1. OVERVIEW OF PACE AND ON LOK LIFEWAYS On Lok Presentation to the Institute for Senior Living April 13, 2012

2. WHAT IS ON LOK? 2 Presentation to the Institute for Senior Living April 13, 2012  Original Vision: Help the low-income seniors in Chinatown/North Beach area of San Francisco stay in their own homes with health and social services needed to maintain independence National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care  Structure Today: On Lok Lifeways, our PACE program, serves almost 1,200 frail seniors in three San Francisco Bay Area Counties On Lok’s 30 th Street Senior Center services over 5,000 seniors annually with traditional senior center services Owns and operates three housing facilities

3. WHAT IS PACE? PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY  Comprehensive services for the frail elderly:  Preventive care  Primary care  Medications  Acute care  Long-term care, including nursing facility when needed  Capitation funding (per member per month):  Combines Medicare, Medicaid, private  Program has full financial risk (with no carve-outs)  Alignment of care needs and financial interests  Monitors elders closely – takes action early to restore health, control cost 3 Presentation to the Institute for Senior Living April 13, 2012

4. WHO BENEFITS FROM PACE? 4 Presentation to the Institute for Senior Living April 13, 2012  Frail older people who want to live in the community  Family members caring for an elder  Providers who want to deliver seamless, high quality care  Senior housing facilities where elders age in place  Policy makers seeking to save tax-payer money and deliver effective care

5. WHO DOES PACE SERVE? 5 Presentation to the Institute for Senior Living April 13, 2012  Eligibility:  55 years or older  Resident of PACE service area  State-certified to need nursing home level care  Can live safely in community at time of enrollment

6. ON LOK’S PACE PARTICIPANT PROFILE 6 Presentation to the Institute for Senior Living April 13, 2012  Profile of typical participant  Female; average age of 83  16 medical conditions  Dependent in 3.7 ADLs (bathing, dressing, etc.)  Dependent in 6.7 out of 7 IADLs (medication management, money management, etc.)  Has some degree of cognitive impairment (62%)  Dually-eligible for Medicare & Medi-Cal (94%)  Enrolled in program last 5.6 years of life  Serves culturally and linguistically diverse population  62% Asian/Pacific Islander, 20% Caucasian, 12% Hispanic, 5% African American, 1% Other  Multi-lingual participants and staff

7. ON LOK LIFEWAYS: PACE OPERATIONS  Provider Operations include:  Eight PACE centers and 9 Interdisciplinary Teams  Home care services, transportation, dietary services  Primary care providers (physicians and nurse practitioners)  Complete network of contract inpatient and specialty providers: hospitals, nursing homes, specialty care, lab, x-ray, pharmacy, etc.  Health Plan Functions include:  Marketing/Member Enrollment: Member services, enrollment, disenrollment  Complaint, grievance and appeals processes  Network management/contract services  Quality assurance and Improvement program  Electronic health records  Claims processing 7 Presentation to the Institute for Senior Living April 13, 2012

8. HOW DOES PACE WORK? 8 Presentation to the Institute for Senior Living April 13, 2012 Interdisciplinary teams assess need, deliver & manage care across settings: Primary Care Transportation Home Care Nursing OT/PT Speech Nutrition Recreation Social Service Settings PACE Center Home Acute Hospital Nursing Home

9. PACE TEAM APPROACH TO CARE MANAGEMENT 9 Presentation to the Institute for Senior Living April 13, 2012  IDT meets regularly: each participant is assessed at least semi-annually with his/her care plan updated at each interval and with a significant change in condition  The goal is to maximize medical management in the outpatient setting – participants are seen timely in clinic to address new issues  The team coordinates information and transitions between hospital and nursing home  Address person-centered values for end-of-life care  Electronic Health Record supports person-centered care planning

10. MEDICAL MANAGEMENT 10 Presentation to the Institute for Senior Living April 13, 2012  The goal is to maximize medical management in outpatient setting and integrate social and functional support needs with IDT  Primary care team on-site: MD, NP, RN  Full-service clinic for urgent care and management of chronic conditions  IV and Respiratory therapy  Wound care management  Frequent visits for management of chronic disease such as CHF, diabetes, chronic lung disease  Effective delivery of end-of-life care  Discussion of advance healthcare directives to promote end of life care based on the values of the person  24 hour call system with on-call physicians and nurses linking to IDT

