Program for All-Inclusive Carefor the Elderly:

An Important Addition to Your CCRCWebinar: 266130329November 2, 2011

““The Road to SuccessThe Road to SuccessThe Road to Success The Road to Success is Always Under is Always Under Construction”Construction”

Lily TomlinLily Tomlin

TIME TOPIC

3:00p-3:10p Welcome-Overview of SessionSpeaker Introductions

Agenda

pLarry Minnix, President/CEO, LeadingAgeShawn Bloom, President/CEO, NPA

3:10p-3:25p PACE 101: Shawn Bloom, President/CEO, NPA

3:25p-3:35p Integrated Medical Delivery: Cheryl Phillips, MDSenior VP, Advocacy, LeadingAge

3:35p-3:50p PACE and CCRCs: Dan GrayPresident, Continuum Development Services

3:50p-4:00p Case Study-Presbyterian Senior LivingSteve Proctor, CEO

4:00p-4:10p Case Study-Presbyterian Villages of MichiganRoger Myers, President/CEO

4:10p-4:30p Questions/Answers

PACE 101

Presented by:

Shawn Bloom, President/CEO

National PACE Associationwww.npaonline.org

Overview

Program of AllProgram of All--inclusive Care inclusive Care for the Elderly (PACE)for the Elderly (PACE)

www.NPAonline.org

Presentation Outline

PACE Overview and Brief History

PACE Experience with Dual Eligibles

Questions/Comments

The The PProgram of rogram of AAllll--inclusive inclusive CCare for the are for the EElderlylderly

Is an integrated system of care for the frail elderly that is:

• Community-based

• Coordinated

• Comprehensive

• Capitated

Who Does PACE Serve?

Adults 55 years of age or older and who are:

• Living in a PACE organization’s service area

• State-certified as eligible for nursing home level of care

• Able to live safely in the community with the services of the PACE program at the time of enrollment

PACE is Community-Based

PACE provides innovative, person-centered care for older adults that allows them to stayadults that allows them to stay in their homes and communities and out of nursing homes

“PACE’s help in being able to keep mom at home has enabled us to keep our family together ”together.

Family Member of a PACE Participant

Employs interdisciplinary teams to deliver and coordinate care across

PACE Provides Coordinated, Comprehensive Care

care settings• Doctors, nurses, therapists, social workers,

dieticians, personal care aides, and other providers

• Day centers, clinics, occupational and physical therapy facilities

Individuals’ homes• Individuals’ homes

• Hospitals and nursing homes, if necessary

PACE Provides Coordinated and Comprehensive Care

Bundles Medicare and Medicaid payments to provide full range ofpayments to provide full range of health care services

Medical care, social services, and other long-term services and supports

Capitated, Pooled Financing

Integration of Medicare, Medicaid and private pay payments by PACE providers

Medicare A/B capitation payments risk- and frailty- adjusted for PACE participants

Medicare Part D payments based on bid amounts

Medicaid capitated payment amounts based p p yon states’ expenditures for long-term care populations

Sources of Service Revenue PACE Programs receive approximately

$5,349 PMPM in 2011: 60% of their revenue from Medicaid

40% from Medicare(A small percentage of program revenue comes from private sources or enrollees paying privately)

2011 Mean Medicare PMPM Rate: $2,018

2011 Mean Medicaid PMPM Rate: $3,331$ ,

PACE Programs are Medicare D providers

PACE Organizations Provide:

All Medicare and Medicaid covered–services and moreservices and more

• medical care• nursing• physical therapy• occupational therapy • recreational therapy• meals• nutritional counseling

• personal care • prescription drugs • social services • audiology• dentistry• optometry • podiatry• nutritional counseling 

• social work• home health care• hospital care

• podiatry • speech therapy • respite care• SNF/NH care

PACE History and Evolution 1983 – On Lok demonstration

1986 – PACE replication demonstrationp

1997 – Congress established PACE as permanent Medicare provider and Medicaid state option (Balanced Budget Act)

Distinct statutory and regulatory designation as a provider based entityas a provider-based entity

Sections 1894 and 1934, Social Security Act

Title 42, Part 460, Code of Federal Regulations

PACE Core Competencies Operates as a provider-based model

Serves exclusively a nursing home eligible population

Produces good outcomes: Participants more likely to have advance care

directives and die at home

PACE participants, caregivers, and employees report high satisfaction with the programreport high satisfaction with the program

PACE participants have reduced hospitalizations and permanent residency in nursing homes

Integrated, Interdisciplinary Team Care

Hands-on interdisciplinary team approach to care management vs individual caseto care management vs. individual case management

Continuous process of assessment, treatment planning, service provision, and monitoring

Focus on prevention, primary, secondary, and tertiary care

PACE is:Fully-Accountable for the Cost and Quality

of Care Provided

How can we move from successfully treating individual diseases, to successfully caring for individuals? Can we do it for less? Proven track record in preserving wellness and promoting

quality care

Integrated and fixed-rate financing system reduces the cost of care compared to nursing home care substantiallyof care compared to nursing home care substantially

