committed to serving california’s diverse communities nami 2009 national convention the on lok...
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committed to serving California’s diverse communities
NAMI 2009 National ConventionThe On Lok Model:
Comprehensive Community Support for Older Adults of Diverse Cultures
Grace Li, MHADirector of Program Operations
Ellen Dekker, MFTMental Health Clinician
San Francisco, CA July 9, 2009
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Outline
1. Overview of On Lok Lifeways• History of On Lok • Overview of PACE Model• Care Planning and How it Work • Legislative and Regulatory Framework
2. The Mental Health Program• Overview of the MHP• The Mental Health Team: Roles and Responsibilities• Case Illustrations
3. Discussion• Q&A
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What Is On Lok?
• Began in 1973 as one of the first adult day health care programs in the country
• National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care
• Family of non-profit corporations with mission of providing quality and affordable care services to seniors
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On Lok’s History & Background
1972 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 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 approval for Medicare and Medi-Cal waivers for capitated reimbursement
1986 On Lok obtains permanent waiver status and attracts major foundations to fund replication of the On Lok Model in different locations as “PACE” (Program of All-inclusive Care for the Elderly)
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On Lok’s History & Background
1996
1997
On Lok expands operation to serve all of San Francisco
PACE became a permanent provider for Medicare and an option for State Medicaid agencies under the Balanced Budget Act in 1997
1999
2002
2003
2006
2008
On Lok receives a Knox-Keene HMO license in order to facilitate its efforts to expand
On Lok expands to Fremont with community physician waiver
On Lok becomes a permanent PACE provider under Medicare and Medi-Cal
On Lok adds another center to serve southern part of San Francisco
On Lok expands to San Jose
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History of the PACE Model
19861986 19901990 19971997 (Nov)(Nov) 1999 1999
First Demonstration
Sites Operational
Legislation Authorizing
PACE Demonstration
Congress AuthorizesPermanent Provider
Status
Balanced Budget Act of 1997, H.R. 2015
Washington, D.C.
Publication of Interim
Final PACE Regulation
First Program Achieves
Permanent PACE
Provider Status
(Nov)(Nov) 2001 2001
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Program Description: PACE Model
• PACE 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 criteria
• PACE coordinates and provides all needed preventive, primary, acute and long term care services so that individuals can continue to live in the community
• PACE uses interdisciplinary teams to assess need, provide and manage care
• 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?
Eligibility Criteria:• 55 years of age or older• Living in a PACE service area• Certified as needing nursing home care• Able to live safely in the community at the
time of enrollment
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Revenues: Integrated Financing Sources
MEDICARERisk Factor plus Frailty AdjustorX county rate1
MEDICAID and/or PRIVATE PAY
Rate at 90% 2 of comparable cost of
long-term care population
MONTHLY 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 Adjustor 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))
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Provider Services: Integrated, Team Managed Care
Interdisciplinary Teams
Program ManagerHome Care Pharmacy
Nutrition
OT/PT
Primary Care/ Nursing
Transportation
Personal Care
Recreation Activities
Social Work
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PACE Comprehensive Services
Interdisciplinary
Coordination
On Lok Participant
A cute H ospital
Care
In-H ome Day H ealth Care Care
Primary Care
Laboratory X-Ray
A mbulance Service
Services
M edical Specialty Services
Restorative/ Supportive
Services
Skilled N ursing
Facility Care
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On Lok’s PACE Participant Profile
• Profile of typical participant
• Female; average age of 84• 13 medical conditions• 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
• Serves culturally and linguistically diverse population 64% Asian/Pacific Islander, 18% Caucasian, 12% Hispanic, 6% African American
• Currently serving over 1030 participants throughout the greater Bay area
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Participants by Living Situation -May 2009
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Care Management
• Interdisciplinary Team (IDT) care planning• 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 members
• Insures and improves quality of care• Maintains participant autonomy
• ICCIS (electronic medical record)• Enables communication of treatment plan, changing conditions and
tracking service utilization
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Participant Evaluations
• Each On Lok Lifeways participant receives a comprehensive team assessment upon enrollment and semi-annually.
• Participants who have experienced a significant change during the preceding quarter (e.g., stroke, hospitalization, etc.) or whose chronic conditions are unstable will receive a complete, in-person assessment each quarter.
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Participant Treatment Planning
• Interdisciplinary Teams (IDT) are responsible for assessing needs, developing treatment plans, and delivering and managing services for On Lok Lifeways participants.
• Treatment plans are modified as needed and reflect the Program’s flexibility in meeting the on-going and ever-changing needs of our participant population.
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Participant Treatment Planning
• The IDT considers a wide range of factors when treatment planning and discusses coordination issues such as:
• Number of days per week of center attendance• (recreation/socialization, maintenance therapies, primary care and nursing services, meals, etc.)
