have degree positions, but we also have
aregivers who are not family members. These are professional caregivers who are
essential to the daily dynamic of our clients. We put them through caregiver training to
get them certified. We wanted every person in our building to have some level of a
professional credential. It was one of the most successful things we've invested in and
we're just seeing the end result of those efforts. We had health staff go through that
training last year and it will be something we continue. Those opportunities for
professional development will continue to add to our stable workforce and potentially
will be a good recruiting tool.
• We have standalone ADHCs, so our buildings look different from what you just saw.
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When people first visit us, we're not a clinical model, so that home feeling, the non -
clinical feel, is important and diffuses a lot of concern. It becomes a real comfort place to
come to daily.
• Because you're building a new facility and are looking to go in potentially with a
cohesive model of an ADHC and residential, some of these would not be as applicable,
but food service is important. We are not currently providing food that we cook. e're
working through catering services at both our locations through the national foo
program.
• Part of design considerations are safety issues. There will be a comprehensiv e ncy
management plan that will be required for an adult day healthcare center. 1t
according to all the regulations in those areas. This last year, we also a4dNn active
shooter plan. We initiated efforts on that three years ago, coordinate cal law
enforcement and are registered. Our blueprint is with the sheriff
• Both our ADHCs have extensive outdoor space. It's incredibly o ant to clients. It's
not only where you have some normalcy or where you do bArbe a utdoor activities,
shuffleboard, etc., it's also where clients get autonom Our vet an really deserve that.
• It's an interesting dynamic when you're creating a pla eYf for a client, while
trying to make sure they feel autonomy and are empow d. It
a fine balance to
achieve. Our outdoor space permits our veteraZing,
ith an opportunity to step outside when
they want to spend time outside with friends atever activity they like to do.
• We keep records of inclement weathermn4ave co ng stations. It's still structured, but
it feels very empowered and very
• An ADHC's planned social activi
veteran. We will celebrate
aTaluable to the overall well-being of a
you want to know if there's something to
celebrate every week, there is Na Yvery focused on the normalcy of bringing
caregivers in and having,�pp �' ai i'es to enjoy and share camaraderie, not only with
people at the center d?efr loved ones and family members.
• Our activities are always en by an agenda, and they're also very engaged with
community partners„such s UCF, OF and Rollins College. All these big players come in
and are very ' po t for some of the activities that we do.
• We do a sh throughout the year for activities that involve exercises that keep
peopl vin d fluid. We track progress, so people who are struggling or losing
mo e pushed in proper ways to maintain what mobility they do have.
•IV,,enjg ith our local ROTC and local valor clubs to engage our clients and prevent
cAQUTRW decline.
• g4nclude
t e core of our activities are music and art. There's a wealth of evidence that supports
importance of music and art for people in the aging process. Our music programs
drum circles, local bands, pianos, karaoke, etc. We also have music playing at
AQ some point in every facility and we do guided exercises like Alzheimer's poetry projects,
opening minds through art, and Memories in the Making. It's all about guiding them
through a process to help them draw the memory and create either an art or poetry item
from what they retain, recall and feel comfortable sharing.
• We also offer a verbal veterans history project aligned with the Library of Congress. We
follow their guidelines and capture the verbal history of our veterans. When that's done,
it's reported to the Library of Congress, so we not only want to honor veterans when
they're with us and receiving our services, we want them to know they'll be remembered.
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Chairman LoCastro said as we get closer to design and all the steps that lead up to the ribbon cutting,
we're going to pull from all those things you mentioned so we know we have the best facility. You have
some proven things that you're sharing with us, so we're not going to forget the proven winners. We
want to add that to our home, as well, so thank you.
2.C. Kurt Micheels, construction projects quality manager, Department of Management Se .ces
(DMS), will outline the DMS policies for moving forward with construction of a Florida s
veterans' nursing home. (via Zoom) IN
Mr. Micheels told the BCC:
• The main thing to consider is that the overall project budget is going toed $4
million, and we don't know what the total budget is going to be agd stv statutes
mandate that we have to advertise for the architect and construoti n nager.
• At the beginning of this project, right now we're waiting fo $ I, 0 for site evaluation.
That money has passed through the legislature and w ' e al fo approval, probably
sometime in late summer.
