PACE

Report
An Introduction to PACE
Julie Erdmann
Community Care
Milwaukee, Wisconsin
www.communitycareinc.org
The times they are a changin’ (Bob
Dylan)
Objectives
• Develop a broad understanding of health care
policy environment
• Develop understanding of PACE background,
operations and future innovations
Changing times for health care financing
• ACO
• Bundled Payment for Care
Improvement
• Community Based Care Transitions
• 30 day readmissions
What in the World is Going on with Long-Term Care?
• 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
• 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
DIFFICULTIES IN THE MANAGEMENT OF A
PERSON’S HEALTH
Why is the “dual eligible” population difficult to
manage?
• 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
• Multiple funding streams
with disparate and
conflicting regulations leads
to unintended financial
incentives and unintended
clinical outcomes
In Fee-for-Service, there is little incentive for
coordination or integration which leads to…
Institutional Care
Primary
Care
In - Home Care
Acute 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 rogram A ll-inclusiveCare E lderly
of
for
the
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 (“transdisciplinary”)
• Management of the care is overseen through
interface of multiple professionals and paraprofessionals on the PACE team
Management and Coordination of Care through
the PACE Interdisciplinary Team
Social Worker
Home Care
Clinic/Nursing
Nutrition/Dietician
Transportation
Recreational
Therapy/Activities
Primary Care
Personal Care
Occupational and
Physical Therapies
OTHER DISCIPLINES
AS NEEDED
(e.g., Pharmacy)
Key Feature of PACE :
Full Alignment of Quality and Financial
Incentives
• 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
Key Feature of PACE :
Full Alignment of Quality and Financial
Incentives
• 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:
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
Part A Part B Part D
Private/3rd Party
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
Optometry
Emergency Room
Outpatient Services
Dental
Therapy Services
Inpatient Care
Labs and X-Rays
Pharmaceuticals
Medical Specialists
Primary Care
Home Care
Transportation
DME
Nursing Home Care
Chore Services
Meals
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.
Key Features of PACE
PACE Organizations fully integrate all Medicare
and Medicaid services into one package for atrisk older adults rather than the fragmented Feefor-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.
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
Hospitalization Rates
50%
40%
43%
All Medicare
30%
20%
20%
16%
10%
0%
Wieland, JAGS 2000; 48:1373-1380
Medicare 55+ with 3
ADL 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 Care
1555 S. Layton Blvd.
Milwaukee, WI 53215
www.communitycareinc.org
Julie Erdmann
[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 Statistics
13 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 Perspective
Amy Callaghan, DO, FACOI
Medical Director
Siouxland PACE
+
Primary Care in the PACE setting

Unique opportunity

Historically these are the
patients that “fall through
the cracks”
+
Primary Care in the PACE setting

Unique opportunity

Positively impact frail elderly

The future of Health Care
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Unable to quantify a
prevented hospitalization
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Care Innovation

Follow standard of
care
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices
 Must consider where
PACE lies in the
spectrum of life
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Must consider where
PACE lies in the
spectrum of life

Identify the participant’s
stage– and discuss goals

Functionality
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Must consider where
PACE lies in the
spectrum of life

Identify the participant’s
stage

Functionality

Palliative
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Must consider where
PACE lies in the spectrum
of life

Identify the participant’s
stage

Functionality

Palliative

End of life

Advancing our
services as needed
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Interdisciplinary care
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Interdisciplinary care

We are all responsible for a
piece of the puzzle
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Interdisciplinary care/ Team
approach
 Recognizing the warning
signs
 Monitor (and report)
outcomes
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Interdisciplinary care

PACE works

Streamline services

In essence, a small ACO

Participants remain living
independently in their home
+
Primary Care in the PACE setting

Unique opportunity

Change of mindset from
traditional practices

Interdisciplinary care

Positive patient outcomes
+
Thank you
Dr. Amy Callaghan
[email protected]

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