Program for All-Inclusive Care for the Elderly: An Important Addition to Your CCRC Webinar: November 2, 2011

TIMETOPIC 3:00p-3:10pWelcome-Overview of Session Speaker Introductions Larry Minnix, President/CEO, LeadingAge Shawn Bloom, President/CEO, NPA 3:10p-3:25pPACE 101: Shawn Bloom, President/CEO, NPA 3:25p-3:35pIntegrated Medical Delivery: Cheryl Phillips, MD Senior VP, Advocacy, LeadingAge 3:35p-3:50pPACE and CCRCs: Dan Gray President, Continuum Development Services 3:50p-4:00pCase Study-Presbyterian Senior Living Steve Proctor, CEO 4:00p-4:10pCase Study-Presbyterian Villages of Michigan Roger Myers, President/CEO 4:10p-4:30pQuestions/Answers Agenda

PACE 101 Presented by: Shawn Bloom, President/CEO National PACE Association

Program of All-inclusive Care for the Elderly (PACE) Overview

Presentation Outline  PACE Overview and Brief History  PACE Experience with Dual Eligibles  Questions/Comments

The Program of All-inclusive Care for the Elderly Is an integrated system of care for the frail elderly that is: Community-based Coordinated Comprehensive Capitated

Who Does PACE Serve?  Adults 55 years of age or older and who are: Living in a PACE organization’s service area State-certified as eligible for nursing home level of care Able to live safely in the community with the services of the PACE program at the time of enrollment

PACE is Community-Based  PACE provides innovative, person-centered care for older adults that allows them to stay in their homes and communities and out of nursing homes “PACE’s help in being able to keep mom at home has enabled us to keep our family together.” Family Member of a PACE Participant

 Employs interdisciplinary teams to deliver and coordinate care across care settings Doctors, nurses, therapists, social workers, dieticians, personal care aides, and other providers Day centers, clinics, occupational and physical therapy facilities Individuals’ homes Hospitals and nursing homes, if necessary PACE Provides Coordinated, Comprehensive Care

PACE Provides Coordinated and Comprehensive Care  Bundles Medicare and Medicaid payments to provide full range of health care services  Medical care, social services, and other long-term services and supports

Capitated, Pooled Financing  Integration of Medicare, Medicaid and private pay payments by PACE providers  Medicare A/B capitation payments risk- and frailty- adjusted for PACE participants  Medicare Part D payments based on bid amounts  Medicaid capitated payment amounts based on states’ expenditures for long-term care populations

Sources of Service Revenue  PACE Programs receive approximately $5,349 PMPM in 2011:  60% of their revenue from Medicaid  40% from Medicare (A small percentage of program revenue comes from private sources or enrollees paying privately)  2011 Mean Medicare PMPM Rate: $2,018  2011 Mean Medicaid PMPM Rate: $3,331  PACE Programs are Medicare D providers

PACE Organizations Provide: All Medicare and Medicaid covered– services and more medical care nursing physical therapy occupational therapy recreational therapy meals nutritional counseling social work home health care hospital care personal care prescription drugs social services audiology dentistry optometry podiatry speech therapy respite care SNF/NH care

PACE History and Evolution  1983 – On Lok demonstration  1986 – PACE replication demonstration  1997 – Congress established PACE as permanent Medicare provider and Medicaid state option (Balanced Budget Act)  Distinct statutory and regulatory designation as a provider-based entity  Sections 1894 and 1934, Social Security Act  Title 42, Part 460, Code of Federal Regulations

PACE Core Competencies  Operates as a provider-based model  Serves exclusively a nursing home eligible population  Produces good outcomes:  Participants more likely to have advance care directives and die at home  PACE participants, caregivers, and employees report high satisfaction with the program  PACE participants have reduced hospitalizations and permanent residency in nursing homes

Integrated, Interdisciplinary Team Care  Hands-on interdisciplinary team approach to care management vs. individual case management  Continuous process of assessment, treatment planning, service provision, and monitoring  Focus on prevention, primary, secondary, and tertiary care

PACE is: Fully-Accountable for the Cost and Quality of Care Provided  How can we move from successfully treating individual diseases, to successfully caring for individuals? Can we do it for less?  Proven track record in preserving wellness and promoting quality care  Integrated and fixed-rate financing system reduces the cost of care compared to nursing home care substantially  A recent HHS report found PACE generates better health outcomes