• Then we need to advertise for the architect, who will d t7esite evaluation part of it,
which involves the Level 1 and Level 2 surveys
[Commissioner Kowal left the meeting at 4: 33 p.m.] • 10
• Some environmental surveys have a e een done on this site, so part of that work will
be to take the existing surveys anyl�ce at remains to be done.
• We'll need to contact the Sout��stlorida Water Management District and talk to them
about what we need to , aid the Building Department because all state facilities
have to be approved uJh ocal authority with jurisdiction.
• The end result of the site lysis would be a report. There's criteria set by the FDVA
(Florida Department f V Brans' Affairs). Then there would be a series of drawings, site
plans that show a hothetical design.
• He was the st te's manager for the Ardie R. Copas (State Veterans' Nursing Home in
Port S . ucie ject that we just built. We were thinking of using that as a baseline, but
ther e la itude on how we proceed, given the variations on how this design might
bv—con i d to fit the site.
're looking at is if we get those funds in late summer, advertising usually takes
a;YntIg
three months, the architect will be selected and then it will probably take us into
to complete the site -evaluation process.
Our deadline for the VA application is around April 2024, so in a perfect world, in the
beginning of 2025, we would get VA approval and the additional funds. Then we'd be
able to get our same architect reactivated to commence design, the schematic design,
design development and construction documents.
From that point, you're looking at about one year of design and about another 1 %2 years
of construction, not taking into account things that can happen, like COVID.
That's how you'd proceed to put the project together and where we are now.
Chairman LoCastro asked if he understood correctly that in a perfect world, next spring the site
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evaluation would possibly be completed, 2025 would be the final VA approvals of the design,
and then it takes about a year to design, so all of 2026 is eaten up with the next steps of design
and construction. Then you're in 2027 or 2028 for a ribbon cutting. Is that a good guesstimate
with what we know today?
Mr. Micheels said that's correct.
2.D. Bob Asztalos, deputy executive director, Florida Department of Veterans' Affairs, w ss
next steps in the process, including budget development and funding timelines.`( o )
Mr. Anatalos told the BCC. r1
• The Florida Department of Veterans Affairs opened its first home in
state veteran nursing homes and one domiciliary, an assisted-livin
• You're really going to build the nursing home for the next gene o:
• The two homes we're in the process of opening now have K e a
veterans and you're going to build for the next generat' . e it
forward on that, as far as expanding the services we of
• Someone asked why there are so many beds. All our ho have 12,
because, under Commissioner Saunders' if
for nursing homes in the early 2000s. Wha
nursing home under all the rules, 120 beds
Every time you deviate from three 4 eJO
additional inefficiencies and staff, etc(
operate 10
if veterans.
World War II
that you're thinking
That's
has a state senator, they wrote the rules
s the most efficient operating
-oAO-bed units. That staffs the most.
a 120-bed nursing home, you add
• That was a regulatory model built it1%w rly 2000s, and that was fine for the World War
II generation, with two, three or Nr �ople in a room with cinder block buildings, but it's
a new world now. `y
• We want to accommo o y making the nursing home less of a medical model
and more like a hotel. As e said, the VA took the Small Home concept to an extreme
but now the pendulum has oved to the center, where you want homes to have small
communities t th 40-bed units.
• That's wh fing becomes more difficult, and we need to find efficiencies.
• As Mi id, t e efficiencies are important. What attracts staff is putting a nursing
hom ilding with neighborhoods, bus routes and transportation.
• n yook at nursing home staff for 120 beds, you probably have 120 staff, mostly
to - workers who work in dietary, housekeeping, and as CNAs. They're paid $15-
$1 hour, so we have to make sure it's in an area where there are neighborhoods where
can live and have transportation.
hose are biggest factors driving staff into veterans' homes.
• As Kurt Micheels said, there's a $500,000 allocation in the budget. We're hoping the
governor signs that, and we can get to work on it because we have a timeline we have to
follow and have to align funding from the County Commission, which taxpayers in your
community generously put up for this home.
• The state, federal government and everybody has their own rules and timelines, but
between now and April 15, 2024, we're going to have to submit our request for the home,
so we're going to have to figure out what exactly we want to build, what services we want,
where we're going to put it and can we build it on that property? We have to put that all
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together and submit it to the VA.
