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PProgram of rogram of AAll Inclusive ll Inclusive CCare for the are for the EElderly: Adapting to the IDD lderly: Adapting to the IDD

populationpopulation

Fredrick T. Sherman MD, MScFredrick T. Sherman MD, MScChief Medical Officer for Community and Managed Care ServicesChief Medical Officer for Community and Managed Care Services

Medical Director, Archcare Senior Life(PACE)Medical Director, Archcare Senior Life(PACE)ArchcareArchcare

Clinical Professor of Geriatrics and Palliative MedicineClinical Professor of Geriatrics and Palliative Medicine

Icahn School of Medicine at Mount SinaiIcahn School of Medicine at Mount Sinai

www.archcare.org

www.NPAonline.org

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PRIMARY CARE OF OLDER ADULTS WITH MULTIPLE CHRONIC CONDITIONS

• * NOT COMPREHENSIVE

• * NOT EVIDENCE-BASED

• * NOT INTEGRATED

• * NOT EFFICIENT

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PProgramrogram ofof AAllll InclusiveInclusive CCareare for thefor the EElderlylderly

An integrated system of care for the frail elderly that is:

• Community-based• Comprehensive• Coordinated• Continuous• Capitated

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The PACE ModelWho 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

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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

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Milestones in the PACE Model History

Waivers/Full Risk

1983

OngoingWaivers

1985

First Center

1973 1978

Demo. Project

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First Demonstration

Sites Operational

1986

Legislation Authorizing

PACE Demonstration

1990 1997

Congress AuthorizesPermanent 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

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Final PACE Rule

(Oct) 2002

Publication of 2nd Interim Final PACE Regulation enhancing opportunities for program flexibility

November 2006

Milestones in the PACE Model History

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PACE Programs Around the Nation

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National Census Growth 1996 – 2012

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PACE is Small in Scale

Each PACE center and IDT can serve up to about 200 enrollees.

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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

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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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What are health issues over past decade in aging ID populationsPersons 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

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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

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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

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The PACE ModelPhilosophy

Honors what frail elders want

• To stay in familiar surroundings

• To maintain autonomy

• To maintain a maximum level of physical, social, and cognitive function

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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

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Integrated Service Delivery and Team Managed Care

Interdisciplinary TeamsSocial Services

Home CarePharmacy

Nutrition

OT/PT

Primary Care Provider

Transportation

Nursing

Activities

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Integrated, Team Integrated, Team Managed CareManaged 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

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• 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)

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PACE Provides Transportation

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PACE Provides PT & OT

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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

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Capitated, Pooled Financing

• Integration of Medicare, Medicaid and private pay payments

• Medicare capitation rate adjusted for the frailty of the PACE enrollees

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Revenue Sources 2012Revenue Sources 2012

MEDICARE $3,087 pmpm 39%

MEDICAID $4,496 pmpm

57%

Monthly Capitation

PRIVATE PAY $274 pmpm 4%

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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

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PACE Costs Jan – Dec 2012

31Wieland, JAGS 2000; 48:1373-1380

Hospitalization Rates I

20%

43%

16%

0%

10%

20%

30%

40%

50%

% Hospitalized/Year

All Medicare

Medicare 55+ with 3ADL deficitsPACE

32Wieland, JAGS 2000; 48:1373-1380

Hospitalization Rates II

2

14

2

0

2

4

6

8

10

12

14

Hospital Days/Year

All Medicare

Medicare 55+ with 3ADL deficitsPACE

33Flanders, Personal Communication, 2004

Hospitalization Rates III

6.9

2.6

0

1

2

3

4

5

6

7

8

Hospital Days/Year

Massachusetts Dually EligibleCommunity LTCUpham's ElderService Plan

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35Wieland, JAGS 2000; 48:1373-1380

Length of Stay

6.6

4.1

0

1

2

3

4

5

6

7

8

Average Length of Stay (Days)

All MedicarePACE

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Nursing Home Placement

100.0%

10.0%

0%10%20%30%40%50%60%70%80%90%

100%

NH CertifiedNH Placement

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• 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 ProvidersChallenge for Providers

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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

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• 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

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Fredrick T. Sherman MD, MSc.Fredrick T. Sherman MD, MSc.Chief Medical Officer Chief Medical Officer

for Community and Managed for Community and Managed Care ServicesCare Services

ArchcareArchcarefsherman@archcare.orgfsherman@archcare.org

Clinical Professor of Geriatrics Clinical Professor of Geriatrics and Palliative Medicineand Palliative Medicine

Icahn School of Medicine at Icahn School of Medicine at Mount Sinai Mount Sinai