PACE 2.0: Adapting and Disseminating PACE to Serve

High Need, High Cost Populations

Principal Investigator: Peter FitzgeraldExecutive Vice President, Policy and Strategy

National PACE Association675 North Washington Street, Suite 300

Alexandria, Virginia 22314peterf@npaonline.org

(703) 535-1519

Proposed Start Date: August 1, 2017Proposed End Date: July 31, 2019

Project Duration: 24 months

1 | P a g e

PACE 2.0: Adapting and Disseminating PACE to Serve

High Need, High Cost Populations

Table of Contents

Section Title Page

Executive Summary 3

1. Introduction 5 PACE Overview 5 High Need, High Cost Adults 6 Proposed Funding Partners 6 Evidence Basis 7

2. Project Need and Opportunity 8 PACE Pilots 10 Operational Flexibilities 11 State Interest 11 Prospective Provider Interest 11

3. Project Approach 124. Project Plan 12

Project Tasks 12 Project Team 16 Project Data Sources 17 Project Timeline 17 Project Deliverables 19 Coordination with Related Projects 20 Analysis of Potential Risks and Mitigation Strategies 20

5. Project Evaluation 216. Leverage and Sustainability 227. Communications and Dissemination 238. Organizational Background 239. Project Leadership 2410.Budget 2611.Budget Justification 27

List of Attachments 28

List of Appendices 28

4/17/2017 2 | P a g e

PACE 2.0: Adapting and Disseminating PACE to Serve High Need, High Cost Populations

Executive Summary

The Program of All-Inclusive Care for the Elderly (PACE) serves one of the health care delivery system’s most challenging high need, high cost populations – low income, frail, older adults. PACE provides these older adults with an age friendly health system that supports their ability to live at home, have their care needs met, and enjoy a high quality of life. Recent enactment of the PACE Innovation Act allows for PACE to serve a wider range of high need, high cost adults through one or more pilots. For example, in addition to low income, frail, older adults, PACE could serve people with physical, intellectual or developmental disabilities, severe and persistent mental illness, or end stage renal disease. While the legislation authorized payments to PACE pilot organizations for service delivery, it did not fund the development of PACE model adaptations for new populations or dissemination strategies related to these new opportunities. The development of these adaptations and strategies, combined with increased operational flexibility proposed by federal regulators, is required to set the stage for an exponential, rather than linear, rate of PACE growth.

With the goal of supporting PACE’s exponential growth from 40,000 to 200,000 individuals, the PACE 2.0 project sets forth a plan for adapted PACE models to serve a wider range of adults with high needs and high costs, inclusive of but not limited to PACE’s current focus population of low income, frail older adults. PACE is a comprehensive, community-based care model that integrates preventive, primary and acute care with services and supports across the full range of care settings, including at home. As care providers, PACE organizations bring access and expertise to meeting the needs of the high need, high cost older adults they serve. Further, the direct care relationship that PACE interdisciplinary team members have with the people they serve results in person centered, timely and effective needs assessment, care planning and care delivery. The strong evidence basis for the quality and cost-effectiveness of the PACE care model supports the value of extending PACE to a greater number of frail older adults and a wider range of high need, high cost populations.

Extending PACE 2.0 services will require adapting the care model’s essential strengths to (1) meet the unique needs of different high need, high cost subpopulations and (2) support accelerated growth and access. The PACE 2.0 project provides the foundation for achieving these goals. The project will estimate by high need, high cost subpopulation the number of people an adapted and more broadly disseminated PACE 2.0 model could serve. Using this estimate, the project will develop dissemination strategies for achieving exponential growth in PACE 2.0 services across a range of

4/17/2017 3 | P a g e

scenarios. These scenarios will consider (1) the scope and type of high need, high cost subpopulations served (2) the PACE model adaptations required, (3) competing programs and services and (4) the impact of current and potential state and federal policy constraints.

Across the range of scenarios, the project will develop both a scale and spread strategy for achieving broader PACE 2.0 dissemination. In large population areas, the scale strategy looks to establish PACE 2.0 organizations that serve a high number of people. For smaller population areas, the spread strategy looks to establish a larger number of PACE 2.0 organizations serving significantly more communities than currently served. A modified spread strategy that addresses rural areas will also be specified. To propel PACE 2.0 growth under these strategies, the project will communicate its findings and share its resources with current or prospective providers; state and federal policy makers; and potential partners interested in contracting for PACE 2.0 services.

4/17/2017 4 | P a g e

PACE 2.0: Adapting and Disseminating PACE to Serve High Need, High Cost Populations

1. Introduction

PACE Overview

The Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive, community-based care model serving primarily low income, frail older adults. PACE provides these older adults with an age friendly health system that supports their ability to live at home, have their care needs met, and enjoy a high quality of life. PACE integrates preventive, primary and acute care with support services, such as assistance with eating and dressing, across the full range of care settings, including at home. PACE operates and provides many of these services directly, while contracting for other services, such as hospitalization or specialist care. Primary care, rehabilitative care, social activities and meals are provided at a PACE Center. In a person’s home, PACE organizations provide personal care assistance and skilled nursing. Transportation to the PACE Center, medical appointments and community activities is also provided by PACE.

Through these directly operated services, PACE organizations bring access and expertise to their communities’ health care delivery systems for high need, high cost older adults. Further, the direct care relationship that PACE interdisciplinary team members have with the people they serve results in care needs assessment, planning and delivery that is person centered, timely and effective. PACE’s comprehensive care model is fully responsible for meeting all of an individual’s care needs. As a result, PACE organizations are incentivized and empowered to address care delivery holistically.

PACE is a covered Medicare benefit and offered as an optional Medicaid benefit in 31 states. For low income, frail elders these programs pay the PACE organization a set monthly amount to provide all required care. Each PACE program has a defined service area within which a person wishing to receive services from the program must reside. There are 122 PACE organizations serving approximately 40,000 individuals in 234 communities across 31 states. Ninety-percent of these individuals are low-income older adults, who are eligible for both Medicare and Medicaid.

The recent enactment of the PACE Innovation Act (PIA) allows for PACE to serve a wider range of high need, high cost adults through one or more pilots. For example, in addition to low income, frail, older adults, PACE could serve people with physical, intellectual or developmental disabilities, severe and persistent mental illness, or end stage renal disease. The Department of Health and Human Services has released a

5 | P a g e

request for information related to implementation of the pilots and is moving forward with their implementation.

High Need, High Cost Adults

Twelve-million adults living in the community are estimated to have high needs, defined as three or more chronic diseases and a functional limitation in their ability to care for themselves (such as bathing or dressing) or perform routine daily tasks (such as shopping or preparing food). More than half of these individuals are older adults (age 65 plus) and low income. High need, high cost adults are more than twice as likely to report their health as fair or poor than other adults with only chronic care needs. Reflecting their high utilization of health care services, including emergency rooms, physician visits and home care, the cost of health care services and prescription medicines for these adults is nearly three times the cost for adults with multiple chronic diseases only, and more than four times the average for all U.S. adults. Within the high need, high cost population, there is considerable variation in use and spending. This suggests that finding solutions for the broader high need, high cost population will benefit from recognizing subpopulations with common needs and health challenges.1

Proposed Funding Partners

The proposed project represents a partnership of The John A. Hartford Foundation, and West Health to support a shared vision of a better health care delivery system for adults with high needs and high costs. By supporting the adaptation and expansion of a successful, evidence-based care model, the PACE 2.0 project addresses the following aligned priorities of the proposed funders:

The John A. Hartford Foundation: As one of its priority areas, The John A. Hartford Foundation seeks to promote a more age-friendly health system through the development of large scale health system transformations, the dissemination of evidence-based models of care, and connecting hospitals and clinics to community based services and supports.

West Health: West Health’s mission is to enable seniors to successfully age in place, with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life and independence.

The project continues prior and ongoing investments in the development and dissemination of PACE by the proposed funding partners. These investments include (in chronological order):

1 S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care—A Population-Based Comparison of Demographics, Health Care Use, and Expenditures, The Commonwealth Fund, August 2016.

4/17/2017 6 | P a g e

PACE Expansion Initiative – funded by the John A. Hartford Foundation, this initiative provided outreach and technical assistance to support the start-up of new PACE organizations.