• We're also going to have to make a decision because currently we have a construction
grant request that's sitting high on the VA priority list. That construction grant is for a
112-bed facility that the VA would give us $42.5 million for, with a total price tag of
$65.4 million, which we could probably modify up to $72 million.
• We'll have to make a decision. Can we build the facility that we want and provideallthe
services we want within the framework of this existing construction grant that's already
high up on the VA priority list? If we decide we can't do that, then we'll have to create a
new grant and take that to the VA by April 15, 2024. 4% IV
• Between the county providing the 35%, which the state would have to put iscrow
account, and the April 15, 2024, deadline, we could start moving ahead.
• There are numerous steps. We'd have to submit that to the VA, whic� have to put
that on its funding list for the 2025-26 year. If Congress appropri s t oney and has
enough to fund it, then we could start moving and then we coul flow Kurt's guidelines.
There's a lot of work and decisions that must be done in the uture.
• He's excited to see the presentations and what other st are ng ecause they're doing
exactly what you all want to do and what we all want to e ost important thing for
the veteran population that we want to take care of is tha e can now provide them with
options.
• The only option we could provide a veteran ow is on -term debt, but if we told them
they could stay in their home and we caeld*ovule t m with adult daycare or
rehabilitation services and keep them* tNO
fine until they need to be in the home, then
you really need a heavy rehab compo enis home, so we're really taking care of the
needs of the post -Vietnam vetera ion.
• We need to work that out be c and April 15, 2024.
• We're excited to be pa Wdu, the Commissioner's, and residents of Collier
County to make this a
Chairman LoCastro told the prese5fers:
• This has beeiaAftry bfneficial for us. He took notes here and while in Tallahassee. We
have so dvantages here in Collier County that maybe some other communities
e don't. have land, the money already committed and the surrounding community
We' o t in the boondocks, although, as we discussed in Tallahassee, staffing is a
c ienge,Tr everyone.
• W o many colleges here, FSW, FGCU and others, that specialize in medical
cou s, and we work really hard to entice graduates to stay here.
• is past
7 life as the CEO of Physicians Regional Medical Center in East Naples, we
ulled from many of those colleges. That's not to say that staffing is all college graduates.
We're trying to get experienced people, but you need a mix, and we have feeder
transportation.
• We're trying to make these homes more like hotels, more comfortable, not like a hospital.
• In my district, the JW Marriott, the biggest company as far as hiring on Marco Island, we
have the ability to make adjustments that are needed because Collier County has such a
robust bus service. We roll a bus out in the early morning hours, and it's totally packed
with workers for the JW Marriott and it pulls up in front of the hotel at the exact time the
general manager asked us to pull it up in front of the hotel. We do that in many places
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countywide, so once we figure out where our veterans home workforce is coming from,
we can make those changes in transportation to take advantage of it.
• We have the appetite here. We don't want the next home; we want the best home. It's
more than a nursing home, it's providing all those other services.
• We're committed. Collier County has not only a large veteran population and many who
don't need that home, but as Commissioner Saunders said, a very robust philanthr is
community and some who are veterans and some who are super patriotic people, s e're
counting on the big supporters of this idea to step forward now that it's become li
• We're going to shake those trees so we can round out the home and make sur �n
maximize it to build a home for the next generation of veterans. A%k
• This will be the benchmark, a model home. We're going to steal great i a om what
Mike presented. We want your starting point to be the Collier Coun om nd we hope
people move forward and improve it from there. We're off to a grams .
Commissioner Saunders thanked all the presenters and said.
• This was very helpful information.
• You have an existing application that could be raised to ill n. Our $30 million plus
interest will be over the 35% required if we're at that nu er.
• Are you able to do something with the $65 milli pplication to increase those numbers?
You said maybe it can be increased to $72 m0%%�Van
an it be increased a bit more to
accommodate a larger structure that's n1br you amend the application to
save some time?
Mr. Aszatalos said yes, it will save time and w mne faster if we could use the existing application.
The VA allows a 10% add -on to it and that's W 'could raise it from %65 million to $72 million.
Chairman LoCastro said we'll tak14
Mr. Aszatalos said we want to desilan this, and we have to ask if the $72 million price tag works.
