1. PACE Service Delivery Model Chris van Reenen, National PACE Association Ann Olson, ICS Rob McCommons, ICS MN PACE Summit July 2004

2. Long-Term Care for Families and Caregivers is… Often unpredictable and costly due to the nature of chronic conditions. Often unpredictable and costly due to the nature of chronic conditions. The responsibility of multiple jurisdictions and service sectors. The responsibility of multiple jurisdictions and service sectors.

3. Long-Term Care for Providers is… Difficult because of: Multiple funding streams Multiple funding streams Disparate and conflicting regulations Disparate and conflicting regulations Health care service sectors with distinct clinical roles and responsibilities Health care service sectors with distinct clinical roles and responsibilities

5. The integration of multiple health and service streams can… Eliminate gaps and fragmentation that exists in fee-for-service and other systems Eliminate gaps and fragmentation that exists in fee-for-service and other systems Coordinate primary, acute and long-term care delivery systems that can readily respond to the needs of the individual Coordinate primary, acute and long-term care delivery systems that can readily respond to the needs of the individual Create a single source of all necessary services for the enrollee rather than multiple jurisdictions and sectors Create a single source of all necessary services for the enrollee rather than multiple jurisdictions and sectors

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

7. The highly successful model of fully-integrated acute and long- term care for frail older adults. It is the only federally qualified provider-type which fully-integrates all Medicare and Medicaid services into one seamless service package for beneficiaries.

8. PACE takes multiple services… … … and reorganizes them in a way that makes sense to persons with long-term care needs, their families, health care providers and payers. This becomes a “one-stop shopping” service package for those individuals at highest risk.

9. In the PACE Model Beneficiaries receive all of their health and social services through the PACE provider organization. Full interdisciplinary teams, including staff physicians, provide and coordinate all services for the enrollee.

10. In the PACE Model An adult day health center typically becomes the focal point of service delivery and most services are often provided directly in the day center setting.

11. In the PACE Model The services of the PACE organization follow the beneficiary across all care settings including the home, hospital and nursing home.

12. In the PACE Model Beneficiaries receive the full range of health and social services they need to maintain their function and remain living at home.

13. In the PACE Model Care decisions at all levels are made through the close involvement of the enrollee and family member and service delivery is flexible and expedient in order to meet the variable needs of the enrollee as they age.

14. PACE Nationally  PACE was developed to replicate On Lok program in San Francisco  First PACE demonstration sites became operational in 1990  PACE was approved as a new Medicare Provider under the Balanced Budget Act of 1997  Federal regulations for PACE were promulgated in 1999 allowing for demonstrations to transition to permanent provider status and growth of new programs  32 PACE and 8 Pre-PACE organizations in 21 states serve 12,000+ enrollees [7/04]

15. Key Features of PACE The PACE organization has the ability to provide services to enrollees as they need them and not according to fee-for- service schedules or other payer mandates.

16. Key Features of PACE 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.

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

18. 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. Providers are at full financial risk from the beginning.

19. Why PACE?  For consumers, PACE provides:  Caregivers who listen to and can respond to their individualized care needs  The option to continue living in the community as long as possible (“nursing home second opinion program”)  Individualized care and supportive services arrangements  One-stop shopping for all health care services

20. Why PACE?  For health care providers, PACE provides:  Capitated, pooled funding which rewards providers that are flexible and creative in providing the best care possible  Ability to coordinate care for the individuals across settings and medical disciplines

21. Why PACE?  For those who pay for care, PACE provides :  Cost savings and predictable expenditures  Comprehensive service package emphasizing preventive vs. acute care  A model of choice for older individuals focused on keeping them at home and out of institutional settings  Cost predictability for the frailest subset of beneficiaries

22. PACE Eligibility  Health problems and limitation that qualify for nursing facility eligibility within State rules  Reside in defined service area  Minimum of 55 years of age  Qualified for Medicare and/or Medicaid OR willing to pay private premium  Able to live safely at home with support from the PACE organization at time of enrollment  Agree to receive covered services through PACE organization

23. Covered Services  Interdisciplinary assessment and care planning  PACE Center services  Primary and specialty medical care  Nursing home (sub-acute to long- term residence)  Home care and home health  Nursing  Home care aides  Physical, occupational and speech therapies  Social services  Home-delivered meals

24. Covered Services  In-patient and out-patient hospital  Diagnostic services including lab and x-ray  Emergency and non-emergency transportation  Prescription and non-prescription drugs  Speech-language pathology services  Nutrition services  Podiatry  Optometry and eye glasses  Audiology and hearing aids  Dental care

25. Covered Services Medical equipment and supplies Orthotics and prosthetics Personal emergency response system Social and environmental supports

26. PACE Center Services  The PACE Center is the hub of primary care and other service delivery  Participants are brought to and from their homes to receive service at the Center  Monitoring of medical conditions  Receive medications or supplies  Exercise and restorative equipment and instruction  Specialty services such as dental care, optometry, and podiatry are also often on site  Center services must include:  Primary care, nursing, social services, rehabilitation, recreation, personal care, meals and nutrition counseling

27. Other Services  Some routine chronic care services can be provided by the PACE organization or contracted  Home care  Transportation  Social and environmental supports  PACE organization arranges all contracted services from diagnostic to specialty treatment to institutional care  Excluded services  Any service not authorized by the Team (except emergency care)  Inpatient private duty or non-medical services  Experimental or cosmetic procedures

28. PACE Interdisciplinary Team  PACE Center Manager  Primary Care Physician  Nurse  Personal Care/Health Worker  Physical Therapist  Occupational Therapist  Recreational Therapist  Social Worker  Dietitian  Home Care Coordinator  Drivers

29. The success of the provider’s operations is predicated on the success of the relationship that’s built between the organization and the participant/family member. Can access the team at any time. HIGH level of interface between the team and family/caregiver occurs in the continuous process of assessment/ reassessment. Regulations provide elaborate grievance and appeal process should participant experience dissatisfaction and choose this option. Participant and Family/Caregiver

30. PACE Interdisciplinary Team Responsibilities Initial comprehensive assessment Routine reassessment Reassessment in response to any significant change in health status Individualized care planning Service delivery and care coordination across entire continuum of services

31. Care Management Mechanism Care Management Mechanism: PACE Interdisciplinary Team PACE provides and coordinates all levels of care for the participant Integration allows for focused, longitudinal care management which spans time, setting and health care professions Chronic care trajectory can be controlled and necessary services accessed immediately

32. Significant Areas of PACE Team Decision-making Days of attendance Allocation of in-home supportive services Need for alternative housing or NF placement Ethical issues between “quality” and “quantity” of life Capability of family/informal systems in meeting participant needs Rehabilitative vs Habilitative services Determining when to add or stop services in order to maximize independence

33. Center Manager  Oversees day-to- day operations  Leadership and continuity in case conferences  Facilitates interdisciplinary team conferences  Troubleshooting in event of an emergency or unusual incident  Problem solving with participants and/or staff 1:PACE Center

34. Primary Care Providers  Provides continuity of care in all settings  Provides assessment and routine re- evaluation  Coordinates all aspects of inpatient and specialty care  Educates and counsels participants, families, and staff  Must be a team player 1.7 (MD+NP):100

35. Center Nurse 3.3 RN :100 1.2 LPN :100 (includes nursing in both Center and home)  Monitors medications  Provides skilled nursing treatment  Coordinates medical services  Counsels and educates participants and their families  Maintains medical supplies in clinic

36. Social Work  Initial and routine assessment  Problem solving  Family conferences  Monitors participant's spirituality needs  Links with social services in the community  Integrates social component into medical model 2.1:100

37. Recreation Therapy  Provides group and individual activities  Provides opportunities for community outings  Reality orientation activities  Provides special programming for dementia care  Adapts activities to maintain/improve physical, mental, social and emotional well- being  Provides leisure education 1 RT: 100

38. Occupational, Physical, and Speech Therapies  Initial and routine assessment  Assess for assistive equipment  Provide therapies at the center, in participant's home and nursing facility  Ongoing therapy related to disabilities and changes in independence  Crisis intervention  Discharge planning.6 OT: 100.7 PT: 100 2.3 Therapy Aides: 100

39. Dietitian  Counsels on proper nutrition, food selection and diet plan  Monitors special diets, nutrition levels and hydration  Coordinates distribution of home delivered meals  Oversees kitchen operations  Initial and subsequent assessments

40. Personal Care Aides  Reports on personal care services and self- care abilities  Provides personal care and ADL assistance  Monitors for changes in participant’s health and social condition  Helps maintain clean and safe home environment  Provides escort services  Orders supplies and coordinates delivery of supplies  Assists in recreation therapy activities 21.1:100 (includes care provided in both Center and home)

41. Transportation  Provides transportation to and from the PACE Center and medical appointments  Delivers portable meals  Maintains cleanliness and safety of vehicles used for transport  Reports to Team regarding changes in health and social condition

42. Factors Critical to PACE Success Achieve census growth to achieve sufficient size to spread fixed costs (e.g. Center expenses and staffing) Manage care to control variable costs (e.g. home care, ADHC attendance, pharmacy, inpatient utilization) Manage risks for acute and long-term care services Obtain working capital to sustain losses until operating reserves can be achieved Develop staffing, PACE center facility and services, and establish provider network

43. Creativity Creating viable alternatives to more costly services Going beyond the traditional Medicare and Medicaid fee-for- service package Working collaboratively with families or other informal social networks to achieve effective outcomes

44. Communication High level of communication ensures changes in participant social, health and functional abilities are identified, services delivered and status is monitored closely

45. Coordination Ensures all services are managed consistently and appropriately May require reducing services if necessary

46. Collaboration Removing barriers between professions creates care management that is greater than the sum of its parts Caring holistically for all areas of the participant’s life creates unique opportunity to achieve outcomes not found in other models