• Type and hours of in-home services• Need for alternative housing or long-term nursing home placement
• Adding, reducing or stopping any given services to maximize independence
• End of life care planning
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Participant Treatment Planning
• Psychosocial intervention and individual counseling/support may include:
• Family counseling• Case management• Life review• Assistance with housing• Financial management• Pre-need funeral trust account• Coordination with primary care provider/psychiatrist for psychiatric
intervention• Bereavement counseling• Group/individual counseling
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Medical 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 hospital
• Home health services
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On Lok’s Enhanced Program Services
• Mental/Behavioral Health (MBH) 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• 29 percent of participant population utilizing services (2008)
• Dementia Training• General overview• How to provide personal care• How to manage wander risk behavior• How to manage sexual behavior
• Chaplaincy Program• Offer on-site chaplain to act as spiritual resource/support to
participants, caregivers, families, staff
committed to serving California’s diverse communities
Mental Health Program for Culturally Diverse Elders
Ellen Dekker, MFTMental Health Clinician
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•2 Licensed Marriage and Family Therapists (MFT; 1.5 FTE)
•1 Licensed Psychologist (0.6 FTE) •1 Licensed Clinical Social Worker (LCSW; 0.8 FTE)
•3 Psychiatrists (0.25 FTE)
Mental and Behavioral Health (MBH) Team
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PSYCHIATRIST
•Medication management as requested by PCP for complex psychiatric diagnoses
PSYCHOLOGIST
•Coordination of services•Assessment of mental and behavioral health needs for new enrollees
•Neuropsychological assessment for participants with cognitive impairments and / or behavioral problems
MBH Team Responsibilities
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LCSW or MFT
•Routine reassessment for participants with mental health diagnosis
•Crisis intervention and management (72 hour involuntary psychiatric hospitalization (CA 5150))
• Individual therapy for participants, and support services for their families or caregivers
•Psycho-education & consultation about mental illness and dementia, and trainings for staff and caregivers
MBH Team Responsibilities
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Psy
chia
tris
ts
Interdisciplinary Team (IDT)
PCP SW
MBH Core Team
Psy
chia
tris
ts
Interdisciplinary Team (IDT)
PCP SW
MBH Core Team
MBH Team
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• Direct Services • Assessment/ Evaluation• Treatment
• Indirect Services• Consultation• Staff Training
MBH Services
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Most common reasons for referral- Depression
- Anxiety
- PTSD
- Mania/ Hypomania
- Psychosis
- Adjustment issues
MBH Services
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MBH - Direct Services
CASE OF MS. G.
64 year old bilingual Hispanic female referred to Mental Health Clinician (MHC)
for recurrent MDD
•Depressive episode resolved within 6 months; hypomanic symptoms observed 6 months later
•PACE setting allowed MHC to note hypomanic episode and note misdiagnosis
•Ms. G. successfully treated for Bipolar II Disorder
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MBH - Direct & Indirect Services
CASE OF MS. B.
79 year old Spanish speaking female, successfully treated for PTSD, was at risk for
relapse because of her recent transfer to a SNF.
Mental Health Clinician was able to provide both direct and indirect services to help prevent a recurrence of PTSD.
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MBH Direct and Indirect Services
CASE OF MR. Y.
78 Year old monolingual Chinese American male with history of Bipolar Disorder was involuntarily
hospitalized for self-injurious behavior by bilingual Chinese MHC.
CHALLENGE:
How to safely maintain Mr. Y in his home environment considering high family burn-out and staff anxiety
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MBH Direct and Indirect Services
MR. Y. MHC PROVIDED:
• Direct Service: supportive counseling to Mr. Y. and his family in the hospital
• Indirect Service: provided education to IDT to decrease anxiety and increase knowledge
CONSEQUENCE:• Mr. Y. discharged and treated with psychotropic medication and regular psychotherapy
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MBH Direct and Indirect Services
CASE OF MR. & MRS. V.
Bilingual Spanish couple in their 90’s, married 50 years, require different levels of care. Mr. V. suffers from moderate-severe Dementia and Ms. V. suffers from MDD. Both are at risk in their current B & C setting.
The IDT disagrees as to whether it is in the
best interest of the couple to place them
in separate settings (SNF and B & C).
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MBH Direct and Indirect Services
MR. & MRS. V.
MHC engaged in multiple roles to help resolve the IDT’s conflict: consultant & facilitator for staff and advocate & therapist for Mrs. V.
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Staff Training
Behavior Management Program
• Why the program is needed
• What the curriculum is comprised of
• Who is trained
• Ongoing consultation
MBH Indirect Services
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Staff Training: In-Services In-services for different disciplines
and for different centers
* Discipline specific ( e.g.: SW training: Suicide Assessment, Cognitive
Deficits
* Center specific
( e.g.: Frontal Lobe Dementia, Personality Disorders)
MBH Indirect Services
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Impact of the On-site
MBH Program
On Lok Lifeways
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Year Prts ServedPsychiatric
Admissions
Percent of Prts receiving MH
Services
2004 1082 11 10.1
2005 1107 2 14.7
2006 1214 3 23.8
2007 1227 3 24.4
2008 1188 2 29.3
Mental Health Utilization
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129.4
27.1
41.2
23.6
8.41
0
20
40
60
80
100
120
140
2004 2005 2006 2007 2008
Ps
yc
hia
tric
In
pa
tie
nt
Da
ys
/10
00
prt
s
Psychiatric Inpatient Days
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• Increases quality of care by providing timely mental health services to the participants;
• Provides mental health services to a higher percentage of enrollees;
• Reduces the number of institutional psychiatric admissions and overall number of inpatient psychiatric days;
• Increases Interdisciplinary Teams (IDTs) awareness of mental and behavioral issues; and
• Decreases staff anxiety by regular collaboration of the IDT and MBH teams on service / treatment development.
On-site MBH program at On Lok
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On Lok
DPH Regulation for Licensure
9 - ADHC
1- Home Health*
DPH Regulation for Licensure
2 - Dietary SF Health Dept Regulation
9 - Clinics DPH Regulation for Licensure
CMS PACE Regulation Knox-Keene HMO RegulationMedi-Cal Regulation/
DHCS Contract
Program Description: Regulatory Framework
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
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On Lok’s Ten PACE Centers
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Jade Center – Lion Dance
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Montgomery Center – Intergenerational Program
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Fremont Center – Recreation with the Sisters
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30th Street Center - Mural
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PACE Programs Around the Nation
70 PACE providers, 33 States
committed to serving California’s diverse communities
Thank you!
Q & A and Wrap UpAll