Accelerating State Access to PACE (ASAP) – funded by the John A. Hartford Foundation, ASAP provided planning and technical support to state agencies with policy and oversight responsibility for PACE.

Rural PACE Technical Assistance Program – Funded by the John A. Hartford Foundation, this technical assistance program supported the adaptation and spread of PACE to rural service areas.

100th PACE Program Milestone Congressional Briefing – the John A. Hartford Foundation provided support to recognize the 100th PACE program milestone as an opportunity to update federal policy makers regarding PACE.

Development of the High Need, High Cost Playbook, Version 2 – jointly funded by the Commonwealth Fund, the John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, and the SCAN Foundation, this resource highlights models, including PACE, that excel in serving high need, high cost individuals.

Successful Aging – Since 2015, West Health has funded a range of services including geriatric emergency room care, home care transportation, meals and activities to promote successful aging.

In addition to the two proposed funders, the Commonwealth Fund has invited a proposal to support the project’s work. The proposal to the Commonwealth Fund will augment the project’s population data analysis tasks described in this proposal and support new tasks related to the development of research papers and issues briefs addressing the policy implications of the project. This supplemental funding from the Commonwealth Fund, if received, would provide approximately $350,000 to support these expanded and new tasks of the project.

Evidence-Basis for Proposed Project

The PACE 2.0 project approach relies on evidence that supports the PACE care model’s effectiveness, adaptability to new high need, high cost populations, and ability to achieve more widespread access. There is strong evidence to support each of these prerequisites for PACE’s dissemination.

Care Model Effectiveness

The more than 20-year history of PACE provides a sustained and consistent assessment of its care model’s effectiveness. This evidence shows that the PACE care model possesses the necessary attributes for serving high need, high cost individuals, allowing it to achieve a high quality of care that supports a high quality of life. For a

4/17/2017 7 | P a g e

review of research related to the PACE care model’s effectiveness please see Attachment 1.

Care Model Adaptability

While adhering to a set of fundamental care model design elements, PACE organizations have demonstrated the ability of the model to be flexible. PACE organizations are using operational variations to provide care and increase capacity. Similarly, PACE organizations are serving a range of high need, high cost individuals, including people with behavioral health needs, physical disabilities and end stage renal disease. Attachment 2 presents an overview of the PACE care model variations used by PACE and the range of needs they are addressing.

Capacity for Growth

Evidence also indicates that the PACE model of care can be scaled to serve more people and spread to provide access in more communities. Though to date the rate of growth has not been sufficient to achieve a high level of access for high need, high cost populations, recent increases in the rate of growth, along with programs that have achieved larger scale and states that have achieved broader access, support the PACE care model’s capacity for growth. For a summary of PACE growth experience please see Attachment 3.

2. Project Need and Opportunity

The proposed project comes at a time of significant need and opportunity for PACE – with the number of people who have high needs and high costs growing, increasing recognition of the health care delivery system’s failure to serve them effectively, and heightened interest by state and federal policy makers in integrated, capitated care models that can serve their most challenging and costly subpopulations. PACE’s sustained growth over a 20-year period, and the recent acceleration of that growth, support its potential to be more broadly and rapidly disseminated. However, if PACE is to make a significant impact on the estimated 12 million high need, high cost adults it will need to achieve exponential, rather than linear, growth moving forward.

To date, PACE growth has been challenged by:

Limitations on the type of people it can serve - PACE’s service population is narrowly defined as people who need a nursing home level of care, preventing PACE from reaching people at earlier stages who need support to manage complex, chronic illness and functional limitations.

Time and investment required to establish or expand service delivery capacity - PACE capacity has been reliant on the PACE program’s own setting of care, the

4/17/2017 8 | P a g e

PACE Center, and staff to meet the care needs of the people it serves. This requires significant lead time and expense to initiate or expand services.

Inconsistent support by state and federal programs - Federal and state policies seeking to enroll large numbers of Medicare and Medicaid beneficiaries in managed care have focused on insurers with broad networks to achieve their goals. This focus has drawn resources away from PACE expansion.

Health care providers’ reluctance to assume financial risk – Health care providers who might initiate PACE development have been wary of the financial risk that comes with the program’s capitated payments, scope of benefits, and complex service population.

While these factors have limited PACE growth, new opportunities are now available for PACE to address the challenges they pose:

Expanded service populations - Congress’ enactment of the PACE Innovation Act authorized PACE pilots to serve an expanded range of populations, with the operational and payment flexibility needed to adapt the model to their needs.

Options for increasing service capacity - proposed updates to the PACE program’s federal regulations will increase the ability to integrate community resources into the PACE care model’s delivery system. This will allow PACE organizations to extend their capacity beyond their own care setting and staff.

Federal and state policy interest – there is heightened interest from the Medicare and Medicaid programs in serving high need, high cost individuals through provider-based solutions. With recent experience showing the significant challenges insurance-based managed care organizations face in serving this population, PACE’s capitated model is being looked to as a solution.

Health Provider Interest - with state Medicaid programs’ diminishment of their fee for service programs, the same health care providers who historically avoided financial risk are now seeking it as a strategy that enables them to be positioned for direct payment, rather than operate as a contracted network provider to a managed care organization.

The proposed project meets these new opportunities with a new approach for expanding access to PACE. Rather than seek incremental growth through a static PACE model, the proposed project seeks exponential growth through a dynamic model that is adapted to serve a broader range of needs with the tools for expanded capacity. Defining a path for a five-fold growth in the number of individuals who are served by PACE is the aim of the proposed PACE 2.0 project. This equates to a dissemination plan that would identify 200,000 people who would benefit from and have access to PACE 2.0. The following sections address the new opportunities supporting PACE’s exponential growth in more detail.

4/17/2017 9 | P a g e

PACE Pilots

In November, 2015 Congress passed the PACE Innovation Act creating the authority to develop PACE pilots serving new populations, with increased operational flexibility and innovative payment systems. The pilots will enable current and new PACE organizations to receive payments for services delivered to a broader range of high need, high cost individuals; however, the PACE Innovation Act did not fund the development of model adaptations for new populations or dissemination strategies related to these new opportunities. The proposed project addresses these gaps by setting the stage for new and expanding PACE organizations to participate in the pilots.

In December, 2016, CMS released its first request for information regarding implementation of the PACE pilots. This request provided significant detail on the design of a PACE pilot for people with physical disabilities, while also inviting comments regarding additional high need, high cost subpopulations including, but not limited to:

Older individuals with Medicare (with and without Medicaid) who do not require nursing home level of care, but require additional non-medical supports to remain in the community

Individuals with Medicare (including individuals under age 55, with and without Medicaid) who have End Stage Renal Disease and who are receiving dialysis treatment

Individuals with Medicare and/or Medicaid (including individuals under age 55) who have severe and persistent mental illness

Individuals with Medicare and/or Medicaid who have intellectual or developmental disabilities (including individuals under age 55)

Individuals with Medicare (with and without Medicaid) who receive support for community living through U.S. Department of Veterans Affairs programs (including individuals under age 55);

Individuals with Medicare and/or Medicaid, including individuals in the categories described above, living in rural communities

The response to the Request for Information (RFI) regarding the pilots indicates a high level of interest in adapting PACE to serve new populations. Beyond the initial pilot for people with physical disabilities that was presented in the RFI, there were high levels of interest in pilots for individuals with complex medical needs and functional limitations, intellectual and developmental disabilities, severe and persistent mental illness and end-stage renal disease.

At the National PACE Association’s recent Spring Policy Forum, Patrick Conway, M.D., who serves as the Deputy Administrator for Innovation & Quality and CMS’ Chief Medical Officer stated his agency’s commitment to moving forward with the PACE

4/17/2017 10 | P a g e

pilots. This commitment was repeated by Tim Engelhardt, Director of the Federal Coordinated Health Care Office which will be responsible for implementing the pilots. While the timeline for initiation of the PACE pilots is still subject to change, Mr. Engelhardt indicated that information about proposed payments for the pilots would be available in the fall of 2017 followed by a CMS request for proposals from prospective PACE pilot organizations in the spring of 2018.