11. WHAT DIFFERENCE DOES THE PACE MODEL MAKE? 11 Presentation to the Institute for Senior Living April 13, 2012 *CY 2011 On Lok **2008 Medicare Data except Readmission data ***2010 http://www.managedcaredigest.com

12. ON LOK PACE OUTCOMES SUMMARY 12 Presentation to the Institute for Senior Living April 13, 2012  Medical Home: 100% of participants have a medical home with a primary care physician and interdisciplinary team responsible for coordinating and providing direct care.  Lower inpatient utilization: Acute care utilization is comparable to the Medicare population even though PACE enrolls an exclusively frail population.  Better follow-up after acute care stay: Readmission rate to acute hospital within 30 days of discharge is half the Medicare average.  End of Life Care: Vast majority of participants remain enrolled through end of life care: 96%  High Rates of Community Residence: 93% reside in the community rather than a nursing home.  High Consumer Satisfaction: In 2011, 93% of participants interviewed at California PACE programs reported that they were very satisfied with the program and 95% reported that would refer a close friend to the program.

13. MEDICARE/MEDI-CAL ELIGIBILITY 13 Presentation to the Institute for Senior Living April 13, 2012

14. ON LOK PACE SOURCES OF REVENUES 14 Presentation to the Institute for Senior Living April 13, 2012

15. PACE RATE-SETTING METHOD 15 Presentation to the Institute for Senior Living April 13, 2012 Medicare  Parts A/B: Risk-adjusted for each enrollee by demographic and diagnostic characteristics, plus frailty adjustor  Part D: Bid premium, risk-adjusted for each enrollee; year-end reconciliation with risk-sharing Medicaid  90% of fee-for-service cost equivalent for comparable long-term care population (California W&I §14593(e).)

16. HOW ON LOK PACE DOLLARS ARE SPENT 16 Presentation to the Institute for Senior Living April 13, 2012 Note: Percentages represent proportion of total service revenues for FY10-11 ($88.9M) Medical Loss Ratio = 91%

17. DISTRIBUTION OF SERVICE EXPENSES 17 Presentation to the Institute for Senior Living April 13, 2012 Note percentages represent proportion of total service expenses for FY10-11 ($80.8M)

18. FEDERAL POLICY ENVIRONMENT IN PACE 18 Presentation to the Institute for Senior Living April 13, 2012  National Trends for PACE  Tremendous growth in recent years  86 approved PACE organizations in 29 states  16 applications pending with applications in 2 new states  PACE innovations in serving rural areas, veterans, etc.  Medicare Payment Methodology and Reporting  Encounter reporting implementation planned for 2013  PACE Flexibility Proposal  Modifying the current PACE Model  Expanded use of community physicians  Alternative care settings  Greater flexibility in IDT composition  Expanding PACE to new populations  Disabled individuals under the age of 55 years  Nursing home residents transitioning back to community

19. MEDICARE & MEDI-CAL SERVICES 19 Presentation to the Institute for Senior Living April 13, 2012  Hospital Services  Physician Services  Limited SNF  Rehab services  Home health services  Kidney dialysis  Durable medical equipment (DME)  Prescription drugs  Hospice Medi-Cal  Medicare cost-sharing (Part B premiums, deductibles)  Medical transportation, vision, expanded mental/ behavior health services  Long-term skilled nursing facility care  Community-Based LTSS (IHSS, MSSP, ADHC/CBAS)  Other HCBS waiver services Medicare

20. PACE VS. TRADITIONAL MANAGED CARE 20 Presentation to the Institute for Senior Living April 13, 2012  Enrolls only nursing home eligible beneficiaries - a small subset of total population  PACE is both an insurer and provider of care  Benefit package includes all Medicare and Medi-Cal services  Covers all home and community-based services (HCBS) and institutional long- term care  Payments are set based on cost of comparable population with services delivered regardless of payment source  Enrolls large numbers of Medi- Cal or Medicare beneficiaries based on eligibility categories  Traditional insurance model – contracts and pays for services  Benefit package includes Medicare or Medi-Cal medical services  Does not cover HCBS services or institutional long-term care services beyond short-stay  Payments are set based on actual costs of providing covered benefits (e.g., Medicare benefit package) PACE Managed Care

