Julie Erdmann
Community Care
Milwaukee, Wisconsin www.communitycareinc.org

Objectives
• Develop a broad understanding of health care policy environment
• Develop understanding of PACE background, operations and future innovations

• 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…
Primary
Care
Acute Care
Institutional Care
In - Home Care
Other...

“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?

P rogram
A of ll-inclusive
C are for the E lderly

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

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
2006Final Regulation
201184 Programs in 29 States

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
Clinic/Nursing
Home Care
Social Worker
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

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
Part A Part B Part D
Medicaid
Card Svcs HCBS Nursing Home
Private/3 rd Party
PACE Organization
PACE Interdisciplinary Team

Services Provided in the PACE Benefit and
Coordinated through the PACE Program Include…
PACE Center
Outpatient Services
Inpatient Care
Medical Specialists
Transportation
Chore Services
Optometry
Dental
Labs and X-Rays
Primary Care
DME
Meals
Emergency Room
Therapy Services
Pharmaceuticals
Home Care
Nursing Home Care
Personal Care
…And Other Necessary Services not typically covered through traditional benefits

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

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.

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

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.

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

• 86 Approved PACE programs
• 16 Pending applications
• 29 states
• 2 new states with pending applications
• More than 25,000 participants

• 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

• 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

20%
43%
16%
Wieland, JAGS 2000; 48:1373-1380
50%
40%
30%
20%
All Medicare
Medicare 55+ with 3
ADL deficits
PACE
10%
0%

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
Julie.Erdmann@commmunitycareinc.org
(414) 902-2460

• Planning started in 2005
• Federal Rural PACE Grant (15 grants of $500,000/site) became available in
2007
• Siouxland PACE opened in 2008

(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

• 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

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

• 44% are between ages 55-64 (average program has 17%)
• High population of males (Veteran Administration referrals from Sioux Falls, SD VA Hospital)

• 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

• 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

• 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

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Primary Care in the PACE setting

Unique opportunity

Historically these are the patients that “fall through the cracks”

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Primary Care in the PACE setting

Unique opportunity

Positively impact frail elderly

The future of Health Care

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Primary Care in the PACE setting

Unique opportunity

Change of mindset from traditional practices

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Primary Care in the PACE setting

Unique opportunity

Change of mindset from traditional practices

Unable to quantify a prevented hospitalization

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Primary Care in the PACE setting

Unique opportunity

Change of mindset from traditional practices


Care Innovation
Follow standard of care

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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

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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

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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

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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

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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

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Primary Care in the PACE setting

Unique opportunity

Change of mindset from traditional practices

Interdisciplinary care

Positive patient outcomes

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Thank you
Dr. Amy Callaghan callagAL@stlukes.org