A recent HHS report found PACE generates better health outcomes

A long history serving dual eligibles, where one size d t fit ll

PACE has:

does not fit all

90 percent of PACE participants are dual eligibles (Medicare & Medicaid eligible)

Dual eligibles have multiple, complex conditions and benefit from the PACE model of comprehensive, individualized carecomprehensive, individualized care

PACE has a long history and unique approach 30+ year track record

PACE is Distinct

30+ year track record

Direct, hands-on provider

Accepts full financial risk for participants’ cost and health care

Exclusively serves a subset of the dual eligible population – frail, older adults

Status of PACE (as of 10/11)

Currently there are 166 PACE centers, operated by 81 sponsoring organizations in 29 states

Over 23,000 PACE participants

One-fifth of PACE organizations indicate that they are approaching enrollment cap imposed by their states

Over one-half of PACE organizations plan to expand with the development of one or more centers in 2011

PACE Responds to Tough Health Care Challenges

For Consumers—Participants/Caregivers: Comprehensive, preferred method of care Stay in the community as long as possible Stay in the community as long as possible One-stop shopping

For Providers: Freedom from traditional FFS restrictions Focus on the entire range of needs of individual

For Payers:For Payers: Value and predictable expenditures Comprehensive service package

New Opportunities for PACE Number of PACE organizations doubled in last 5

years to 76:

• Rural PACE grants 13 rural programsRecent History • Rural PACE grants – 13 rural programs

• More diversity among interested sponsors (e.g., hospices)

• State interest in PACE expansion

PACE/Veterans Administration Start-up Program

New demonstrations being developed to

History

Looking Ahead

g p

• Expand current PACE program and offer the model to different populations that would benefit from its services

Integrated Medical Delivery

Presented by:

Cheryl Phillips, MD

Senior Vice President, Advocacy

LeadingAgewww.LeadingAge.org

How is PACE Clinical Care Delivered?

The center of care delivery is the interdisciplinary team (IDT)p y ( )

Care plans are created with (not just for) the individual and family and includes social, cultural, functional aspects of care – in addition to the medical needs

Most of the services are coordinated through gthe adult day center – thus social care is integrated directly with medical care

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What Does the IDT Look Like?

Interdisciplinary teams assess need, deliver & manage care across settings:

PrimaryCareHome

Care

Nursing

OT/PT

Speech

Recreation

Social Services

Settings/Services

• Adult Day Health Care

• Personal Care

• Home Care

• Nursing Home

• Hospital

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Transportation

OT/PT

Nutrition

• Medical Specialists

• Pharmacy

• Lab/X-ray Medications/DME

Care Management = Care Coordination

Interdisciplinary Team (IDT) Care Planning• Integrates skilled assessment and evaluation findings and

regular assessments by PACE IDT members (physician, nurse, rehab therapists, social worker, dietary, recreation and home care staff) into new or revised person-centered care plan.

Frequent Monitoring• Regular attendance at day center combine with home care

according to individualized care planaccording to individualized care plan

• Input from professionals and paraprofessionals

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Care Management = Care Coordination

Collaborative Care Planning with Participants and Family Membersy• Insures and improves quality of care

• Maintains participant autonomy

• Comprehensive medical record integrates person-centered goals across the team

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Medical Management

The goal is to maximize medical management in the outpatientg psetting and integrate social and functional support needs with IDT

Primary care team on-site: MD, NP, RN

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Medical Management 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• Daily clinic care and observation can often prevent

hospitalizations• 24 hour call system with on-call physicians and

nurses linking to IDTnurses linking to IDT• Effective person-centered and team-based delivery

of end-of-life care

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CCRCs Have Much of the Clinical Structure

Many already have on-site clinics and nursing staff

Culture of wellness and prevention is central to CCRC model

Care Coordination is already a skill set –coordinating information and person-specific goals across settings of care

CCRC staff understand the intersection of clinical conditions with function and the goal to maintain independence for as long as possible

Synergies of PACE and the CCRC

Presented by:

Dan Gray, President

Continuum Development Serviceswww.consulting-cds.com

CCRC Challenges

Chronic downturn in the economy

Continuing housing crisisContinuing housing crisis

Upcoming 11% reduction in Medicare Part A reimbursement for skilled nursing

States slashing Medicaid payments

Plummeting investment income and valueg

Shrinking charitable contributions

Mission

Broadening Your Market

Mission

Market

BusinessBusiness

CCRCs and The Future

Mission—reach out to older adults who cannot afford to be in a CCRC or wish tocannot afford to be in a CCRC or wish to remain in their own home

Market—broadens the market from 2% served to the possibility of serving all seniors

Business—diversify into revenue notBusiness diversify into revenue not capital intensive services