21. CALIFORNIA PACE DEVELOPMENT 21 Presentation to the Institute for Senior Living April 13, 2012  Operating PACE organizations:  AltaMed Senior Buena Care serving East Los Angeles and surrounding communities  Centers for Elder Independence serving Alameda and Contra Costa Counties  On Lok Lifeways serving San Francisco, Alameda (Tri-City) and Santa Clara Counties  St. Paul’s PACE serving San Diego County  Sutter Senior Care serving Sacramento County  PACE organizations in development  Seven organizations have submitted PACE Provider Application (PPA) to DHCS  Four additional organizations submitted letters of intent to develop PACE

22. CHALLENGES 22 Presentation to the Institute for Senior Living April 13, 2012  Ensuring PACE is a choice for eligible individuals in counties where Medi-Cal managed care exists  Ensuring that PACE-eligible individuals have timely access to services in the enrollment process  Establishing a PACE Medi-Cal rate-setting methodology that reflects the unique characteristics of the model and provide adequate rates  Significant capital investment is needed to develop facilities, maintain operations and expand PACE centers, unlike traditional managed care plans  Streamlining burdensome regulatory requirements including Shortening application and start-up processes  Need to implement flexbilities to bring PACE to scale

23. OPPORTUNITIES 23 Presentation to the Institute for Senior Living April 13, 2012  PACE encompasses goals of federal and state health reform  Person-centered care based on shared decision-making and values- based choices for people with chronic diseases and long-term needs.  True “medical home” that is available to the individual and their family/caregivers – 24 hours/day, 7 days/week.  Full integration of all health care services on ongoing basis, across delivery settings through an interdisciplinary team to facilitate care transitions.  Provider accountability for quality and quantity of all services provided.  Payment method which incentivizes the right care, at the right time, in the right place.  California PACE programs have infrastructure for expansion  State leadership can expand PACE, a proven model of acute and long-term care integration for low-income, frail older adults

24. INNOVATION AND BUSINESS DEVELOPMENT 24 Presentation to the Institute for Senior Living April 13, 2012 And…beyond PACE

25. BUSINESS DEVELOPMENT GOALS 25 Presentation to the Institute for Senior Living April 13, 2012 INNOVATION GROWTH EFFICIENCYSUSTAINABILITY

26. DEPARTMENT FOCUS 26 Presentation to the Institute for Senior Living April 13, 2012

27. POLICY & PRACTICE DRIVERS Population Size LongevityDiversity Aging in Place Chronic Disease Economic Security CaregivingTechnology Long term services and supports Housing Health Care Caregiver Support Financing 27 Presentation to the Institute for Senior Living April 13, 2012

28. EMERGING TRENDS AND TENSIONS 28 Presentation to the Institute for Senior Living April 13, 2012 Decreased Financing & Increased Demand Aging in Community Integrated Systems of Care Decentralized Services New Roles for Medical Groups Social and Non- medical Supports

29. AGING IN COMMUNITY 29 Presentation to the Institute for Senior Living April 13, 2012 Older Adult Housing Medical care/care coordination Non-medical supports CommunityTechnology Caregiver support

30. FUTURE UNKNOWNS 30 Presentation to the Institute for Senior Living April 13, 2012 How will the state continue to support PACE?

31. FUTURE UNKNOWNS 31 Presentation to the Institute for Senior Living April 13, 2012 NEW BUSINESS DEVELOPMENT (NON-PACE)  What do older adults and their caregivers need? What do they want?  What can they pay for? What are they willing to pay for?  How will “it” be created?  How will “it” be paid for?  What role will insurance play?  How will the private sector respond?

32. SO … WHERE WE ARE HEADED? 32 Presentation to the Institute for Senior Living April 13, 2012 Build on On Lok’s strong reputation and core strengths Target populations - Pre-PACE, middle income, Medicare New products, partnerships, and lines of business  Well elder to end of life - care management/care coordination, flexible service packages, consumer choice

33. OUR OPPORTUNITY OUR CHALLENGE 33 Presentation to the Institute for Senior Living April 13, 2012 What do Consumers Want? What is Flexible & Not Dependent on Government Funding? What is Viable & Sustainable?

34. Q & A AND WRAP UP 34 Presentation to the Institute for Senior Living April 13, 2012

35. 35 Presentation to the Institute for Senior Living April 13, 2012