You're right, there 4areexc fundf that Collier County collected in addition to the 35%, so the question
is, as Mike pointedA may require that the adult daycare portion, if we're going to take that
route, has to be fun°o ugh state funds. The question we'd have to answer is, do we want to
use state funds andtin an adult daycare, as opposed to creating and building a conference room
for three peopled it on later. That would be one of the questions if we use those excess
'outpatient therapy. He heard Mike say they're not funding outpatient therapy,
our own construction there for outpatient therapy?
> you do it through the adult day healthcare program. If you do therapy that way,
►atient, so you'd have inpatient therapy as part of the veterans' home and then
lumped in with the adult day program.
Mr. Aszatalos said what we'd have to do is defend and lay out the list of other services we want in this
building, in addition to all your services. We'd have to see what the VA will fund and what are the
additional services that we would put in the building that they would not fund, but they would allow us
to fund and look at our budget and then go from there.
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Commissioner Saunders noted that the North Las Vegas model on about 12 acres is different from the
Small Home design we see around the state and appears to be a relatively new type of design. Is it
possible for us to look at the Las Vegas design? Would it be approved by the state and federal agencies?
Mr. Kolejka said it's already approved for Nevada by the federal government.
Commissioner Saunders said so if it's going to be approved by the federal VA, could this be a ved
by the Florida Department of Veterans Affairs?
Mr. Aszatalos said he's excited about the scope of services, but Kurt would know more the
construction side because he built our Ardie R. Copas home and completely renovateFinFlorida.
o e in
Orlando. Commissioner Saunders noted that the Las Vegas model is different from th o Could
it be a model in Collier County?
Mr. Micheels said the Ardie R. Copas plan was designed to VA requ e s, t we had some
budgetary difficulties and then word came out that we didn't have to li ra y adhere to the VA
requirements and could make some changes, so Ardie R. CopaAa by rid design that takes into
account these things. It's very similar to some of the things M' shown, so we have a lot of latitude.
You could possibly do something closer to the VA CI�C . Living Center) greenhouse design,
where we could go through a hybrid. AHCA likelyApAda ove it, as long as we meet the spirit of
59A-4, or whatever has become the guidelines, bute rtely doable.
Commissioner Saunders said assuming that t Vegas model will fit on our 11.7 acres, plus
possibly a bit more, and we want to go u Cor
cond floor for the adult day healthcare, there would
have to be a splitting of what the cos the main building/nursing home portion and then
perhaps different funding for adult da e. Is it possible to split out all those costs so we could utilize
the $72 million from the federal governor t, which would include our 35% and whatever we have left
over or additional money, if peces�t, , to add on to it. Is that possible?
Mr. Kolejka said you u ave to split it out by VA requirements, so you would have two grants.
You could use the Nsi gr t to fund the veteran's home and you would then have a separate
application for the y healthcare in which the construction cost would have to be 100% borne by
the state of Flor hat would give you a separate application that would be inspected once it's
done and you'll ell able for the per diem for that minimum of 18 hours a week per participant at the
65% rate in atients' per diem.
rr Saunders said at today's market or the market you may see in a few years, can you
Vegas home for 72 million?
Mr. Kolejka said we recently priced our 105-bed Salt Lake project, which is a bit smaller, and the
construction cost is currently coming in at about $52 million and the total cost, including ancillary costs,
for Salt Lake is about $64 million.
Commissioner Saunders asked, so $72 million -plus could get that portion of the deal done?
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Mr. Kolejka said it's conceivable. That's in today's dollars.
Commissioner Saunders said they appreciate everything the state is doing and Kurt's flexibility in
terms of looking at this because it is different from what you had done, but this could be the answer for
Collier County in the sense that it definitely would fit on our site. It's more efficient to operate, meets
the needs of the veterans who would be residents there and gives us the opportunity to go up on
second floor to provide other services, so he's optimistic we can move forward with it. He thanNi
all for this information.
Chairman LoCastro said our concern will always be the funds. We're in the middle yftViping a
behavioral -health facility in Collier County and it doesn't have a five-year timeline already
found that what $25 million would have built 10 months ago won't build the sari 1'ty now. A lot
can happen in five years. Hopefully, we won't have hurricanes or storms that Will i ease the cost of
materials and construction teams. We're in a tough spot now where we're mift our behavioral -
health facility and having to make some difficult decisions on wheth to in s aller, tighter,
different or build in different phases. It would be disappointing if the or differences in costs
five years from now. We're going to charge forward, but it's obviousl something we want to continue
to keep on the short list and look at how far the dollars will go.
