An Introduction to PACE Julie Erdmann Community Care Milwaukee, Wisconsin .
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Transcript of An Introduction to PACE Julie Erdmann Community Care Milwaukee, Wisconsin .
An Introduction to PACE
Julie Erdmann
Community CareMilwaukee, Wisconsinwww.communitycareinc.org
The times they are a changin’ (Bob Dylan)
• Develop a broad understanding of health care policy environment
• Develop understanding of PACE background, operations and future innovations
Objectives
Changing times for health care financing
• ACO• Bundled Payment for Care
Improvement• Community Based Care Transitions• 30 day readmissions
• In 2011, estimates are that over 10 million people received Medicaid-financed long-term care services.
• 59% were 65 or older.
• A majority were dually-eligible
• Avg. expenditures for Medicare beneficiaries with ADL limitation(s) is 4 times higher than for Medicare beneficiaries with no ADL impairments
What in the World is Going on with Long-Term Care?
• 15% of Medicaid eligibles are duals
• Of those 15% account for almost 40% of Medicaid spending
• At $20,000 per year in 2005, the cost of a dually-eligible individual to Medicare and Medicaid was 5 times greater than spending for other Medicare beneficiaries
• Health needs are inherently unpredictable and costly due to the nature of chronic conditions
• Individuals need a variety of services that cut across multiple delivery sectors and different professional / para-professional domains, each with distinct clinical focus and boundaries
• People are, by definition, impoverished either through a lifetime of poverty or impoverished in response to a sentinel health care event that triggers the need for Medicaid-funded services
DIFFICULTIES IN THE MANAGEMENT OF A PERSON’S HEALTH
Why is the “dual eligible” population difficult to manage?
• Multiple funding streams with disparate and conflicting regulations leads to unintended financial incentives and unintended clinical outcomes
Difficulties in the management of a person’s health
In Fee-for-Service, there is little incentive for coordination or integration which leads to…
Acute Care
In - Home Care
Institutional Care
Primary Care
Other...
As an example:
“Why is it so much easier for me to get my 84-year old patient’s Coronary By-Pass surgery paid for than a bath in his house?
– What does the person need?– How does it allow them to continue living
independently?– How does it improve their quality of life?
PACE is…
P A ECrogram ll-inclusivefor
lderlyaretheof
To qualify for PACE, participants must be:
• 55 years of age or older
• Living in a designated PACE service area
• Certified as needing nursing home care
• Able to live safely in the community with the services of the PACE Organization at the time of enrollment
The PACE Model History
Began with On Lok in San Francisco’s Chinatown Neighborhood
1973- First Adult Day Health Center
1978- Demonstration Project
1983- Waivers/Full Risk
1990- First Demonstration Sites
1999- CMS Final Interim Regulation
2002- CMS Regulation Addendum
2006- Final Regulation
2011- 84 Programs in 29 States
To create order in an irrational health care system, PACE…
1. Manages and coordinates the entire care delivery system
2. Brings into full alignment quality and financial incentives of the provider and care recipient
3. Integrates otherwise fragmented service and funding streams into a seamless service package for people in greatest need
Key Feature of PACE:Management and Coordination of the Care Spectrum
• Interdisciplinary system of longitudinal care delivery and coordination that spans time, setting and health care jurisdictions (“trans-disciplinary”)
• Management of the care is overseen through interface of multiple professionals and para-professionals on the PACE team
Management and Coordination of Care through the PACE Interdisciplinary Team
Social WorkerHome Care Transportation
Nutrition/Dietician
Occupational and Physical Therapies
Primary Care
OTHER DISCIPLINES AS NEEDED(e.g., Pharmacy)
Personal Care
Recreational Therapy/Activities
Clinic/Nursing
Key Feature of PACE :Full Alignment of Quality and FinancialIncentives
• The PACE model is designed with incentives for PACE Organizations to deliver services that are based on what the individual needs and not according to what fee-for-service will pay
• This creates a financial and quality incentive for the delivery of the optimal level of services in the least restrictive environment
• Provider assumes financial risk of service costs in exchange for fixed capitation payment
• CAPITATION= fixed payment on a per enrollee basis in exchange for providing necessary services from a menu of mandated services the provider must cover
• Payment to the PACE organization is based on membership in PACE and not on units of services delivered
Key Feature of PACE :Full Alignment of Quality and FinancialIncentives
Key Feature of PACE:Integration of Funding and Service Streams
Consolidation of disparate service and revenue streams into one service package that creates a
single source of services
Medicare Medicaid Private/3rd Party
Part A Part B Part D Card Svcs HCBS Nursing Home
PACE Organization
PACE Interdisciplinary Team
Services Provided in the PACE Benefit and Coordinated through the PACE Program Include…
PACE Center
Outpatient Services
Inpatient Care
Medical Specialists
Transportation
Chore Services
Optometry
Dental
Labs and X-Rays
Primary Care
DME
Meals
Emergency Room
Therapy Services
Pharmaceuticals
Home Care
Nursing Home Care
Personal Care
…And Other Necessary Services not typically covered through traditional
benefits
In the PACE Model
Beneficiaries receive all of their necessary health and social services through the PACE provider organization.
In addition to Participant’s Rights, enrollees have access to robust Grievance and Appeal procedures
Full interdisciplinary teams, including primary care physicians, provide and coordinate all services for the enrollee.No benefit limitations, co-pays or deductibles
Key Features of PACE
The intensive Interdisciplinary care planning process allows the PACE organization to provide services to individuals as they need them and not
according to benefit reimbursement payment schedules.
PACE Organizations fully integrate all Medicare and Medicaid services into one package for at-
risk older adults rather than the fragmented Fee-for-Service system.
Re-Align the funding sources and Right-Size the services
Key Features of PACE
The PACE Organization pools capitated or fixed payments, typically from Medicare and Medicaid, to provide all of the needed services in the PACE
benefit package.
Key Features of PACE
The principal care management mechanism in PACE is the interdisciplinary team which directly
provides and coordinates all care for the individual.
Key Features of PACE
PACE is the Comprehensive Integration of…
• Service Delivery Systems
(Health and Social Services)• Care Management• All Medicare and Medicaid Services• Primary, Acute, Specialty and Long-Term Care
Services• Service Provision and Health Plan Systems
PACE Statistics
• 86 Approved PACE programs• 16 Pending applications• 29 states• 2 new states with pending applications• More than 25,000 participants
PACE Participant
• Average age 81• 90% are dual eligibles• 64% have 3 or more ADL limitations• Medically complex their risk scores 2.5
times higher than a fee for service Medicare beneficiary
Potentially Avoidable Hospitalization (PAH) rate
• Compared to a dual eligible NH member PACE’s PAH rate is 44% lower
• Compared to a similar HCBW population PACE’s PAH rate is 54% lower
Wieland, JAGS 2000; 48:1373-1380
Hospitalization Rates
16%
43%
20%
0%
10%
20%
30%
40%
50%
All Medicare
Medicare 55+ with 3ADL deficits
PACE
PACE was accountable care before accountable care was cool
• Medical Home• Patient Centered (care and care plans)• Responsible for quality and cost (capitated)• Provide accountable care across preventative,
primary, acute, and long-term care services• PACE emphasizes preventive, primary, and
community-based care over avoidable high-cost specialty and institutional care
Community Care:• Private, 501(c)(3) founded in 1977
• Original demonstration site for Wisconsin’s Home and Community Based Services programs
• One of the first PACE demonstration sites now serving 852 participants in 2 counties.
• Family Care Partnership a Medicare Advantage Special Needs Plan serving 567 adults with physical disabilities, developmental disabilities, and frail elders in 9 counties.
• Family Care a long-term care managed care program serving 7636 adults with physical disabilities, developmental disabilities, and frail elders in 11 counties.
