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

GraceLi@onlok.orgwww 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