A long history serving dual eligibles, where one size does not fit all  90 percent of PACE participants are dual eligibles (Medicare & Medicaid eligible)  Dual eligibles have multiple, complex conditions and benefit from the PACE model of comprehensive, individualized care PACE has:

PACE has a long history and unique approach  30+ year track record  Direct, hands-on provider  Accepts full financial risk for participants’ cost and health care  Exclusively serves a subset of the dual eligible population – frail, older adults PACE is Distinct

Status of PACE (as of 10/11)  Currently there are 166 PACE centers, operated by 81 sponsoring organizations in 29 states  Over 23,000 PACE participants  One-fifth of PACE organizations indicate that they are approaching enrollment cap imposed by their states  Over one-half of PACE organizations plan to expand with the development of one or more centers in 2011

PACE Responds to Tough Health Care Challenges For Consumers—Participants/Caregivers:  Comprehensive, preferred method of care  Stay in the community as long as possible  One-stop shopping For Providers:  Freedom from traditional FFS restrictions  Focus on the entire range of needs of individual For Payers:  Value and predictable expenditures  Comprehensive service package

New Opportunities for PACE  Number of PACE organizations doubled in last 5 years to 76: Rural PACE grants – 13 rural programs More diversity among interested sponsors (e.g., hospices) State interest in PACE expansion  PACE/Veterans Administration Start-up Program  New demonstrations being developed to Expand current PACE program and offer the model to different populations that would benefit from its services Recent History Looking Ahead

Integrated Medical Delivery Presented by: Cheryl Phillips, MD Senior Vice President, Advocacy LeadingAge

How is PACE Clinical Care Delivered?  The center of care delivery is the interdisciplinary team (IDT)  Care plans are created with (not just for) the individual and family and includes social, cultural, functional aspects of care – in addition to the medical needs  Most of the services are coordinated through the adult day center – thus social care is integrated directly with medical care 25

What Does the IDT Look Like? 26 Interdisciplinary teams assess need, deliver & manage care across settings: Primary Care Transportation Home Care Nursing OT/PT Speech Nutrition Recreation Social Services Settings/Services Adult Day Health Care Personal Care Home Care Nursing Home Hospital Medical Specialists Pharmacy Lab/X-ray Medications/DME

Care Management = Care Coordination  Interdisciplinary Team (IDT) Care Planning Integrates skilled assessment and evaluation findings and regular assessments by PACE IDT members (physician, nurse, rehab therapists, social worker, dietary, recreation and home care staff) into new or revised person-centered care plan.  Frequent Monitoring Regular attendance at day center combine with home care according to individualized care plan Input from professionals and paraprofessionals 27

Care Management = Care Coordination  Collaborative Care Planning with Participants and Family Members Insures and improves quality of care Maintains participant autonomy Comprehensive medical record integrates person-centered goals across the team 28

Medical Management  The goal is to maximize medical management in the outpatient setting and integrate social and functional support needs with IDT  Primary care team on-site: MD, NP, RN 29

Medical Management  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 Daily clinic care and observation can often prevent hospitalizations 24 hour call system with on-call physicians and nurses linking to IDT Effective person-centered and team-based delivery of end-of-life care 30

CCRCs Have Much of the Clinical Structure  Many already have on-site clinics and nursing staff  Culture of wellness and prevention is central to CCRC model  Care Coordination is already a skill set – coordinating information and person-specific goals across settings of care  CCRC staff understand the intersection of clinical conditions with function and the goal to maintain independence for as long as possible

Synergies of PACE and the CCRC Presented by: Dan Gray, President Continuum Development Services

CCRC Challenges  Chronic downturn in the economy  Continuing housing crisis  Upcoming 11% reduction in Medicare Part A reimbursement for skilled nursing  States slashing Medicaid payments  Plummeting investment income and value  Shrinking charitable contributions

MissionMarketBusiness Broadening Your Market

CCRCs and The Future  Mission—reach out to older adults who cannot afford to be in a CCRC or wish to remain in their own home  Market—broadens the market from 2% served to the possibility of serving all seniors  Business—diversify into revenue not capital intensive services

