Develop a broad understanding of health care policy environment Develop understanding of PACE background, operations and future innovations Objectives
Changing times for health care financing ACO Bundled Payment for Care Improvement Community Based Care Transitions 30 day readmissions
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 higher than for Medicare beneficiaries with no ADL impairments What in the World is Going on with Long-Term Care?
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
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 DIFFICULTIES IN THE MANAGEMENT OF A PERSON’S HEALTH Why is the “dual eligible” population difficult to manage?
Multiple funding streams with disparate and conflicting regulations leads to unintended financial incentives and unintended clinical outcomes Difficulties in the management of a person’s health
In Fee-for-Service, there is little incentive for coordination or integration which leads to… Acute Care In - Home Care Institutional Care Primary Care Other...
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?
PACE is… PAEC rogramll-inclusive for lderlyare theof
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
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
To create order in an irrational health care system, PACE… 1.Manages and coordinates the entire care delivery system 2.Brings into full alignment quality and financial incentives of the provider and care recipient 3.Integrates otherwise fragmented service and funding streams into a seamless service package for people in greatest need
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
Management and Coordination of Care through the PACE Interdisciplinary Team Social Worker Home Care Transportation Nutrition/Dietician Occupational and Physical Therapies Primary Care OTHER DISCIPLINES AS NEEDED (e.g., Pharmacy) Personal Care Recreational Therapy/Activities Clinic/Nursing
Key Feature of PACE : Full Alignment of Quality and Financial Incentives 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
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 Key Feature of PACE : Full Alignment of Quality and Financial Incentives
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 MedicareMedicaidPrivate/3 rd Party Part APart BPart DCard SvcsHCBSNursing Home PACE Organization PACE Interdisciplinary Team
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
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
Key Features of PACE 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.
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 Key Features of PACE
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. Key Features of PACE
The principal care management mechanism in PACE is the interdisciplinary team which directly provides and coordinates all care for the individual. Key Features of PACE
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
PACE Statistics 86 Approved PACE programs 16 Pending applications 29 states 2 new states with pending applications More than 25,000 participants
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
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
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
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.
For more information, please contact: Community Care 1555 S. Layton Blvd. Milwaukee, WI 53215 www.communitycareinc.org Julie Erdmann Julie.Erdmann@commmunitycareinc.org (414) 902-2460
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
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
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
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
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
February 2012 Statistics 13 hospital admissions (8 acute/5 obs), 6 ER visits 22 persons residing in ICF facilities
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)
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
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
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!!!
+ PACE: The Medical Director’s Perspective Amy Callaghan, DO, FACOI Medical Director Siouxland PACE
+ Primary Care in the PACE setting Unique opportunity Historically these are the patients that “fall through the cracks”
+ Primary Care in the PACE setting Unique opportunity Positively impact frail elderly The future of Health Care
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Unable to quantify a prevented hospitalization
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Care Innovation Follow standard of care
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Must consider where PACE lies in the spectrum of life
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Must consider where PACE lies in the spectrum of life Identify the participant’s stage– and discuss goals Functionality
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Must consider where PACE lies in the spectrum of life Identify the participant’s stage Functionality Palliative
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Must consider where PACE lies in the spectrum of life Identify the participant’s stage Functionality Palliative End of life Advancing our services as needed
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Interdisciplinary care
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Interdisciplinary care We are all responsible for a piece of the puzzle
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Interdisciplinary care/ Team approach Recognizing the warning signs Monitor (and report) outcomes
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Interdisciplinary care PACE works Streamline services In essence, a small ACO Participants remain living independently in their home
+ Primary Care in the PACE setting Unique opportunity Change of mindset from traditional practices Interdisciplinary care Positive patient outcomes
+ Thank you Dr. Amy Callaghan callagAL@stlukes.org