Operational Flexibility

In addition to the pilots, more operational flexibility for the permanent PACE program was supported in a recently issued notice of proposed rulemaking that would update the federal PACE regulation. This update, if finalized to be consistent with the notice’s draft, would give PACE organizations more flexibility to work with community-based physicians, adult day care centers, and other community settings. The update would also allow PACE organizations more flexibility to tailor their interdisciplinary teams to the needs of each individual PACE participant.

State Interest

Concurrently at the state level, Medicaid programs continue to seek solutions to control costs while meeting the needs of their high need, high cost populations. PACE exists today as an option that 31 state Medicaid programs have actively elected to provide (rather than a mandatory benefit), and its capitated (per person, per month) payment model is aligned with the shift by many states to managed care for Medicaid benefits. While offering Medicaid programs the same advantages of predictable, capitated expenditures, PACE also offers Medicaid beneficiaries a provider-based alternative to enrollment in an insurance-based health plan. As a result, notwithstanding the broader funding challenges state Medicaid programs may face, PACE is well positioned to increase its role in helping states care for high need, high cost populations. Confirming the high level of interest in PACE, a 2015 survey of states by the National Association of State Units on Aging and Disability found that expansion of PACE was planned or under consideration in 24 states.2

Prospective Provider Interest

As state and federal payers shift funding away from fee for service payments, health care providers are increasingly looking for effective care models that allow them to manage the financial risk of caring for a complex population. PACE offers a proven provider-based model that allows other providers to retain their role in direct care delivery, rather than shifting towards an insurer-based, network care delivery model. As a result, the response to new opportunities for growing PACE is expected to be broader in terms of the types of providers, inclusive of institutional and community-based long 2 State of the States in Aging and Disability, 2015 Survey of State Agencies, NASUAD

4/17/2017 11 | P a g e

term care providers, health systems, hospice organizations, and community health centers. This will create opportunities for new PACE organizations to serve additional communities.

3. Project Approach

With the goal of achieving a five-fold exponential growth in the number of high need, high cost individuals served by PACE, from 40,000 to 200,000, the project approach is data-driven with a recognition of the internal (PACE care model fit for new populations, operational requirements) and external (state and federal policy, market competition) constraints on achieving growth. Because of the uncertainty related to these constraints, the project’s population estimates and projections are developed across a range of scenarios.

The care model constraints reflect the need to retain features of the PACE care model that are essential to its success while developing new, adapted models designed to address high need, high cost subpopulations. The project will examine the natural experiment occurring in PACE organizations that have implemented care model variations (e.g. integrating community based physicians into the PACE delivery system) to assess what impact these variations have on the effectiveness of the program and on its capacity for growth. The results of this assessment will be used to determine what care model constraints should be applied in the PACE 2.0 service population projections.

To support the use of the projected impact estimates by states and providers seeking dissemination of PACE, these estimates will be reported at the state and service area level. Further support is provided by the project’s consideration of the work force requirements for exponential growth and the quality standards needed to monitor the performance of PACE 2.0 as it grows.

4. Project Plan

The PACE 2.0 project sets forth a plan for disseminating PACE to an exponentially higher number of high need, high cost individuals, inclusive of the frail, older adults PACE currently serves and the new subpopulations it would be able to serve under recently authorized PACE pilots.

Project Tasks

1. Estimate the PACE 2.0 High Need, High Cost Population – estimate the number of people PACE 2.0 would serve by high need, high cost subpopulation across a range of scenarios.

4/17/2017 12 | P a g e

a. Population and Subpopulation Estimates - Estimate the potential high need, high cost population and subpopulations that PACE could serve at the national, state and service area level. This estimate will be developed using Medicare and Medicaid claims, Census and the Medical Expenditures Panel survey (MEPS) data to identify by age, diagnoses and functional limitations the number of people a PACE 2.0 program could serve.

b. PACE Model Variations Assessment - To identify the high need, high cost subpopulations for which the PACE model could be most effectively adapted, the project will assess current PACE organizations’ experience with variations in the standard PACE care model. These variations could include integration of community services (e.g. primary care providers, adult day care, centers for independent living, collocated services with housing), telehealth, and consumer-directed personal care. Using survey data describing PACE organization’s care model variations, the program will consider the impact of these variations on performance. Performance measures will include outcomes, utilization, and cost drawn for data sets collected by the National PACE Association from PACE organizations. To supplement the quantitative analysis, the project will collect qualitative information. The qualitative information collected will describe the features that differentiate PACE operations and include case studies of PACE organizations that have implemented care model innovations to support growth and better serve their enrollees. Utilizing the quantitative and qualitative information collected, the model variations assessment will address the variations’ expected impact on serving people with different needs and on increasing access to the PACE program’s services,

c. Growth Constraints Model - Develop a growth constraint model reflecting: (1) the potential for adapted PACE care models to meet the needs of distinct high need, high cost subpopulations based on the findings of the PACE Model Variations Assessment (b. above), (2) a competitive market analysis of alternative programs and services, and (3) PACE market penetration experience to date. The competitive market analysis will consider state Medicaid and federal Medicare support for other programs serving high need, high cost individuals as well as the operational presence of these programs in specific states and service areas. The PACE market penetration experience to date will use PACE enrollment, geographic service area and Census data to estimate the percent of people eligible for PACE who are actually enrolled in the program.

d. State and Federal Policy Scenarios - Specify state and federal policy scenarios for the range of high need, high cost subpopulations PACE could serve, level of operational flexibility to support innovation, and

4/17/2017 13 | P a g e

opportunities to develop new or expand existing PACE organizations. Please see Attachment 4 for a table of these scenarios. These scenarios will be developed in consultation with state and federal policy makers and will consider the impact that payment and regulatory policies could have on PACE dissemination. For example, the scenarios could consider the need for alternative Medicare or Medicaid payment rates for new populations, or, the application of home and community based settings regulations to PACE.

e. PACE 2.0 Service Population Projections - Based on the population and subpopulation estimates (a. above) and the application of the growth constraints models (c. above), develop national, state and service area level projections of the number of people expected to receive services across a range of state and federal policy scenarios (d. above).

2. Scale and Spread Strategies for Achieving Exponential Growth - Develop combined scale and spread strategies to achieve a five-fold increase in PACE services (from 40,000 to 200,000 people) for each of the specified scenarios.

a. Scale Strategy - the scale strategy will identify current or new PACE organizations in large population areas that could serve significantly more people (1,000 or more) than the current average of PACE organizations (325 people). Service areas for these large scale PACE organizations will be determined based on experience to date (i.e. where are PACE organizations serving 1,000 people or more) and the size of the potential service populations by service area as determined by project task 1, above.

b. Spread Strategy - the spread strategy identifies PACE organizations that could be developed in significantly more communities than currently served (234 communities). A distinct spread strategy for rural areas will also be developed to promote broad access to PACE. For example, rural PACE organizations may seek more flexibility to use mobile health clinics, telehealth and a wider range of community-based care settings to serve their larger, and less populated, service areas. The identification of spread service areas will be determined by the number of PACE organizations needed to achieve broad geographic access across a state, and, the size of the potential service populations by service area as determined by project task 1, above.

c. PACE Provider Growth Planning – To support the implementation of the spread and scale strategies by current and prospective PACE organizations, the project will produce an actionable guide for current and

4/17/2017 14 | P a g e

future PACE organizations to plan for growth, prioritize operational research, and assess service area opportunities. This guide will indicate how the information generated by the project can be applied to analyzing and prioritizing growth opportunities.

d. Workforce Considerations - Mindful of the health care work force challenges associated with rapid growth, develop a white paper addressing challenges and potential solutions. The white paper will be developed based on staffing ratios for supporting the PACE care delivery system, supported by access to staffing data collected by the National PACE organization from its members. The white paper will consider health care workforce projections and the impact of the health care workforce on PACE’s capacity for growth.

e. Quality Standards and Assurance Considerations – To address the impact that care model variations and rapid growth may have on PACE quality, develop a white paper with recommendations for establishing quality standards and a process for assuring PACE sustains its current level of performance. The white paper will draw on quality measures under development specifically for the current PACE program by the federal government, National Quality Forum measures for related populations (e.g. dual eligible), and quality measures used by PACE organizations for quality improvement and assurance activities.