Commissioner McDaniel noted that the application 4 hi^t iority list for the VA, along with
the timing that comes with it. Is it possible to use tl)NapQlican that's high up on the VA priority list
and phase the project so we have enough available have 50 beds? He noticed that a few
projects were phased to be set up for future expa i;�ney*
ould it be possible to utilize the application we
have in place, move forward with those rven i*phase the project to start off with 60 beds and the
magic number is 120 beds, then do a se ara ation in 2024, 2026 or whenever for the balance of
that construction? Can that be part o e iscu ion?
Mr. Kolejka said the VA provides some exibility to adjust the bed count up or down. Historically,
we've been able to adjust th t nuni$r by about 10%, either positive or negative. There are other
elements that can come t ear. For example, we've had a couple of projects like the second Kentucky
home we're doing in li Green, which looks a bit like the Post Falls, Idaho, project. We reduced
the number of beds o 0 to 0 beds because we realized that the construction costs could not support
that because they put VO
plication in almost 10 years ago, so the VA allowed us to reduce that while
still maintainin the priority list. That's an example of where we were able to reduce it by
more than 10%. t cally, we've gone up or down about 10%, so you can change the number of beds
and not se our of on the VA list.
C mi 'oar McDaniel noted that we're already in the process with an application that's fairly high
up the riority level for approval, but he doesn't know if we can do 120 beds for $72 million and
10%, Ws extra money. Can we explore the opportunity of seizing the opportunity or the advantage of
having an application that's already high up on the priority list to be able to take advantage of that and
not lose the time, have to reapply and go back through again. Is that plausible with the state process?
Mr. Aszatalos said as Mike said, it's a 112-bed application and you could swing that 10% either way.
We have to think that through because you also want to factor in the need for the home and the veteran
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population. Collier County has a high need for a nursing home, a lot of veterans who will need to be in
beds. When he looks at the need study, he doesn't see an issue with finding veterans to fill a 120-bed
nursing home, so what would be the justification for telling the VA there's a high need for a nursing
home, a community that needs 120 beds, but we're going to build a 60-bed nursing home? We have to
think that through. There may be a 10% adjustment either way, but you need to think that through a lot
more if you want to shift beyond that modification.
Commissioner McDaniel said he wasn't suggesting scaling it back from 120 to 60. He was s esting
they build the 60 beds with the available funds that we have in an application already in the nd
high up on the priority list and if we had to do another application for the adult daycare a second
phase, that's the approach he was taking. He's not suggesting scaling down to 60 beds
stion is
once we come up with the design, is it phase -able to accomplish that? He's seen th s nalysis and
agrees the community can support a 120-bed facility.
Mr. Aszatalos said he'll review that with his team to give him a better ans
Commissioner Saunders said it sounds like there's enough money i p ' ation to do the 120-
beds and go up or down 10%, that we don't have to worry about tryin to phase this. It's obviously
1- - - *1 -1 - -- - -A---- `� - - -- - I - � � - - -
- - - • V
Commissioner McDaniel said it depends on the d
Chairman LoCastro said the state controls times d oesn't want to get ahead of themselves and
build too many homes that sit empty because tang and occupancy. But if, as Commissioner
Saunders says, there's something that seem , ,,might fit, a previous building that has been built, or
something that's currently being des' a �n't need to redesign the wheel, but does that speed up
the timeline a bit if there are some blu ants for a current facility? He assumes they look those
blueprints and note that there are some g t things there, rather than just starting from scratch. Does
that tighten the timeAts
of,*ese other facilities have a similar footprint to us? Obviously, we're
always looking to mments, but does that tighten anything or is it not negligible? What
stretches the timelinbut staffing. Can the architects steal from other designs to tighten the
timeline?
Mr. Aszatalos a Tggest factor in the timeline is the U.S. Department of Veterans Affairs, the
biggest shar- - cause they're going to own 65% of the building and they have a very lengthy
process. e it's ry helpful to use things that they have seen before. That's the real benefit of Mike's
prese ti e showed us what the U.S. Department of Veterans Affairs has already looked at in
of r sta d approved, and that will help our application go a long way in that process. If we added a
se e t t no other state Department of Veterans Affairs has put in there, that would take more time by
the U. . A.
