An Introduction to PACE

1. An Introduction to PACE Julie Erdmann Community Care Milwaukee, Wisconsin www.communitycareinc.org

2. The times they are a changin’ (Bob Dylan)

3. Objectives • Develop a broad understanding of health care policy environment • Develop understanding of PACE background, operations and future innovations

4. Changing times for health care financing • ACO • Bundled Payment for Care Improvement • Community Based Care Transitions • 30 day readmissions

5. What in the World is Going on with Long-Term Care? • In 2011, estimates are that over 10 million people received Medicaid-financed long-term care services. • 59% were 65 or older. • A majority were dually-eligible • Avg. expenditures for Medicare beneficiaries with ADL limitation(s) is 4 times higherthan for Medicare beneficiaries with no ADL impairments

6. 15% of Medicaid eligibles are duals Of those 15% account for almost 40% of Medicaid spending At $20,000 per year in 2005, the cost of a dually-eligible individual to Medicare and Medicaid was 5 times greater than spending for other Medicare beneficiaries

7. DIFFICULTIES IN THE MANAGEMENT OF A PERSON’S HEALTH Why is the “dual eligible” population difficult to manage? • Health needs are inherently unpredictable and costly due to the nature of chronic conditions • Individuals need a variety of services that cut across multiple delivery sectors and different professional / para-professional domains, each with distinct clinical focus and boundaries • People are, by definition, impoverished either through a lifetime of poverty or impoverished in response to a sentinel health care event that triggers the need for Medicaid-funded services

8. Difficulties in the management of a person’s health • Multiple funding streams with disparate and conflicting regulations leads to unintended financial incentives and unintended clinical outcomes

9. Other... In Fee-for-Service, there is little incentive for coordination or integration which leads to… Fragmentation Institutional Care Primary Care In - Home Care Acute Care

10. As an example: “Why is it so much easier for me to get my 84-year old patient’s Coronary By-Pass surgery paid for than a bath in his house? • What does the person need? • How does it allow them to continue living independently? • How does it improve their quality of life?

11. PACE is… P A C E of for the rogram ll-inclusive are lderly

12. To qualify for PACE, participants must be: • 55 years of age or older • Living in a designated PACE service area • Certified as needing nursing home care • Able to live safely in the community with the services of the PACE Organization at the time of enrollment

13. The PACE Model History Began with On Lok in San Francisco’s Chinatown Neighborhood 1973- First Adult Day Health Center 1978- Demonstration Project 1983- Waivers/Full Risk 1990- First Demonstration Sites 1999- CMS Final Interim Regulation 2002- CMS Regulation Addendum 2006- Final Regulation 2011- 84 Programs in 29 States

14. To create order in an irrational health care system, PACE… • Manages and coordinates the entire care delivery system • Brings into full alignmentquality and financial incentives of the provider and care recipient • Integrates otherwise fragmented service and funding streams into a seamless service package for people in greatest need

15. Key Feature of PACE:Management and Coordination of the Care Spectrum • Interdisciplinary system of longitudinal care delivery and coordination that spans time, setting and health care jurisdictions (“trans-disciplinary”) • Management of the care is overseen through interface of multiple professionals and para-professionals on the PACE team

16. Management and Coordination of Care through the PACE Interdisciplinary Team Social Worker Transportation Home Care Clinic/Nursing Recreational Therapy/Activities Nutrition/Dietician Primary Care Personal Care OTHER DISCIPLINES AS NEEDED (e.g., Pharmacy) Occupational and Physical Therapies

17. Key Feature of PACE :Full Alignment of Quality and FinancialIncentives • The PACE model is designed with incentives for PACE Organizations to deliver services that are based on what the individual needs and not according to what fee-for-service will pay • This creates a financial and quality incentive for the delivery of the optimal level of services in the least restrictive environment

18. Key Feature of PACE :Full Alignment of Quality and FinancialIncentives • Provider assumes financial risk of service costs in exchange for fixed capitation payment • CAPITATION= fixed payment on a per enrollee basis in exchange for providing necessary services from a menu of mandated services the provider must cover • Payment to the PACE organization is based on membership in PACE and not on units of services delivered

19. Key Feature of PACE:Integration of Funding and Service Streams Consolidation of disparate service and revenue streams into one service package that creates a single source of services Medicare Medicaid Private/3rd Party Part A Part B Part D Card Svcs HCBS Nursing Home PACE Organization PACE Interdisciplinary Team

20. Services Provided in the PACE Benefit and Coordinated through the PACE Program Include… PACE Center Outpatient Services Inpatient Care Medical Specialists Transportation Chore Services Optometry Dental Labs and X-Rays Primary Care DME Meals Emergency Room Therapy Services Pharmaceuticals Home Care Nursing Home Care Personal Care …And Other Necessary Services not typically covered through traditional benefits

21. In the PACE Model Beneficiaries receive all of their necessary health and social services through the PACE provider organization. In addition to Participant’s Rights, enrollees have access to robust Grievance and Appeal procedures Full interdisciplinary teams, including primary care physicians, provide and coordinate all services for the enrollee. No benefit limitations, co-pays or deductibles

22. Key Features of PACE Flexibility The intensive Interdisciplinary care planning process allows the PACE organization to provide services to individuals as they need them and not according to benefit reimbursement payment schedules.