3. Outreach - To promote implementation of the spread and scale strategies, provide data analysis results, reports and resources to PACE 2.0 stakeholders including:

State Policy Makers Federal Policy Makers Provider Organizations Potential Private Payers for PACE 2.0 Consumer Organizations

The project will accomplish this outreach through the National PACE Association’s communications resources including its website, meetings and visual learning resources. Additionally, the project will work with organizations representing consumers, policy makers, and providers to disseminate the project’s findings and resources. Dissemination activities will include presentations at conferences, articles for newsletters, and cohosted webinars.

Project Team

4/17/2017 15 | P a g e

The PACE 2.0 project team will bring together researchers, operating PACE organizations, policy experts, and consultants with experience in spreading and scaling effective models to define a dissemination plan for serving people with high needs and high costs. An Advisory Committee will guide and inform the project’s overall design and implementation.

The project’s external research partner will estimate the potential population and subpopulations at the national, state and service area level for PACE 2.0. This research partner will have access to Census, Medicare and Medicaid claims, and Medical Expenditure Panel Survey (MEPS) data. To assure the independence of the estimates, the external research partner’s research design and analysis will be guided by project officers from the funders. The project’s principal investigator will work with the external research partner and funders’ project officers to assure that the growth constraints model (see below) can be applied to the population and subpopulation estimates generated.

For the growth constraints model, the project will work with a health services research consultant to (1) assess PACE experience to date with care model variations and (2) complete a market assessment of alternative programs and services. The care model variations assessment will inform consideration of PACE 2.0’s fit for distinct high need, high cost subpopulations and capacity for growth. In addition to documenting existing model variations, the care model variations assessment will identify potential additional care model adaptations needed to serve more diverse populations. For example:

People with End Stage Renal Disease - if PACE 2.0 organizations can have a greater impact on people with end stage renal disease, can the PACE organization provide outpatient dialysis as part of the PACE center’s services.

Accessing Specialist Care – can PACE organizations make greater use, particularly in rural areas, of telemedicine to help participants access specialist care?

Other growth constraint model factors of PACE market penetration experience and operational requirements will be developed by the project staff with the support of its subcontractor with expertise in exponential dissemination of successful service models.

In collaboration with the project’s population estimate and exponential dissemination partners, the project’s health services research partner will apply the growth constraints model to the population and subpopulation estimates. This analysis will be conducted across a range of federal and state policy scenarios, developed by project staff in consultation with state and federal policy experts. The resulting projections for high need, high cost people who could be served by PACE will be used by the project’s exponential dissemination subcontractor to specify a dissemination plan. This

4/17/2017 16 | P a g e

dissemination plan will consider the combination of three strategies for disseminating PACE 2.0: scaling PACE, spreading PACE, and delivering PACE in rural areas.

For a detailed description of project staff, consultants and subcontractors please see Attachment 5.

The project’s work will be guided at key stages in its development by an Advisory Committee formed by West Health. This Advisory Committee’s membership, including Mark McClellan, Jennie Chin Hansen and Melanie Bella, consists of leaders in Medicare policy, Medicaid policy, health delivery systems, and high need, high cost subpopulations. Expenses, including honoraria, travel and meetings, associated with convening the Advisory Committee to support the PACE 2.0 project will be incurred directly by West Health, and are therefore not included in the proposed PACE 2.0 budget.

Project Data Sources

The project will use a range of data sources for its population and subpopulation estimates, analysis of PACE care model variations, and development of its growth constraints model. For the population and subpopulation estimates, these sources include Census, Medicare and Medicaid claims, and Medical Expenditure Panel Survey data. For the assessment of PACE care model variations, the data sources include DataPACE2, PACE Financial Benchmarking Data, PACE Audit Experience Data and survey data collected by the National PACE Association. For a full description of the project’s data sources, please see Attachment 6.

Project Timeline

The proposed project would begin on August 1, 2017 and continue for 24 months through July 31, 2019. After completion of a project plan review and kick-off, the project timeline is organized based on the sequential nature of its data analysis plan, followed by specification of a combined scale and spread strategy, with subsequent stakeholder outreach to promote the strategy’s implementation. Completion of the initial population and subpopulation estimates is designed to coincide with the potential announcement in spring, 2018 of the PACE pilot opportunity. These estimates will be used to quantify the potential impact of the pilots and support prospective PACE pilot organizations’ planning. The announcement of the PACE pilots also informs the project’s development of policy scenarios for PACE dissemination. The project’s scale and spread strategies will incorporate the PACE pilot opportunities into the specification of dissemination plans, across the range of identified policy scenarios, for achieving exponential PACE growth. The timeline below provides additional information on the steps to be completed. The project task identifiers in the timeline refer to the project plan outlined in Section 4 of the proposal (above).

4/17/2017 17 | P a g e

August - October, 2017

Review project plan with funders Establish Project Staff Team Subcontract with External Research Partner Outreach to and Selection of Potential Advisory Committee Members Convening of Advisory Committee

November, 2017 – January, 2018

Begin Project Task 1a: High Need, High Cost Population and Subpopulation Estimates – review of data sources, development of analysis design

Contract with Policy, Quality, and Workforce Consultants Subcontract with Exponential Dissemination organization

February – April, 2018

Ongoing Project Task 1a: Estimate the PACE 2.0 Potential Service Population – review of data analysis results, initial draft of national and state level results

Begin Project Task 1b: PACE Model Variations Assessment – Identify data sources; develop analysis plan; select case study sites

Begin and Complete Project Task 1d: Identify range of state and federal policy scenarios related to populations and service areas that could be served by PACE 2.0

May - July, 2018

Complete Project Tasks 1a and 1b Begin and Complete Project Task 1c – develop the growth constraints model,

including competitive market assessment.

August – October, 2018

Begin Project Task 1e – apply growth constraints model to potential service population estimates for each identified state and federal policy scenario

Begin Project Tasks 2d and e – define scope of Workforce and Quality considerations and preliminary research reviews.

Convene Advisory GroupNovember, 2018 – January, 2019

Complete Project Task 1e – report projected impact population results, by scenario, at the national, state and service area

4/17/2017 18 | P a g e

Begin Project Tasks 2a and b: Develop the PACE 2.0 scale and spread strategies, by scenario

Ongoing Project Tasks 2d and e – continue research review; draft of Workforce and Quality considerations

Milestone : PACE 2.0 Projected Impact Estimates

February – April, 2019

Complete Project Tasks 2a and b – specify combined scale and spread strategies for achieving exponential growth of PACE 2.0, across the range of scenarios

Begin Project Task 2c – identify components of service population estimates and spread/scale strategies to be applied by PACE organizations for growth planning.

Complete Project Tasks 2d and e – complete research reviews; finalize considerations

Begin Project Task 3: develop targeted outreach plan; conduct outreach to stakeholders: state and federal policy makers, providers and consumers

Begin Project Evaluation – review project measures and data sources for evaluation

Convene Advisory Committee Milestones : PACE 2.0 Dissemination Strategies; White Paper: Workforce

Considerations; White Paper: Quality Considerations

May – July, 2019

Complete Project Task 2c – continue and complete development of provider growth planning guide

Complete Project Task 3 – continue and complete outreach to targeted stakeholder organizations

Project Evaluation – apply project measures to project outcomes Final Project Report Milestones : Project Evaluation Results; Final Project Report

Project Deliverables

The project will produce the following major deliverables:

1. Report: PACE 2.0 Projected Impact Estimates2. Chart Book: PACE 2.0 Projected Impact Estimates by State and Service Area3. Assessment: What Can We Learn from PACE Innovations?4. Growth Plan: Scale and Spread Strategies for PACE 2.05. Provider Action Guide: Prioritizing and Planning for PACE Growth Opportunities

4/17/2017 19 | P a g e

6. Outreach: Policy, Provider, Payer and Consumer Stakeholders

Coordination with Related Projects and Partners

The PACE 2.0 project would benefit from coordination with other projects supporting the dissemination of effective models, working with state and federal policy makers, and developing innovative solutions for high need, high cost adults. For a listing of related projects and partners the proposed project would seek to coordinate with, please see Attachment 7.

