1. 1 Program of All Inclusive Care for the Elderly: Adapting to the IDD population Fredrick T. Sherman MD, MSc Chief Medical Officer for Community and Managed Care Services Medical Director, Archcare Senior Life(PACE) Archcare Clinical Professor of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai www.archcare.org www.NPAonline.org

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3. 3 PRIMARY CARE OF OLDER ADULTS WITH MULTIPLE CHRONIC CONDITIONS * NOT COMPREHENSIVE * NOT EVIDENCE-BASED * NOT INTEGRATED * NOT EFFICIENT

4. 4 P rogram of A ll Inclusive C are for the E lderly An integrated system of care for the frail elderly that is: Community-based Comprehensive Coordinated Continuous Capitated

5. 5 The PACE Model Who Does It Serve? 55 years of age or older Living in a PACE service area Certified as needing nursing home care Able to live safely in the community with the services of the PACE program at the time of enrollment

6. 6 FIVE Pillars of PACE : Concurrent, Continuous processes for care of older adults with multiple chronic conditions –*INITIAL COMPREHENSIVE ASSESSMENT AND REGULAR REASSESSMENTS –*PLAN OF CARE –*CARE COORDINATION –*ACTIVE INVOLVEMENT IN CARE BY PATIENT, FAMILY, CAREGIVERS, AND STAFF –*TRANSITIONAL CARE

7. 7 Milestones in the PACE Model History Waivers/ Full Risk 1983 Ongoing Waivers 1985 First Center 1973 1978 Demo. Project

8. 8 First Demonstration Sites Operational 1986 Legislation Authorizing PACE Demonstration 19901997 Congress Authorizes Permanent Provider Status Balanced Budget Act of 1997, H.R. 2015 Washington, D.C. (Nov) 1999 Publication of Interim Final PACE Regulation First Program Achieves Permanent PACE Provider Status (Nov) 2001 Milestones in the PACE Model History

9. 9 Final PACE Rule (Oct) 2002 Publication of 2 nd Interim Final PACE Regulation enhancing opportunities for program flexibility November 2006 Milestones in the PACE Model History

10. 10 PACE Programs Around the Nation

11. 11 National Census Growth 1996 – 2012

12. 12 PACE is Small in Scale Each PACE center and IDT can serve up to about 200 enrollees.

13. 13 Typical PACE Patient –*Average age 80 years old –*Takes 8 medications –*90% are medically complex with 4 or more chronic conditions, low income and dual eligibles –*50% are demented –*50% are incontinent –>50% are dependent in at least 3 ADLS including bathing, dressing and toileting

14. 14 Common Problems of Aging ID populations Mental illness: depression, dementia, delirium, anxiety Neurological syndromes: Seizures increase in vascular and Alzheimer’s dementia Pressure ulcers in dysmobile IDD patients Constipation Falls Dysphagia, GERD, dental erosions, esophagitis, anemia, aspiration pneumonia Behavioral disorders: look first for pain or other medical problems; use behavioral management techniques; –Data poor on neuroleptics; GDR

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16. 16 What are health issues over past decade in aging ID populations Persons with ID survive and live in to late life No studies on “multi-morbidity” Polypharmacy studies are scarce Cardiovascular disease and some cancers less common Environmental risks (lack of exercise, overweight, obesity, and dental problems) are increasing

17. 17 Hospitalizations for I/DD: 1995-2001 Mental Disorders: 33% (schizoprenia,depression) Dental Disorders: 40% of day-surgery admissions High ambulatory care sensitive conditions: 3x greater than age/sex adjusted general pop In-hospital surgery rates—low Highest hospitalization rates age 40-44

18. 18 CHALLENGES FOR PRIMARY CARE FOR IDD * COMMUNICATION ISSUES * CAREGIVER UNABLE TO PROVIDE ESSENTIAL INFORMATION * FREQUENT RELOCATIONS *FEARFUL ABOUT PHYSICAL EXAM AND TESTS *INCREASED # OF HEALTH ISSUES *EXTRA CLINICIAN TIME