3. Public Comments
Eldon Solomon told the BCC. -
He's the CEO and director of The Journey Home.
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• He introduced Jacqualene Keay, the veteran outreach team site director.
• The Journey Home is a national veteran outreach organization that understands that the
journey coming home to access care can be very difficult, so we're here to build and
bridge the gap between the access to care veterans have and are not using.
• This week in Collier County, only 24% of veterans eligible for VA services use those
services. Nationally, the numbers are 35-40%, so there's a big gap between the nu ber of
veterans who have access to care and who use that care.
• Another alarming number is there are about 1.4 million veterans at risk of beco
homeless on any day.
• The diagram you have shows the services we provide veterans.
• He applauds the courage Collier County has taken to put this facility in ac It matches
the courage of our veterans, is challenging and The Journey Home e a partner
with Collier County's veteran services. �.
• There are many great organizations in Collier County that pro e rans services, but
there are many veterans who aren't using the services and w wa t nd them.
• Thank you for letting us be here to help us find those ns.
Jacqualene Keay told the BCC:
• She did some cursory research on nursing home 1 lorida and nationwide and occupancy
and understaffing are the biggest challenges.
• She cautions that as they move forwa dot eog an to resolve the occupancy and
staffing issues, or they'll end up like o acilities.
• 50% of the facilities are being used, s w eed to be proactive with the staffing -shortage
strategy. Part of that is to build e s or housing, if that is feasible or plausible, near
or onsite.
• Another option is to pr �mg allowance. We must find a way to keep and lure
the workforce to Collie ty.
• She loves the idea that the my is working together as a community to bring this plan to
reality.
facirty manager in Indiana, who has years of experience running our
ties, which provide services to veterans. We came up with some ideas for
we can provide.
o have dementia, as well as Alzheimer's care, mental -health, abuse, addiction,
`d s'Wvice groups. We talked about military sexual trauma because when you think
vTo will be occupying these nursing homes, it's people her age and generation.
very diverse and we come with complex issues and traumas, so we want to have
available for those.
We want to provide a purpose to the veterans. They can volunteer around the facility.
They want to feel like they're serving a purpose, doing something greater than just being
housed in these facilities.
Adult daycare is a great idea, and she'd love to see a VA and clinic annex onsite, as well
as community partnerships. One of the best community partnerships is Golden Paws
Assistance Dogs because a lot of these veterans have service animals.
They could build a dog park for service animals. Those are things to think about.
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Mr. Mullins apologized for exceeding the two-hour time slot that was advertised. He appreciates the
presenters' patience in getting through this process. It's been very beneficial to everyone involved.
Chairman LoCastro noted that Bob told them they could get an extra 10% and they can summarize
these ideas to the county's benefit. We're full speed ahead. Thanks for bearing with us. You're all
experts in your field. Kurt, we really appreciate all your guidance on the engineering side, and we know
we can learn a lot from the other facilities that have already been built and we've already talked ut
maybe visiting one or two others. We don't want the next one, we want the best one. That spea
volumes about our focus. Bob knows that when we were up in Tallahassee, we talked about ting
to get such tunnel vision on a timeline that doesn't build us the best one, so if we need to . the scale
a bit, it's not stalling. It's making it more advantageous to get the best one, to mWtiagrams
m asure
twice and cut once. That's our focus. Commissioner Saunders thanked everybody for participating. John Mullins h of our
site, which may be worth sharing with Mike and Kurt, if they haven't alre d Bob has seen them,
and it'll be nice to get other folks here to take a look at that site tom e s� 're�fnoving in the right
direction. He's very optimistic about that $72 million. He thought we to have to do a new
application, but it sounds like we may be able to stick with that to sav a bit of time. He thanked
Commissioners and staff for this very important workshop.
4. Adjourn 0
There being no further business for the good of �nty, the meeting was adjourned by order
of the chairman at 5:21 p.m.
ER COUNTY BOARD OF
LINTY COMMISSIONERS
Rick LoCastro, Chairman
ATTEST:
CRYSTAL K. %"ZE . CLERK
These'finutes were approved the Commission/Council on ,
as presented or as amended
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