Analysis of Potential Risks and Mitigation Strategies

The project relies substantially on access to data that can inform its goal setting and dissemination strategies. Further, to be most valuable the data sources required by the project would be linked at the service area level. To mitigate against the risk of insufficient data for the population and subpopulation estimates, the project will work with an external research partner that has access to and experience with the range of data sources required. These include: Census, Medicare and Medicaid claims, and the Medical Expenditures Panel Survey. To mitigate against the risk of insufficient data for evaluating PACE experience with care model variations, the project will supplement its quantitative analysis with qualitative case studies of PACE organizations using care model variations.

A related risk is that the data available to the project may not be current. The project will mitigate against this risk by using trending factors to update the data and to develop data projections that will prolong the usefulness of the data analysis and findings.

To develop the projected PACE 2.0 impact estimates the project’s analysis will need to account for state and federal policy factors. These factors are very much subject to change and predicting their direction is difficult to do with a high degree of confidence. To mitigate against this risk, the project will use a range of scenarios to allow for different policy developments.

The project also proposes to inform state and federal policy makers of the impact that a disseminated PACE 2.0 model could have. This imposes the risk of competition for the time and attention of these policy makers during a time when many health care policy issues are undergoing change. The project will address this risk by developing and communicating reports that have actionable information for policy makers, providers and consumers. The project will build on the National PACE Association’s existing relationships with federal and state policy makers to highlight the opportunities for improved care presented by PACE 2.0. The project will supplement its own direct outreach to state and federal policy makers with support from providers and consumers. These providers and consumers will be able to draw on the project’s impact estimates,

4/17/2017 20 | P a g e

model adaptations and dissemination strategies to directly communicate their interest in expanding PACE access to policy makers.

5. Project Evaluation

The project will be evaluated using the following measures related to each of its project deliverables:

Deliverable 1: Report - PACE 2.0 Projected Impact Estimates

Measure 1.1: What is the number of people, by high need, high cost subpopulation, at the national and state level, who could be served by a PACE 2.0 model? What is the level of confidence in this estimate?

Measure 1.2: Does the potential service population estimate identify high need, high cost subpopulations with the greatest potential to be served by PACE 2.0? What is the level of confidence in this estimate?

Measure 1.3: Of the people who could be served by PACE 2.0, what is the number of people it is projected to impact, under a range of scenarios incorporating identified growth constraints?

Deliverable 2: Chart Book: PACE 2.0 Projected Impact Estimates by State and Service Area

Measure 2.1: Are population impact estimates able to be reported at the national, state and service area level in a way that guides the development of scale and spread strategies for dissemination?

Measure 2.2: At the different levels of analysis (national, state, service area), what is the level of sensitivity in the projections to varying the assumptions in the range of scenarios?

Deliverable 3: Assessment: What Can We Learn from PACE Innovations?

Measure 3.1: Does the Assessment inform the development of PACE 2.0 care models that can support extending the model to a broader range of high need, high cost subpopulations and the achieving exponential growth?

Measure 3.2: Are the case studies meaningful for PACE dissemination to a broader range of high need, high cost subpopulations?

Deliverable 4: Growth Plan: Scale and Spread Strategies for PACE 2.0

4/17/2017 21 | P a g e

Measure 4.1: Does the Growth Plan provide a path towards achieving exponential, rather than linear, growth in the number of people served by PACE 2.0 i.e. from 40,000 individuals to 200,000 individuals?

Measure 4.2: Is the growth plan clear in how the scale and spread strategies complement each other?

Measure 4.3: Is the rural-specific spread strategy sufficiently adapted to meet the challenges of serving these areas and populations?

Deliverable 5: Provider Action Guide: Prioritizing and Planning for PACE Growth

Measure 5.1: Is the Provider Guide actionable for a current PACE organization to prioritize, plan for and achieve PACE growth?

Measure 5.2: Is the Provider Guide actionable for a prospective PACE organization to prioritize, plan for and achieve PACE growth?

Measure 5.3: Does the Provider Guide address provider opportunities in large, midsize and rural service areas?

Outcome 5: Outreach

Measure 4.1: To what extent are the project’s analyses, results and recommendations about PACE dissemination opportunities communicated to federal and state policy makers?

Measure 4.2: What is the number of provider organizations to whom the PACE 2.0 projected impact population estimates at the service level are distributed, including distribution at individual meetings, conferences and through on-line access?

Measure 4.3: Does the outreach to consumer groups reflect the range of high need, high cost subpopulations the PACE 2.0 models could serve?

7. Leverage and Sustainability

The proposed project brings together funding support from The John A. Hartford Foundation and West Health to leverage the resources of each. The project is also in a position to leverage support from the Commonwealth Fund for an invited proposal that would augment its potential service population analysis and policy outreach goals. In addition, the National PACE Association is providing in-kind staff contributions to the project for the following:

4/17/2017 22 | P a g e

Communications - the in-kind staff contribution will provide for editing, formatting and posting of project materials on the NPA website.

Education - NPA will contribute staff time from its education staff to support presentations of the project’s results and resources at NPA-sponsored forums and webinars.

PACE 2.0 Project Staff - NPA is contributing in-kind to a part of the proposed project’s principal investigator’s and project manager’s time.

NPA will retain intellectual property rights to the project’s deliverables. Notwithstanding its rights to the deliverables, consistent with the proposed outreach plan NPA will seek to share the resources and findings of the project as widely as possible to promote broad and rapid dissemination of PACE 2.0.

8. Communication and Dissemination

NPA will share the information obtained and the materials developed with current and prospective PACE organizations, state agencies and policy makers, and federal policy makers within Congress and the Administration. The communication and dissemination of the project’s resources and findings will be accomplished for a range of stakeholders including:

Current and Prospective PACE Organizations State Policy Makers Federal Policy Makers Provider Organizations Consumer Organizations

For a description of the outreach approaches the project would take to each of these audiences please see Attachment 8.

9. Organizational Background

The National PACE Association (NPA) vision is for the PACE model of care to be recognized as the most innovative, accessible, valuable and effective model of care promoting the highest level of independence for individuals with significant health care needs. To fulfill this vision, NPA provides leadership and support for the growth, innovation, quality and success of the PACE model of care. NPA supports PACE programs through federal and state policy, education, communication, data benchmarking, and analytic activities. In its 20-year history, NPA has led a number of successful campaigns, including the initial pilot and permanent authorization of the PACE program, PACE implementation and expansion to 31 states, authorization of the rural PACE demonstration enabling PACE to serve rural communities, and other

4/17/2017 23 | P a g e

initiatives. In recent years, the association developed a toolkit to help PACE organizations with “Strategies for Incorporating PACE into State Integrated Care Initiatives,” led a “mystery shopper” initiative targeting individual state and local options counseling services to determine their level of PACE awareness, and created a toolkit for PACE organizations seeking to influence state options counseling policies.

The National PACE Association has a dedicated team of individuals who specialize in policy, work closely with members of Congress, senior administration officials and their staff, as well as state policy-makers to advocate on behalf of PACE, educate, and promote a reimbursement and regulatory environment that enables PACE programs to continue to provide high-quality, individualized and innovative care to older Americans.

Under the federal tax code, the National PACE Association is a 501(c)(3) tax-exempt, charitable organization.

10.Project Leadership

Peter Fitzgerald, Principal Investigator - Peter is the Executive Vice President for Policy and Strategy at the National PACE Association, where he guides the association’s policy and advocacy efforts, at the federal and state level, to support its strategic priorities. Before his current position at NPA, Peter served as the Senior Vice President for Integrated Care Strategies at Volunteers of America, where he was responsible for the planning and development of new PACE programs and aging supports nationally. Earlier experiences working with long term care providers and managed care organizations have contributed to his perspective on how PACE and other capitated models can integrate and improve care for high need, high cost individuals. Peter has a Master’s of Science in Health Care Planning and Finance from the London School of Economics and the London School of Hygiene and Tropical Medicine. He earned his Bachelor’s degree in Public Policy from the College of William and Mary.

