An Introduction to PACE Julie Erdmann Community Care Milwaukee, Wisconsin

An Introduction to PACE

Julie Erdmann

Community CareMilwaukee, Wisconsinwww.communitycareinc.org

The times they are a changin’ (Bob Dylan)

• 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…

P A ECrogram ll-inclusivefor

lderlyaretheof

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 WorkerHome 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 FinancialIncentives

• 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 FinancialIncentives

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

Medicare Medicaid Private/3rd Party

Part A Part B Part D Card Svcs HCBS Nursing 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

Wieland, JAGS 2000; 48:1373-1380

Hospitalization Rates

16%

43%

20%

0%

10%

20%

30%

40%

50%

All Medicare

Medicare 55+ with 3ADL deficits

PACE

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 Care1555 S. Layton Blvd.Milwaukee, WI 53215

www.communitycareinc.org

Julie ErdmannJulie.Erdmann@commmunitycareinc.org

(414) 902-2460

Siouxland PACE Sioux City, IA

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 Statistics13 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 PerspectiveAmy Callaghan, DO, FACOIMedical DirectorSiouxland 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