CCRCs and The Future  Many CCRCs have strategically developed home- and community- based services for the broader community  Mission: develop a broad array of services for older adults regardless of economic or functional status

Economic Status AdequateInadequateImpoverished Functional Status Independent Retirement Communities Life Care at Home Rental Retirement Communities, Middle and low income Tax-credit financed housing Affordable Housing Needs Assistance Home Care Adult Day Care Assisted Living Home Care Adult Day Care Assisted Living Home Care Adult Day Care Frail Private Pay PACE Home Care Nursing Home Spend Down into PACE Home Care Nursing Home-Spend Down PACE Home Care Nursing Home Continuum of Care

Synergies  Housing with Services  Care Management across the Continuum  Social Accountability/Medicaid  Capital to Fund PACE Start-up  The Future of Senior Living and PACE  Common Not-for-Profit and Faith- Based Traditions

Housing With Services  Great place to market PACE—up to 20% may be nursing home eligible  Let costly place to provide services  Transportation, which can be costly, can be avoided CCRCs are experienced developers and operators of housing with services—a valuable component of PACE

Care Management Across the Continuum  Several CCRCs are adding Chief Medical Directors to integrate services across continuum  In PACE, Medical Directors and Nurse Practitioners are integral to the model PACE is a platform for improving care management and developing a comprehensive service continuum

Social Accountability/Medicaid  Increasing need to document social accountability efforts—tax issue  Opportunity to serve Medicaid population combined with Medicare—more profitable than serving Medicaid only population PACE allows CCRCs to expand their mission to the economically disadvantaged while being good stewards of the organization’s resources

Capital to Fund PACE  Reasonable estimate is $15k per participant slot--$4.5m to develop a 300- participant program  Financing opportunities include short-term bank loans, internal loans refinanced into long-term debt after stabilization Many CCRCs have the liquidity and the mission imperative to make a strategic investment in PACE

Future of Senior Living and PACE CCRCs having PACE in their continuum will be the leaders in these innovations and in ACOs

Not-For-Profit and Faith-Based Traditions Senior living organizations have led innovations in caring for the frail elderly for past 100 years  Restraint-free environments  Small households  Greenhouses®  Culture change  Assisted living  PACE

CCRCs and PACE CCRCs should become the leading provider of PACE in the future

Presbyterian Senior Living Presented by: Steve Proctor President/CEO Presbyterian Senior Living

Presbyterian Senior Living  9 th largest senior care provider on Zeigler 100  24 locations in Pennsylvania, Maryland, Delaware and SE Ohio  Upscale CCRCs to affordable housing, skilled nursing, personal care, and assisted living  Historic commitment to serving low to moderate income seniors throughout the continuum  Approach to social responsibility – we earn money from upscale operations to fund services to those in need

Strategic Focus—Long-Term Care Continuum  Offer a continuum of care to persons in a wide range of financial circumstances  The continuum should be flexible, cohesive, quality driven  Elements of the continuum provided directly by PSL or in partnership with others  PACE is an extension of our affordable housing and services strategy which enables PSL to offer a full range of services to those with limited resources

PACE in Pennsylvania  Called Living Independently for Seniors (LIFE)  County by county franchise  Commitment to expansion has faded with leadership changes within state government

PACE in the Lehigh Valley  Separate location from other operations (2 CCRCs, 1 free standing AL with specialty dementia product, and adult day program with a 20-year history)  Opened in February 2009, first enrollment May 2009  Slower than expected start up due to resistance from AAA  Current census is 58  Program benefits from the synergy of a wider continuum

PACE in Lancaster  Market saturation–county has 18 retirement communities  New location opening in December 2011  Located next to 1500 member church with extraordinary physical plant available to retirement community

PACE in Lancaster  Campus will serve 200 senior families with AL, market rate rental, tax credit housing – no skilled nursing component  Relationship with Albright Senior Services— PACE provider  Strong response—considered model for the future

Presbyterian Villages of Michigan Presented by: Roger Myers President/CEO Presbyterian Villages of Michigan

PVM Locations

PACE Eligibles

Program Outcomes

East Jefferson Project Area

East Jefferson Building Design 61

East Jefferson Building Design

East Jefferson Condo Structure

East Jefferson Organizational Chart

Questions LeadingAge National PACE Association