Sam Kunjukunju, Project Manager - Sam has a Master’s in Business Administration and a Master of Public Health. He has worked in the field of aging since he began his graduate education in 2007. He currently supports NPA’s policy team through policy analysis, developing policy briefs, managing projects, facilitating PACE research, and serving as an internal liaison between data and policy.

Chris van Reenen, PhD, Federal Policy – Chris leads NPA’s federal policy work and serves as a key point of contact with federal regulatory agencies overseeing PACE. Chris has worked on state and federal policy issues for Special Needs Plans as well as PACE. She is an expert on the PACE care model, as well, having worked at On Lok during the model’s conceptual development and with many of the replication sites established during the PACE demonstration.

4/17/2017 24 | P a g e

Liz Parry, State Policy - Liz leads NPA State policy initiatives and provides strategic counsel and technical support to PACE organizations on a range of state policy issues. Prior to her work at NPA, Liz worked for the Children’s Hospital Association to promote state and federal policies that support this high cost, high need population. She has also held policy positions for the American Academy of Nursing and the American Institute for Medical and Biological Engineering. Liz holds a Master of Public Policy degree from George Mason University.

For resumes of the project leadership staff please see Attachment 10.

4/17/2017 25 | P a g e

11.Budget

[this page left blank to insert budget spreadsheet]

4/17/2017 26 | P a g e

12. Budget Narrative

[This page left intentionally blank to insert budget narrative]

4/17/2017 27 | P a g e

13. Attachments1. PACE Care Model Effectiveness2. PACE Care Model Variations3. PACE Growth Experience4. State and Federal Policy Scenarios5. Project Team Description6. Project Data Sources7. Related Projects for Coordination8. Project Outreach Approach

14. Appendices

1. National PACE Association Budget2. Letters of Support3. Project Leadership Resumes4. IRS Determination Letter5. Intellectual Property Rights6. National PACE Association Most Recent Auditor’s Report

4/17/2017 28 | P a g e

Attachments

1. PACE Care Model Effectiveness

2. PACE Care Model Variations

3. PACE Growth Experience

4. State and Federal Policy Scenarios

5. Project Team Description

6. Project Data Sources

7. Related Projects for Coordination

8. Project Outreach Approach

29 | P a g e

Attachment 1: PACE Care Model Effectiveness

The long and consistent evidence-basis for the PACE care model supports its ability to effectively meet the comprehensive care needs of high need, high cost individuals. In the Institute of Medicine report “Retooling for an Aging America,” PACE is recognized as a model of care with the capacity to bring geriatric expertise and care coordination to the needs of older adults.3 A subsequent study in 2010 by Chad Boult and Darryl Wieland highlighted PACE as one of three chronic care models that include processes to improve the effectiveness and efficiency of complex primary care.4 An earlier study found that PACE participants experienced better self-rated health status, fewer unmet needs, and improved health care management than individuals with similar needs receiving services through other programs and services.5 Not surprisingly, the effectiveness of the PACE care model results in reduced hospital admissions and emergency room visits, as evidenced in a number of state-specific (Massachusetts6, New York 7, Wisconsin8) and national studies.9

Better care that avoids unnecessary hospitalizations and emergency room visits extends the life expectancy of people with chronic care and functional support needs. A study of PACE participants in South Carolina found that “PACE participants had a substantial long-term survival advantage compared with aged and disabled waiver clients.”10 This finding is supported by a national study which found that PACE participants had a lower mortality rate than individuals in nursing homes or home and community based services provided by state Medicaid waiver programs.11

Providing effective and timely care helps people live longer, avoid hospitalizations, and experience a higher quality of life with better health outcomes. Moreover, the PACE

3 Retooling for an Aging America: Building the Health Care Workforce, Institute of Medicine, April 11, 2008.4 Boult, C. & Wieland, G.D. (2010). Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through.” JAMA, Vol. 304, No. 17, pp. 1937-19435 Leavitt, M., Secretary of Health and Human Services. (2009). Interim report to Congress. The quality and cost of the Program of All-Inclusive Care for the Elderly6 Division of Health Care Finance and Policy, Executive Office of Elder Affairs. (2005). PACE Evaluation Summary. Accessed on May 25, 2011 at: http://www.mass.gov/Eeohhs2/docs/dhcfp/r/pubs/05/pace_eval.pdf7 Nadash, P. (2004). Two models of managed long-term care: comparing PACE with a Medicaid-only plan. Gerontologist, 44(5), pp. 644-654.8 Kane, R. L.; Homyak, P.; Bershadsky, B; & Flood, S. (2006). Variations on a theme called PACE. Journal of Gerontology Series A, Vol., 61, No. 7, pp. 689-693.9 Micah Segelman; Szydlowski, J.; Kinosian, B.; McNabney, M et al (2014). Hospitalizations in the Program of All-Inclusive Care for the Elderly. Journal of the American Geriatrics Society 62:320–324, 201410 Wieland, D., Boland, R., Baskins, J., and Kinosian, B. (2010). Five-year survival in a Program of All-Inclusive Care for the Elderly compared with alternative institutional and home- and community-based care. J Gerontol A Biol Sci Med Sci. July: 65(7), pp. 721-72611 The Effect of PACE on Costs, Nursing Home Admissions and Mortality: 2006 – 2011 Mathematica Policy Research evaluation prepared for U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy (2014)

4/17/2017 30 | P a g e

care model is achieving these results for less than or the same amount of cost as other programs. In Medicaid, states pay PACE programs on average 16.5% less than the costs of caring for a comparable population through other Medicaid services, including nursing homes and home and community-based waiver programs.12 In Medicare, payments to PACE organizations are equivalent to the costs for a comparable population to receive services through the fee-for-service program.13

12 NPA Analysis of PACE Upper Payment Limits and Capitation Rates, March, 2017.13 The Effect of PACE on Costs, Nursing Home Admissions and Mortality: 2006 – 2011 Mathematica Policy Research evaluation prepared for U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy (2014)

4/17/2017 31 | P a g e

Attachment 2: PACE Care Model Variations

PACE Model is Adaptable to Serve Broader Range of High Need, High Cost Adults

Though the PACE model’s focus population is low income, frail older adults, there is considerable variation in the types of people PACE organizations are serving:

People with Physical Disabilities – PACE enrollees age 55-64 make up the fastest growing segment of its service population. A recent analysis of this age group found that 22% have a diagnosis indicating a physical disability.

People with Behavioral Health Needs – approximately 60% of the current PACE population has a behavioral health need. This increases to nearly 78% among those aged 55-64.

People with End Stage Renal Disease (ESRD) – 851 individuals with ESRD are currently served by PACE. This is two-percent of the total PACE population.

The ability of PACE to serve these subpopulations within its current focus population of low income, frail older adults indicates the model’s ability to be adapted to a broader range of high need, high cost (HNHC) subpopulations.

PACE Model is Adaptable to Support Growth

PACE organizations are ready to innovate and have demonstrated that the care model can be adapted to support growth. As shown in Chart 2 below, the innovations that PACE organizations are currently implementing include:

Community Based Primary Care Providers (CB-PCPs) – PACE organizations are integrating community based primary care providers (CB-PCPs) into the PACE interdisciplinary team to expand access, increase capacity, and maintain longstanding relationships between older adults and their primary care giver

Community Based Activities (CB-Activities) – PACE organizations are integrating community activity locations, including adult day centers and senior centers, into their delivery system

Nurse Practitioners (NPs) – PACE organizations are utilizing nurse practitioners to provide primary care

Behavioral Health – PACE organizations are enhancing behavioral health and substance abuse services and programs for older adults

Veterans – PACE programs are serving Veterans with long term service and support needs

Rural Service Areas – PACE organizations are reaching rural areas to serve older adults.

4/17/2017 32 | P a g e

The range and scope of these innovations provide a natural experiment with the potential to guide care model variations that would support broader application to people with HNHC and more rapid growth. To date, these innovations have occurred through waivers of the current, prescriptive PACE regulations and eligibility requirements. Looking forward, the opportunity to further innovate under revised regulations with more flexibility and through PACE pilots that can serve a broader range of HNHC subpopulations would accelerate the rate of PACE dissemination.