19. 19 The PACE Model Philosophy Honors what frail elders want To stay in familiar surroundings To maintain autonomy To maintain a maximum level of physical, social, and cognitive function

20. 20 Brief Overview of PACE Services Provided nursing physical therapy, occupational therapy recreational therapy meals nutritional counseling social work medical care home health care personal care prescription drugs social services audiology dentistry optometry podiatry speech therapy respite care Hospital and nursing home care when necessary

21. 21 Integrated Service Delivery and Team Managed Care Interdisciplinary Teams Social Services Home Care Pharmacy Nutrition OT/PT Primary Care Provider Transportation Nursing Activities

22. 22 Integrated, Team Managed Care INTERDISCIPLINARY TEAM (IDT) MANAGED vs. individual case manager PLAN OF CARE implemented by IDT Continuous process of assessment, treatment planning, service provision and monitoring of PLAN OF CARE IDT focuses on preventive care, early detection and aggressive intervention

23. 23 Over 160 PACE centers, operated by 89 organizations, in 30 states, serving over 27,000 participants Between 2005 and 2010, number of participants doubled Enrollment grew about 30% between 2009 and 2012 22 new programs in development “pipeline” expected to open in 2013 Status of PACE Development (as of December, 2012)

24. 24 PACE Provides Transportation

25. 25 PACE Provides PT & OT

26. 26 PACE Core Competencies  Provider based model  Tightly controlled care management and utilization systems  Serves largely a nursing home eligible population in the community when enrolled  Good care outcomes, high enrollee satisfaction and low disenrollment rates  Established existing program with a proven track record

27. 27 Capitated, Pooled Financing Integration of Medicare, Medicaid and private pay payments Medicare capitation rate adjusted for the frailty of the PACE enrollees

28. 28 Revenue Sources 2012 MEDICARE $3,087 pmpm 39% MEDICAID $4,496 pmpm 57% Monthly Capitation PRIVATE PAY $274 pmpm 4%

29. 29 Source of Service Revenue PACE Programs receive approximately: –2/3 of their revenue from Medicaid –1/3 from Medicare (A small percentage of program revenue comes from private sources or enrollees paying privately) 2012 Mean Medicare PMPM Rate: $2,057 2012 Median Medicaid PMPM Rate: 3,343 PACE Programs are Medicare D providers

30. 30 PACE Costs Jan – Dec 2012

31. 31Wieland, JAGS 2000; 48:1373- 1380 Hospitalization Rates I

32. 32Wieland, JAGS 2000; 48:1373- 1380 Hospitalization Rates II

33. 33Flanders, Personal Communication, 2004 Hospitalization Rates III

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35. 35Wieland, JAGS 2000; 48:1373- 1380 Length of Stay

36. 36 Nursing Home Placement

37. 37.Begin to think in terms of People vs. Sentinel Events. Abandon the assumption that more is better. Understand that not all aspects of care are clinically based, some require simple creativity. Embrace the importance of a consistent care delivery system over time. Challenge for Providers

38. 38 CAREGIVERS: PARENTS *Parents provide their IDD adult children with a home throughout their life course *Parents age *Parents become sick, disabled, and need care *Parents die

39. 39 www.NPAonline.org Core Resources Set for PACE (CRSP) (copyright NPA) –Core operational program components (i.e. policies, procedures and model materials) –Model PACE provider applications Financial Planning Tools (copyright NPA) –Case studies of successful sites –Baseline Scenario –Financial Proforma and Users Guide –Business Planning Checklist Exploring PACE Membership Category Resources for States National PACE Association Resources

40. 40 Fredrick T. Sherman MD, MSc. Chief Medical Officer for Community and Managed Care Services Archcarefsherman@archcare.org Clinical Professor of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai