OLkLifOn Lok Lifeways Program of All-Inclusive Care for ... · Canadian Research Network for Care...
Transcript of OLkLifOn Lok Lifeways Program of All-Inclusive Care for ... · Canadian Research Network for Care...
Canadian Research Network for Care in the Community (CRNCC):( )
E-Symposium on Aging at Home
O L k LifOn Lok Lifeways Program of All-Inclusive Care for the Elderly
Grace Li MHAGrace Li, MHADirector of Program Operations
[email protected] onlok org
committed to serving California’s diverse communities
www.onlok.orgJune 22, 2009
OverviewOverview
O i f O L k Lif1.Overview of On Lok Lifeways• History of On Lok • Overview of PACE Model• Care Planning and How it Works• Medical Management and Quality Assurance• Legislative and Regulatory Framework• Legislative and Regulatory Framework• Future for On Lok
2.Discussion• Q&A
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Wh t I O L k?What Is On Lok?
B i 1973 f th fi t•Began in 1973 as one of the first adult day health care programs in the countryy
•National prototype for the Program of All-inclusive Care for the Elderly y(PACE) model of care
•Family of non-profit corporations y p pwith mission of providing quality and affordable care services to seniors
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O L k’ Hi t & B k dOn Lok’s History & Background
1972 O L k f d d fit i ti1972 On Lok founded as a non-profit organization• Premise was that providing services to maintain seniors in their own homes
was both a better and lower cost model of care
1975 On Lok’s first major regulatory/reimbursement victory in1975 On Lok s first major regulatory/reimbursement victory in pioneering new models of care for the elderly• As one of five demonstration projects in CA, On Lok successfully advocated for
Adult Day Health Care to become a reimbursable service under Medi-Cal
1979 Health Care Financing Administration (HCFA) grants waiver to offer a comprehensive program for care for the elderly• A true revolution in the method and quality of health care for the elderly
1983 On Lok gets appro al for Medicare and Medi Cal ai ers for1983 On Lok gets approval for Medicare and Medi-Cal waivers for capitated reimbursement
1986 On Lok obtains permanent waiver status and attracts major
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p jfoundations to fund replication of the On Lok Model in different locations as “PACE” (Program of All-inclusive Care for the Elderly)
O L k’ Hi t & B k dOn Lok’s History & Background
1996 On Lok expands operation to serve all of San Francisco
1997 PACE became a permanent provider for Medicare and option for State Medicaid agencies under the Balanced Budget Act in 19971997
1999 On Lok receives a Knox-Keene HMO license in order to facilitate its efforts to expand
2002
2003
On Lok expands to Fremont with community physician waiver
On Lok becomes a permanent PACE provider under Medicare2003
2006
On Lok becomes a permanent PACE provider under Medicare and Medi-Cal
On Lok adds another center to serve southern part of San Francisco
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2008FranciscoOn Lok expands to San Jose
History of the PACE ModelHistory of the PACE Model
First Program First Program
First First Demonstration Demonstration
SitesSites
Legislation Legislation Authorizing Authorizing
Congress Congress AuthorizesAuthorizesPermanent Permanent P idP id
Publication Publication of Interim of Interim
Final PACEFinal PACE
Achieves Achieves Permanent Permanent
PACE PACE ProviderProviderSites Sites
OperationalOperational
ggPACE PACE
DemonstrationDemonstration
Provider Provider StatusStatus
Balanced Budget Act of 1997, H.R. 2015
Final PACE Final PACE RegulationRegulation
Provider Provider StatusStatus
Washington, D.C.
19861986 19901990 19971997 (Nov)(Nov) 19991999 (Nov)(Nov) 20012001
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P D i ti PACE M d lProgram Description: PACE Model
• PACE is a provider-based Medicare and Medicaid managed carePACE is a provider based Medicare and Medicaid managed care program• PACE serves individuals at least 55 years old and who are certified
by the State to meet nursing home eligibility criteriaby the State to meet nursing home eligibility criteria • PACE coordinates and provides all needed preventive, primary,
acute and long term care services so that individuals can continue to live in the communityto live in the community• PACE uses interdisciplinary teams to assess need, provide and
manage care• PACE programs receive capitation payments from Medicare and• PACE programs receive capitation payments from Medicare and
Medicaid and assume full financial risk for the care of their participants
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The PACE Model: Who Does It Serve?The PACE Model: Who Does It Serve?
Eligibility Criteria:• 55 years of age or older• 55 years of age or older• Living in a PACE service area• Certified as needing nursing home careg g• Able to live safely in the community at the time of
enrollment
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Revenues: Integrated Financing SourcesRevenues: Integrated Financing Sources
MEDICARE MEDICAIDMEDICARERisk Factor plus Frailty AdjustorX county rate1
MEDICAIDand/or PRIVATE PAY
Rate at 90% 2 of comparable cost ofX county rate1 comparable cost of
long-term care population
MONTHLY CAPITATIONMONTHLY CAPITATION
1 Risk Factor (based on individual demographic and medical diagnoses) combined with organizational Frailty Adjustor (based on ADL) is applied to county fee-for-service rates; new methodology for Frailty
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y j ( ) pp y ; gy yAdjustor being phased in over 2008-2012
2 California law requires DHCS to set PACE capitation rates at no less than 90% of the fee-for-service equivalent cost for a comparable long-term care population (California Welfare and Institutions Code §14592 (c))
P D i ti O L k LifProgram Description: On Lok Lifeways
On Lok Lifeways is both a Health Plan and a HealthOn Lok Lifeways is both a Health Plan and a Health Provider•The Health Plan Operations include:
• Marketing: Member services, enrollment, disenrollment• Network management/contract services• Quality Assurance
MIS/ICCIS ( l t i di l d )• MIS/ICCIS (electronic medical records)• Claims Processing•The Provider Operations include:
• 9 PACE centers and 10 Interdisciplinary Teams• Home care services, transportation, dietary services• Primary care providers (physicians and nurse practitioners)
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• Complete network of contract inpatient and specialty providers: hospitals, nursing homes, specialty care, lab, x-ray, pharmacy, etc.
PACE Comprehensive ServicesPACE Comprehensive Services
I H l h C Primary In-Home Day Health Care Primary
Care Services
Interdisciplinary
On Lok
Acute Hospital
Care
Laboratory X-Ray
Ambulance
Coordination
Participant Care Service
Medical Specialty Services
Restorative/ Supportive
Services
Skilled Nursing
Facility Care
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Provider Services: Integrated, Team Managed Care
Interdisciplinary TeamsProgram ManagerHome Care PhHome Care Pharmacy
NutritionRecreation Activities
Social Work
Primary Care/ Nursing
Personal Care
OT/PTTransportation
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IDT Care Planning & ManagementIDT Care Planning & Management
• Interdisciplinary Team (IDT) Care Planningp y ( ) g• Daily IDT meetings to review and discuss care needs and
changes in status• Treatments• Evaluations•Frequent Monitoring
• Average contact with each participant is 2.2 days/week• Quarterly assessments•Collaborative Care Planning with Participants and Family Membersy
• Insures and improves quality of care• Maintains participant autonomy• ICCIS (electronic medical record)
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( )• Enables communication of treatment plan, changing conditions
and tracking service utilization
Medical ManagementMedical Management
• The goal is to maximize medical management in the outpatient setting and integrate social and functional support needs with IDT• Primary care team on-site: MD, NP, RN• Full-service clinic for urgent care and management of chronic
conditions IV and Respiratory therapy Wound care management Frequent visits for management of chronic disease such as CHF,
diabetes, chronic lung disease
• Effective management of end-of-life care Require discussion of advance healthcare directives within 6 months of
enrollment Goal is to provide care of terminal illness in home instead of acute
h it l
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hospital
• Home health services
Cost Controls: Hospitalization RatesCost Controls: Hospitalization Rates
Utili ti M di M diUtilization Measure On Lok* Medicare
FFS**Medicare
Advantage***
DischargesDischarges/1000
377 361 279
Acute Days 1 642 2 073 1 430Acute Days /1000 1,642 2,073 1,430
Avg. Stay4.4 5.7 5.1
(ALOS)4.4 5.7 5.1
ER Visits /1000 267 Not available 316
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*FY05-06 On Lok data**2005 Medicare FFS Data***2006 National HEDIS Reporting
On Lok’s PACE Participant ProfileOn Lok s PACE Participant Profile
• Profile of typical participant• Profile of typical participant• Female; average age of 84• 13 medical conditions
Dependent in 2 7 ADL’s (bathing dressing etc )• Dependent in 2.7 ADL’s (bathing, dressing, etc.)• Has some degree of cognitive impairment (59%)• Dually-eligible for Medicare & Medi-Cal (94%)• Enrolled in program last 3-4 years of life• Enrolled in program last 3 4 years of life
• Serves culturally and linguistically diverse population 63% Asian/Pacific Islander, 19% Caucasian,
11% Hi i 7% Af i A i11% Hispanic, 7% African American
• Currently serving over 1030 participants throughout the greater Bay area
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area
Participants by Living Situation for May 2009
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O L k’ E h d P S iOn Lok’s Enhanced Program Services
M t l/B h i l H lth P• Mental/Behavioral Health Program• Hired an internal mental/behavioral health team (Psychologist, LCSW,
MFT) and contract with other providers (Psychologists, Psychiatrists)• Developed practice guidelines staff training materials referral protocol• Developed practice guidelines, staff training materials, referral protocol• 17 percent of participant population utilizing services
• Dementia Training• General overview• General overview• How to provide personal care• How to manage wander risk behavior• How to manage sexual behaviorHow to manage sexual behavior
• Chaplaincy Program• Offer on-site chaplain to act as spiritual resource/support to
participants, caregivers, families, staff
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p p , g , ,
Q lit O i htQuality Oversight
Quality Assurance and Improvement Committee (QAIC)•Quality Assurance and Improvement Committee (QAIC)• Meets quarterly• Community physicians and On Lok medical staff and IDT members
Reports to Board• Reports to Board• Focus is to look at key clinical areas and measure outcomes•Development of treatment guidelines that are designed to meet the unique needs of this populationmeet the unique needs of this population•Comprehensive Quality Plan is approved by Board•QAIC also reviews grievances, oversees credentialing and manages all unusual occurrences and sentineland manages all unusual occurrences and sentinel events.
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Program Description: Regulatory F k
CMS PACE R l i K K HMO R l i Medi-Cal Regulation/
Framework
CMS PACE Regulation Knox-Keene HMO Regulation Medi Cal Regulation/DHCS Contract
On Lok
9 - ADHC DPH Regulation for Licensure
9 - Clinics DPH Regulation for Licensure
DPH Regulation for Licensure1- Home Health*
2 - Dietary SF Health Dept Regulation
CMS = Centers for Medicare and Medicaid Services
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CMS = Centers for Medicare and Medicaid ServicesDHCS = California Department of Health Care ServicesDPH = California Department of Public Health•Licensed, but not Medicare certified as a Home Health Agency.•PACE Regulations found at: http://www.cms.hhs.gov/PACE/03_Regulation&Background.asp#TopOfPage
On Lok’s Ten PACE Centers
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Jade Center Lion DanceJade Center – Lion Dance
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Montgomery Center – IntergenerationalMontgomery Center Intergenerational Program
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Fremont Center – Recreation with the Si tSisters
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30th Street Center Mural30th Street Center - Mural
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Future for On LokFuture for On Lok
C ti d th d i• Continued growth and expansion• Planning for a second center in Fremont, CA is underway; Co-
location of low income senior housing and PACE services. Partner with Eden Housing (2011).
• On Lok PACEpartners (www.pacepartners.net)• On Lok’s technical assistance and consulting services to support:
• Prospective PACE – is PACE right for you?• Pursuing PACE – assisting organizations to navigate their regulatory
landscape and design and develop a PACE Program, including PACE Provider applicationProvider application
• Operational PACE – special projects; health plan management services
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PACE Programs Around the NationPACE Programs Around the Nation
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70 PACE providers, 33 States
Q & A and Wrap Up
All
committed to serving California’s diverse communities