23. Key Features of PACE All Inclusive Care PACE Organizations fully integrate all Medicare and Medicaid services into one package for at-risk older adults rather than the fragmented Fee-for-Service system. Re-Align the funding sources and Right-Size the services

24. Key Features of PACE Capitated Financing The PACE Organization pools capitated or fixed payments, typically from Medicare and Medicaid, to provide all of the needed services in the PACE benefit package.

25. Key Features of PACE Interdisciplinary Care The principal care management mechanism in PACE is the interdisciplinary team which directly provides and coordinates all care for the individual.

26. PACE is the Comprehensive Integration of… • Service Delivery Systems (Health and Social Services) • Care Management • All Medicare and Medicaid Services • Primary, Acute, Specialty and Long-Term Care Services • Service Provision and Health Plan Systems

27. PACE Statistics • 86 Approved PACE programs • 16 Pending applications • 29 states • 2 new states with pending applications • More than 25,000 participants

28. PACE Participant • Average age 81 • 90% are dual eligibles • 64% have 3 or more ADL limitations • Medically complex their risk scores 2.5 times higher than a fee for service Medicare beneficiary

29. Potentially Avoidable Hospitalization (PAH) rate • Compared to a dual eligible NH member PACE’s PAH rate is 44% lower • Compared to a similar HCBW population PACE’s PAH rate is 54% lower

30. Hospitalization Rates Wieland, JAGS 2000; 48:1373-1380

31. PACE was accountable care before accountable care was cool • Medical Home • Patient Centered (care and care plans) • Responsible for quality and cost (capitated) • Provide accountable care across preventative, primary, acute, and long-term care services • PACE emphasizes preventive, primary, and community-based care over avoidable high-cost specialty and institutional care

32. Community Care: • Private, 501(c)(3) founded in 1977 • Original demonstration site for Wisconsin’s Home and Community Based Services programs • One of the first PACE demonstration sites now serving 852 participants in 2 counties. • Family Care Partnership a Medicare Advantage Special Needs Plan serving 567 adults with physical disabilities, developmental disabilities, and frail elders in 9 counties. • Family Care a long-term care managed care program serving 7636 adults with physical disabilities, developmental disabilities, and frail elders in 11 counties.

33. Community Care 1555 S. Layton Blvd. Milwaukee, WI 53215 www.communitycareinc.org For more information, please contact: Julie Erdmann Julie.Erdmann@commmunitycareinc.org (414) 902-2460

34. Siouxland PACE Sioux City, IA

35. Program of All-Inclusive Care for the Elderly • Planning started in 2005 • Federal Rural PACE Grant (15 grants of $500,000/site) became available in 2007 • Siouxland PACE opened in 2008

36. Began as a partnership with Health Inc. (collaboration of St. Luke’s & Mercy Hospitals) • Operated in collaboration with Hospice of Siouxland • Operated under a hospice & palliative care program model • Program struggled from start • Medical care was not coordinated (multiple community physicians) • PACE medical clinic was not utilized • Inadequate staffing and staffing turnover (including physicians) • Program lost money from start

37. In 2011, Health Inc. decided to drop program • St. Luke’s assumed ownership in July 2011 • Program lost money in 2011 & is budgeted to lose money in 2012

38. PACE: By the Numbers • Program currently has 124 participants from six counties • Woodbury (Sioux City), Plymouth, Sioux, Ida, Monona, Cherokee • Approximately 100 participants from Woodbury County • Day center/clinic  located in western Sioux City • 37 FTEs from all PACE disciplines

39. PACE: By the Numbers cont’d • Approximately 35 persons attend day center daily (persons average 5-6 times per month) • 1,200 medical trips in February 2012 • 1,700 prescriptions ordered in February 2012 • 700 meals served at day center in February 2012

40. February 2012 Statistics13 hospital admissions (8 acute/5 obs), 6 ER visits 22 persons residing in ICF facilities

41. Our Siouxland PACE Participants 44% are between ages 55-64 (average program has 17%) High population of males (Veteran Administration referrals from Sioux Falls, SD VA Hospital)

42. Challenges Large service area (have requested to reduce by two counties) Financial Stability Learning to manage medical care to prevent hospitalizations & nursing home admissions Staffing stability Transportation Steep learning curve to learn how to operate a PACE program Younger population with a high percentage of mental health/chemical dependency issues

43. Strengths Strong support from St. Luke’s Strong referral numbers the past several months Belief that PACE is the right way to provide care to an elderly, vulnerable population Positive support from CMS and Iowa DHS Strong feeling of program satisfaction of participants and staff

44. PACE Fiscal Keys Adequate State Medicaid Rate Maintain and grow monthly census Manage Participant's Care…Manage Participants Care… Manage Participant's Care!!! Reduce hospitalizations/readmissions Delay and eliminate need for nursing home/ALF admissions Preventative Care!!!

45. PACE: The Medical Director’s Perspective Amy Callaghan, DO, FACOI Medical Director Siouxland PACE

46. Primary Care in the PACE setting • Unique opportunity • Historically these are the patients that “fall through the cracks”

47. Primary Care in the PACE setting • Unique opportunity • Positively impact frail elderly • The future of Health Care

48. Primary Care in the PACE setting • Unique opportunity • Change of mindset from traditional practices

49. Primary Care in the PACE setting • Unique opportunity • Change of mindset from traditional practices • Unable to quantify a prevented hospitalization

50. Primary Care in the PACE setting • Unique opportunity • Change of mindset from traditional practices • Care Innovation • Follow standard of care