4/17/2017 33 | P a g e

Attachment 3: PACE Growth Experience

Despite the strong evidence supporting PACE, dissemination of its care model is not occurring rapidly enough to meet the increasing needs of HNHC adults. Concept development for the PACE care model was completed in 1986 by On Lok, a program serving older adults in San Francisco. The concept was then tested through a national, Congressionally-authorized demonstration to replicate PACE across 15 communities. In 1997, based on the positive evaluation of the demonstration programs, PACE was permanently authorized as a Medicare benefit and a state Medicaid option. From this point, PACE grew nationally to 100 programs in 2014 and now 122 programs. A substantial part of this growth was in rural areas, with 14 new rural PACE organizations initiating services between 2007 and 2009. In total, the 122 PACE programs operating today serve approximately 40,000 people in 234 communities, across 31 states (please see Appendix 7 for a list of current PACE programs).

Table 1: PACE Model Development Stages and Growth

Year(s) PACE Model Development Stage

PACE Organizations

Communities Served

People Served (nearest 1,000)

1983-1986 Model Development, On Lok

1 1 300

1986-1997 Model Testing/Replication 16 16 1,500

2009 Milestone - Rural PACE Expansion (14 programs)

77 106* 18,000

2014 Milestone – 100th PACE Organization

100 196 32,000

1997-2017 Model Implementation 122 234 40,000

*estimated based on annual growth rate prior to 2014.

On average, PACE growth during its implementation phase (since 1997) has been at a rate of 5 new PACE organizations and 11 new service communities per year. During this same time, the average growth in the number of people enrolled in PACE was 1,925 people per year. More recently, since achieving the 100th PACE organization milestone in 2014, the rate of PACE growth has accelerated to an average of 7 new PACE organizations and 13 new service communities per year. This growth has resulted in an additional 2,667 individuals per year being enrolled in PACE. Compared to the annual growth rate of PACE prior to 2014, this represents an almost 50% increase over the past three years.

4/17/2017 34 | P a g e

Scale and Spread Models for PACE Dissemination Are Effective

The PACE 2.0 project’s hypothesis is that PACE 2.0 can be disseminated to achieve a five-fold increase, from 40,000 to 200,000, in the number of HNHC adults it serves. There is support for this hypothesis in the scale achieved by a subset of PACE organizations and the spread achieved in a subset of states. While the average enrollment for a PACE organization was 325 in 2014, the five largest PACE organizations had an average enrollment of 1,980 and ranged from 1,055 to 3,813 individuals as indicated in Table 2 below.

Table 2: Five Largest PACE Organizations by Enrollment

PACE Organization

Metropolitan Statistical Area (MSA)

State 1/1/2014 Enrollmen

t

July 1, 2013 MSA Population Estimates

CenterLightNew York-Newark-Jersey

City, NY-NJ-PA Metro Area

NY 3,813 19,949,502

InnovAge Greater

ColoradoDenver-Aurora-Lakewood,

CO Metro Area CO 2,056 2,697,476

AltaMed Health Services

Los Angeles-Long Beach-Anaheim, CA Metro Area CA 1,592 13,131,431

On Lok Lifeways

San Francisco-Oakland-Hayward, CA Metro Area CA 1,382 4,516,276

Providence ElderPlace

Portland-Vancouver-Hillsboro, OR-WA Metro

AreaOR 1,055 2,314,554

The number of enrollees in these five largest PACE organizations suggests that the design of the PACE model can be scaled up to serve a significantly larger number of people than the average PACE program is currently serving. Some of the growth could occur by expanding existing PACE organizations, while growth in unserved, large population areas would require the development of new PACE organizations.

Disseminating the model to achieve exponential growth also requires spreading the model to a significantly larger number of communities, with smaller concentrations of older adults. Though in many states PACE services are limited to only one or two communities, six states have achieved access to PACE for more than 40% of their low income older adults (see Chart 1) by establishing services across a high number of communities.

4/17/2017 35 | P a g e

The high levels of access achieved in these states indicates that the PACE model can be spread to significantly more communities.

4/17/2017 36 | P a g e

Attachment 4: State and Federal Policy ScenariosFederal Policy Scenario Potential State Policy Scenario

Current States, Current Growth Limits

Current States, Open Growth

New States

Current Population: Frail Older Adults; Current Regulation

Current Population; Revised Regulation

Current Population; Revised Regulation; Medicare-only Reforms

New HNHC Subpopulations

Federal Policy Scenario Descriptions

Current Population: Frail Older Adults; Current Regulation – under this scenario, PACE is restricted to serving its currently eligible population of people over the age of 55 who require a nursing home level of care and wish to live in the community at the time of enrollment into PACE; PACE organizations in this scenario continue to operate under the current federal regulations with limited operational flexibility; though PACE can enroll moderate and higher income individuals, federal requirements limit the affordability of PACE for them.

Current Population; Revised Regulation – under this scenario the current eligibility requirements remain in place; however, the PACE federal regulation has been revised to allow for more operational flexibility.

Current Population; Revised Regulation; Medicare-only Reforms – under this scenario, as above, the current eligibility requirements remain in place and the PACE regulation has been revised to allow more flexibility. In addition, Medicare-only reforms have made PACE more affordable for these individuals.

New HNHC Subpopulations – under this scenario, pilots have been initiated to allow PACE to serve new High Need, High Cost populations, with the flexibility to adapt the PACE model to the needs of these individuals.

37 | P a g e

State Policy Scenario Descriptions

Current States, Current Growth Limits – this scenario assumes that PACE is limited to the 31 states that include PACE as a Medicaid benefit and that for those states imposing limits on growth (e.g. monthly enrollment caps, or restrictions on the number of PACE organizations) the limits remain in place.

Current States, Open Growth – this scenario assumes that PACE is limited to its current 31 states but that none of these states impose limits on the growth of PACE.

New States – this scenario assumes that the 19 states without PACE add it to their Medicaid programs and do not impose limits on its growth.

4/17/2017 38 | P a g e

Attachment 5: Project Team Description

Project staff will include the following roles and responsibilities:

Principal Investigator – Peter Fitzgerald, EVP, Policy and Strategy at the National PACE Association will be the project’s principal investigator. Peter will oversee and manage all tasks of the project, maintain communications with the project’s external consultants and advisors, and monitor the progress of the project to assure it is achieving its goals.

Project Manager – Sam Kunjukunju, Director, Project Management will provide management support, including development and tracking of project timelines, project planning, and project communications.

Federal Policy Advisor – Chris van Reenen, PhD, VP, Regulatory Affairs will serve as the project’s federal policy expert, helping to define federal policy constraints and develop recommendations for mediating or removing those constraints to support broader dissemination of PACE.

State Policy Advisor – Liz Parry, Senior Director, State Policy will serve as the project’s state policy expert, helping to define state policy constraints and develop recommendations for mediating or removing those constraints to support broader dissemination of PACE.

Data Analyst – TBN, an NPA staff data analyst will support the project’s analysis of PACE organizations enrollment, utilization, quality and cost experience to inform the projected PACE 2.0 model innovations and population impact estimate.

Consultants will support the project staff in the following areas:

Policy Consultant – a policy consultant will advise the project regarding state and federal programs and services that impact the need for PACE 2.0 services. The policy consultant will also contribute to the project staff’s assessment of state and federal policies and regulations that may constrain growth, and assist in developing recommended alternatives that would support dissemination of PACE 2.0.

Workforce Consultant – a workforce consultant will advise the project on the workforce demands of disseminating PACE 2.0 exponentially and the strategies for meeting those demands. These demands include adequate access to primary care providers, personal care assistants, rehabilitative therapists, mental and behavioral health providers, and the full range of health professionals needed to implement the PACE 2.0 model of care.

Quality Consultant – a quality consultant will develop a set of quality measures for monitoring the dissemination of PACE 2.0 to assure that its care model variations and

39 | P a g e

innovations retain the ability to provide care and support quality of life at the high levels attained by the current PACE model.

Health Services Research Consultant – a health services research consultant will work with NPA staff to review data related to the assessment of current PACE model variations, develop a qualitative assessment of those variations and complete case studies of PACE organizations implementing the variations. The Health Services Research partner will also describe competing programs and services that will impact PACE growth. The consultant will use the model variations and competitive market assessment to formulate a growth constraints model.