CCRCs and The Future

Many CCRCs have strategically developed home- and community-based services for the broader community Mission: develop a broad array of

services for older adults regardless ofservices for older adults regardless of economic or functional status

Economic StatusAdequate Inadequate Impoverished

Functional Status

Continuum of Care

Functional StatusIndependent

Retirement CommunitiesLife Care at Home

Rental Retirement Communities, Middle and low income Tax-credit financed housing

Affordable Housing

Needs Assistance

Home CareAdult Day CareAssisted Living

Home CareAdult Day CareAssisted Living

Home CareAdult Day CareAssisted Living Assisted Living y

Frail

Private Pay PACEHome CareNursing Home

Spend Down into PACEHome CareNursing Home-Spend Down

PACEHome CareNursing Home

Synergies

Housing with Services

Care Management across the Care Management across the Continuum

Social Accountability/Medicaid

Capital to Fund PACE Start-up

The Future of Senior Living and PACE The Future of Senior Living and PACE

Common Not-for-Profit and Faith-Based Traditions

Housing With Services

Great place to market PACE—up to 20% may be nursing home eligible20% may be nursing home eligible

Let costly place to provide services

Transportation, which can be costly, can be avoided

CCRCs are experienced developers and CCRCs are experienced developers and operators of housing with services—a valuable component of PACE

Care Management Across the Continuum

Several CCRCs are adding Chief Medical Directors to integrate services gacross continuum

In PACE, Medical Directors and Nurse Practitioners are integral to the model PACE is a platform for improving care

management and developing a comprehensivemanagement and developing a comprehensive service continuum

Social Accountability/Medicaid

Increasing need to document social accountability efforts—tax issueaccountability efforts tax issue

Opportunity to serve Medicaid population combined with Medicare—more profitable than serving Medicaid only population

PACE allows CCRCs to expand their mission to the economically disadvantaged while being good stewards of the organization’s resources

Capital to Fund PACE

Reasonable estimate is $15k per participant slot--$4.5m to develop a 300-participant slot $4.5m to develop a 300participant program

Financing opportunities include short-term bank loans, internal loans refinanced into long-term debt after stabilization

Many CCRCs have the liquidity and the mission imperative to make a strategic investment in PACE

Future of Senior Living and PACE

CCRCs having PACE in their gcontinuum will be the leaders in these innovations and in ACOs

Not-For-Profit and Faith-Based Traditions

Senior living organizations have led innovations in caring for the frail elderly g yfor past 100 yearsRestraint-free environmentsSmall householdsGreenhouses®Culture changegAssisted livingPACE

CCRCs and PACE

CCRCs should become theCCRCs should become the leading provider of PACE in the future

Presbyterian Senior Living

Presented by:

Steve Proctor

President/CEO

Presbyterian Senior Livingwww.presbyterianseniorliving.org

Presbyterian Senior Living

9th largest senior care provider on Zeigler 100

24 locations in Pennsylvania, Maryland, y , y ,Delaware and SE Ohio

Upscale CCRCs to affordable housing, skilled nursing, personal care, and assisted living

Historic commitment to serving low to moderate income seniors throughout the continuumincome seniors throughout the continuum

Approach to social responsibility – we earn money from upscale operations to fund services to those in need

Strategic Focus—Long-Term Care Continuum

Offer a continuum of care to persons in a wide range of financial circumstances

The continuum should be flexible, cohesive, quality driven

Elements of the continuum provided directly by PSL or in partnership with others

PACE is an extension of our affordable housing gand services strategy which enables PSL to offer a full range of services to those with limited resources

PACE in Pennsylvania

Called Living Independently for Seniors (LIFE)(LIFE)

County by county franchise

Commitment to expansion has faded with leadership changes within state governmentg

PACE in the Lehigh Valley

Separate location from other operations (2 CCRCs, 1 free standing AL with specialty d ti d t d d lt d ithdementia product, and adult day program with a 20-year history)

Opened in February 2009, first enrollment May 2009

Slower than expected start up due to resistance from AAAfrom AAA

Current census is 58 Program benefits from the synergy of a wider

continuum

PACE in Lancaster

Market saturation–county has 18 retirement iticommunities

New location opening in December 2011

Located next to 1500 member church with extraordinary physical plant available to retirement community

PACE in Lancaster

Campus will serve 200 senior families with AL, market rate rental tax credit housing – nomarket rate rental, tax credit housing no skilled nursing component

Relationship with Albright Senior Services—PACE provider

Strong response—considered model for the futurefuture

Presbyterian Villages of Michigan

Presented by:

Roger Myers

President/CEO

Presbyterian Villages of Michiganwww.pvm.org

PVM Locations

PACE Eligibles

Program Outcomes

Program Outcomes

Program Outcomes

Program Outcomes

East Jefferson Project Area

East Jefferson Building Design

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East Jefferson Building Design

East Jefferson Condo Structure

East Jefferson Organizational Chart

Questions

LeadingAgewww.LeadingAge.org

National PACE Associationwww.npaonline.org