For more information, please contact:
Community Care1555 S. Layton Blvd.Milwaukee, WI 53215
www.communitycareinc.org
Julie [email protected]
(414) 902-2460
Siouxland PACE Sioux City, IA
Program of All-Inclusive Care for the Elderly
• Planning started in 2005• Federal Rural PACE Grant (15 grants of
$500,000/site) became available in 2007
• Siouxland PACE opened in 2008
Began as a partnership with Health Inc. (collaboration of St. Luke’s & Mercy Hospitals)
– Operated in collaboration with Hospice of Siouxland– Operated under a hospice & palliative care program
model– Program struggled from start
• Medical care was not coordinated (multiple community physicians)
• PACE medical clinic was not utilized• Inadequate staffing and staffing turnover (including
physicians)• Program lost money from start
In 2011, Health Inc. decided to drop program
– St. Luke’s assumed ownership in July 2011– Program lost money in 2011 & is budgeted to lose
money in 2012
PACE: By the Numbers
• Program currently has 124 participants from six counties
• Woodbury (Sioux City), Plymouth, Sioux, Ida, Monona, Cherokee
• Approximately 100 participants from Woodbury County• Day center/clinic located in western Sioux City• 37 FTEs from all PACE disciplines
PACE: By the Numbers cont’d
– Approximately 35 persons attend day center daily (persons average 5-6 times per month)
– 1,200 medical trips in February 2012– 1,700 prescriptions ordered in February 2012– 700 meals served at day center in February 2012
February 2012 Statistics13 hospital admissions (8 acute/5 obs), 6 ER visits 22 persons residing in ICF facilities
Our Siouxland PACE Participants
• 44% are between ages 55-64 (average program has 17%)
• High population of males (Veteran Administration referrals from Sioux Falls, SD VA Hospital)
Challenges
• Large service area (have requested to reduce by two counties)
• Financial Stability• Learning to manage medical care to prevent
hospitalizations & nursing home admissions• Staffing stability • Transportation• Steep learning curve to learn how to operate a PACE
program• Younger population with a high percentage of mental
health/chemical dependency issues
Strengths
• Strong support from St. Luke’s • Strong referral numbers the past several months• Belief that PACE is the right way to provide care
to an elderly, vulnerable population• Positive support from CMS and Iowa DHS• Strong feeling of program satisfaction of
participants and staff
PACE Fiscal Keys
• Adequate State Medicaid Rate• Maintain and grow monthly census• Manage Participant's Care…Manage Participants Care… Manage Participant's Care!!!
•Reduce hospitalizations/readmissions•Delay and eliminate need for nursing home/ALF admissions•Preventative Care!!!
+
PACE: The Medical Director’s PerspectiveAmy Callaghan, DO, FACOIMedical DirectorSiouxland PACE
+Primary Care in the PACE setting
Unique opportunity Historically these are
the patients that “fall through the cracks”
+Primary Care in the PACE setting
Unique opportunity
Positively impact frail elderly
The future of Health Care
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Unable to quantify a prevented hospitalization
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices Care Innovation Follow standard of
care
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Must consider where PACE lies in the spectrum of life
+Primary Care in the PACE setting Unique opportunity
Change of mindset from traditional practices
Must consider where PACE lies in the spectrum of life
Identify the participant’s stage– and discuss goals Functionality
+Primary Care in the PACE setting Unique opportunity
Change of mindset from traditional practices
Must consider where PACE lies in the spectrum of life
Identify the participant’s stage Functionality Palliative
+Primary Care in the PACE setting Unique opportunity
Change of mindset from traditional practices
Must consider where PACE lies in the spectrum of life
Identify the participant’s stage Functionality Palliative End of life
Advancing our services as needed
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Interdisciplinary care
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Interdisciplinary care We are all responsible for
a piece of the puzzle
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Interdisciplinary care/ Team approach Recognizing the warning
signs Monitor (and report)
outcomes
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Interdisciplinary care
PACE works Streamline services In essence, a small ACO Participants remain living
independently in their home
+Primary Care in the PACE setting
Unique opportunity
Change of mindset from traditional practices
Interdisciplinary care
Positive patient outcomes