The project will subcontract for the following components of the project’s work:

Population Data Analysis, Modeling and Estimates – a subcontractor (e.g. Johns Hopkins Bloomberg School of Health) with access to Census, Medicare and Medicaid, and Medical Expenditures Panel Survey (MEPS) data will develop and implement an analysis plan to estimate the potential service population for PACE 2.0, project the PACE 2.0 impact population, model a range of scenarios, and report results at the national, state and service area level.

Exponential Dissemination – a subcontractor with expertise in achieving exponential growth for successful delivery system models will support the project’s development of its spread and scale strategies, and related model innovations required to achieve dissemination. This subcontractor will support the assessment of current PACE innovations and the conceptualization of the PACE 2.0 model design to test its ability to achieve rapid and broad growth for current and expanded HNHC subpopulations.

4/17/2017 40 | P a g e

Attachment 6: Project Data Sources

The project will use a range of data sources for its population and subpopulation estimates, analysis of PACE care model variations, and development of its growth constraints model.

Population and Subpopulation Estimates

Census Data – Census data related to disability, age and income from the general population survey and the American Community Survey will be used to support the development of the potential high need, high cost population and subpopulations that PACE 2.0 could serve.

Medicare Program Data Sets – Medicare program data sets provide information on diagnoses, age and utilization of services. The project will 5% sample data sets on inpatient claims and chronic conditions to support the development of its population and subpopulation estimates.

Medicaid Program Data Sets – Medicaid claims data provides information on diagnoses, age, and utilization of services. The primary data sources are Medicaid Statistical Information System (MSIS), the Medicaid Analytic eXtract (MAX) files, and the CMS-64 reports. These data sets provide information on population demographic characteristics, utilization, and payments

Medical Expenditure Panel Survey - The Medical Expenditure Panel Survey (MEPS) is a set of large-scale surveys of families and individuals, their medical providers, and employers across the United States. MEPS is the most complete source of data on the cost and use of health care and health insurance coverage. It includes data elements describing disability (self-reported limitations in activities of daily living, instrumental activities of daily living), cognitive functioning and utilization of health services.

Assessment of PACE Care Model Variations

DataPACE2 – DataPACE2 provides information on the demographic, diagnostic and functional limitations of PACE enrollees, as well as their utilization of services, outcomes and satisfaction. The data is collected by the National PACE Association on a voluntary basis from PACE organizations. Currently, 89% of PACE organizations participate in the data collection. Data is submitted quarterly.

PACE Financial Benchmarking Data – The PACE Financial Benchmarking Data set includes the per member per month cost of PACE services by type of service (e.g. primary care) or expense (e.g. administrative). The data is collected by the National PACE Association on a voluntary basis from PACE organizations. Currently, 63% of PACE organizations participate in the data collection. Data is submitted annually.

4/17/2017 41 | P a g e

PACE Audit Experience Data – The PACE Audit Experience Data source collects the results of federal quality assurance audits of PACE organizations. Data is collected on a quarterly basis and updated as audits occur. Data submittal is voluntary, with an 80% rate of participation.

PACE Model Variations Survey Data – The PACE Model Variations Survey Data collects information on PACE organizations’ use of care model variations including community-based physicians, alternative care settings and nurse practitioners as primary care providers. The survey data is collected annually, with a 90% response rate.

4/17/2017 42 | P a g e

Attachment 7: Related Projects and Partners

Related projects that would be helpful to coordinate with include:

Development of the High Need, High Cost Playbook, Version 2 – this project highlights models that excel in serving high need, high cost individuals, among whom older adults with long term service and support needs represent some of the most significant challenges. The proposed PACE 2.0 project would look to the playbook to identify care model features that could be incorporated into a PACE 2.0 model.

Age Friendly Health Systems – this project targets acute care settings to promote age-friendly care solutions. The PACE 2.0 project would benefit from the promising practices promoted by the project.

Home-Based Primary Care: Making Health Systems More Age-Friendly – this project’s support for home based primary care can inform the design of PACE 2.0 care model’s innovations.

Building the Capacity of the Aging & Disability Networks to Ensure the Delivery of Quality Integrated Care – a PACE 2.0 delivery system would be able to work with aging and disability networks to expand capacity and integrate care for HNHC subpopulations. The proposed project can draw on the efforts to build the capacity of these networks.

Building a Collective Strategy to Accelerate Progress in End-of-Life Care – this project shares the proposed project’s aim of disseminating more broadly an effective care model. The proposed project can share strategies for accomplishing this goal with the End-of-Life-Care project.

Community Catalyst – policy and advocacy work will be a valuable complement to the proposed project’s goal of addressing state and federal policy constraints on PACE 2.0 dissemination.

43 | P a g e

Attachment 8: Project Outreach Approach

Audience: Current and Prospective PACE Organizations.

NPA’s membership includes current and prospective PACE organizations. Further, NPA’s website and meetings reach these organizations.

NPA’s website – the website is a central hub of resources for all members of the PACE community and for organizations considering PACE development. PACE programs regularly access the website to utilize the information, such as templates, toolkits, and case studies. Project staff will develop a PACE 2.0 section on the website to support dissemination of the project’s resources and reports broadly. Access to this page will be open to the public and be promoted through NPA’s communications and social media.

Annual Conference – NPA’s annual conference brings together current and prospective PACE organizations and is looked to as a primary source of information on innovations and growth strategies. NPA staff will present at the annual conference to highlight the findings, results and resources of the project.

Monthly Learning Series – NPA hosts a monthly learning series to feature effective practices and strategies being implemented by PACE organizations. NPA will work with its PACE organization members to develop a learning series presentation on scaling and spreading PACE to achieve growth.

Keeping the PACE – NPA sends out an e-newsletter once a month with information on calls, webinars, events, regulatory and policy changes, and toolkits.

Presentations at Health Care Provider Forums – project staff will seek opportunities to present at forums with health care providers, including forums sponsored by the National Association of Community Health Centers, Leading Age, American Society on Aging, and others.

High Need, High Cost Playbook, Version 2 – the project will coordinate with the playbook to disseminate its resources and findings.

Integrated Care Resource Center – the project will provide summaries of its resources and findings to the Integrated Care Resource Center to reach prospective PACE 2.0 organizations.

Audience: Federal and State Policy Makers

Spring Policy Forum – NPA hosts its Spring Policy Forum every April, which is typically attended by numerous staff from the Center for Medicare and Medicaid Services, representatives from state agencies, and representatives from PACE organizations who

4/17/2017 44 | P a g e

lead their policy efforts. During the Forum, NPA staff will present on the project, discuss our strategy and findings, and share information about the resources developed and next steps.

State PACE Associations – Currently, there are nine State PACE Associations that work with the National PACE Association to support and address policy efforts in their respective states. NPA will host a State PACE Association Leadership Council meeting to present the results of the project and discuss ways in which the work can be applied and implemented in their states.

Public Policy Calls/webinars – NPA hosts a public policy call with members on a quarterly basis. We will share with the group our strategy, efforts, lessons learned, available materials, and future implementation plans.

Presentations at National and State Policy Forums – project staff will seek opportunities to present at forums with national and state policy makers, including forums sponsored by the National Association of Medicaid Directors and the National Association of State Units on Aging and Disability.

Integrated Care Resource Center – the project will provide summaries of its resources and findings to the Integrated Care Resource Center to reach state and federal policy makers.

Audience: Consumers

PACE 4 You – NPA maintains a consumer-oriented website with information about PACE and will provide the project’s materials and resources to consumers through this website.

Consumer Organizations – NPA will conduct outreach to consumer organizations representing the range of HNHC subpopulations reflected in the PACE 2.0 growth plan.

Family Caregivers – NPA will conduct outreach to family caregiver organizations to provide information about the project, its findings and its resources.

Audience: Payers

Managed Care Organizations – NPA will conduct outreach to managed care organizations with potential interest in contracting with PACE 2.0 organizations.

Accountable Care Organizations – NPA will conduct outreach to accountable care organizations with potential interest in contracting with PACE 2.0 organizations.

4/17/2017 45 | P a g e