Program for All-Inclusive Carefor the Elderly:

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

TIME TOPIC

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

Agenda

PACE 101

Presented by:

Shawn Bloom, President/CEO

National PACE Associationwww.npaonline.org

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

www.NPAonline.org

Overview

Presentation Outline

PACE Overview and Brief History PACE Experience with Dual Eligibles Questions/Comments

The The PProgram of rogram of AAll-inclusive ll-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 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.”

Family Member of a PACE Participant

Employs interdisciplinary teams to deliver and coordinate care across care settings• Doctors, nurses, therapists, social workers,

dieticians, personal care aides, and other providers

• Day centers, clinics, occupational and physical therapy facilities

• Individuals’ homes

• Hospitals and nursing homes, if necessary

PACE Provides Coordinated, Comprehensive Care

PACE Provides Coordinated and Comprehensive Care

Bundles Medicare and Medicaid payments 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 on 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 more

• medical care• nursing• physical therapy• occupational therapy • recreational therapy• meals• nutritional counseling • social work• home health care• hospital care

• personal care • prescription drugs • social services • audiology• dentistry• optometry • podiatry • speech therapy • respite care• SNF/NH care

PACE History and Evolution 1983 – On Lok demonstration

1986 – PACE replication demonstration

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

Distinct statutory and regulatory designation as 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 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 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 substantially

A recent HHS report found PACE generates better health outcomes

A long history serving dual eligibles, where one size 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 care

PACE has:

PACE has a long history and unique approach 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

PACE is Distinct

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 One-stop shopping

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

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 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

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

Recent History

Looking Ahead

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)

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 the adult day center – thus social care is integrated directly with medical care

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What Does the IDT Look Like?

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

Primary Care

Transportation

Home Care

Nursing

OT/PT

Speech

Nutrition

Recreation

Social Services

Settings/Services

• Adult Day Health Care

• Personal Care

• Home Care

• Nursing Home

• Hospital

• 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 plan

• Input from professionals and paraprofessionals

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Care Management = Care Coordination

Collaborative Care Planning with Participants and Family Members• 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 outpatientsetting 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 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 crisis

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

States slashing Medicaid payments

Plummeting investment income and value

Shrinking charitable contributions

Broadening Your Market

CCRCs and The Future

Mission—reach out to older adults who cannot 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 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 of economic or functional status

Economic StatusAdequate Inadequate Impoverished

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 Care

Frail

Private Pay PACEHome CareNursing Home

Spend Down into PACEHome CareNursing Home-Spend Down

PACEHome CareNursing Home

Continuum of Care

Synergies

Housing with Services Care Management across the

Continuum Social Accountability/Medicaid Capital to Fund PACE Start-up 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 eligible

Let costly place to provide services Transportation, which can be costly, can be

avoided 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 across continuum

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

management and developing a comprehensive service continuum

Social Accountability/Medicaid

Increasing need to document social accountability 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 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 continuum 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 for past 100 years

Restraint-free environments Small households Greenhouses® Culture change Assisted living PACE

CCRCs and PACE

CCRCs 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,

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 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 and 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)

County by county franchise Commitment to expansion has faded

with leadership changes within state government

PACE in the Lehigh Valley

Separate location from other operations (2 CCRCs, 1 free standing AL with specialty dementia 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 AAA

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

continuum

PACE in Lancaster

Market saturation–county has 18 retirement communities

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 – no skilled nursing component

Relationship with Albright Senior Services—PACE provider

Strong response—considered model for the future

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