Program for All-Inclusive Care for the Elderly:
An Important Addition to Your CCRC
Webinar: 266130329
November 2, 2011

Lily Tomlin

TIME
3:00p-3:10p
3:10p-3:25p
3:25p-3:35p
3:35p-3:50p
3:50p-4:00p
4:00p-4:10p
4:10p-4:30p
TOPIC
Welcome-Overview of Session
Speaker Introductions
Larry Minnix, President/CEO, LeadingAge
Shawn Bloom, President/CEO, NPA
PACE 101: Shawn Bloom, President/CEO, NPA
Integrated Medical Delivery: Cheryl Phillips, MD
Senior VP, Advocacy, LeadingAge
PACE and CCRCs: Dan Gray
President, Continuum Development Services
Case Study-Presbyterian Senior Living
Steve Proctor, CEO
Case Study-Presbyterian Villages of Michigan
Roger Myers, President/CEO
Questions/Answers

PACE
Presented by:
Shawn Bloom, President/CEO
National PACE Association www.npaonline.org

www.NPAonline.org

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

The Program of All-inclusive Care for the Elderly
Is an integrated system of care for the frail elderly that is:
• Community-based
• Coordinated
• Comprehensive
• Capitated

 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 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

PACE Provides Coordinated, Comprehensive Care
 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 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

 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

 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
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
 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
 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
 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

PACE
 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
 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
(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

PACE
Recent
History
Looking
Ahead
 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

Presented by:
Cheryl Phillips, MD
Senior Vice President, Advocacy
LeadingAge www.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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Speech
Home
Care
OT/PT
Nutrition
Interdisciplinary teams assess need, deliver & manage care across settings:
Primary
Care
Recreation
Nursing
Transportation
Social
Services
Settings/Services
• Adult Day Health Care
• Personal Care
• Home Care
• Nursing Home
• Hospital
• Medical Specialists
• Pharmacy
• Lab/X-ray
Medications/DME
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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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 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
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 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

Presented by:
Dan Gray, President
Continuum Development Services www.consulting-cds.com

 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

 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

 Many CCRCs have strategically developed home- and communitybased services for the broader community

Mission: develop a broad array of services for older adults regardless of economic or functional status

Adequate
Retirement Communities
Life Care at Home
Home Care
Adult Day Care
Assisted Living
Private Pay PACE
Home Care
Nursing Home
Economic Status
Inadequate
Functional Status
Independent
Rental Retirement Communities,
Middle and low income Tax-credit financed housing
Needs Assistance
Home Care
Adult Day Care
Assisted Living
Frail
Spend Down into PACE
Home Care
Nursing Home-Spend Down
Impoverished
Affordable Housing
Home Care
Adult Day Care
PACE
Home Care
Nursing Home

 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

 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

 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

 Reasonable estimate is $15k per 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



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


Presented by:
Steve Proctor
President/CEO
Presbyterian Senior Living www.presbyterianseniorliving.org

 9 th 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

 Called Living Independently for Seniors
(LIFE)
 County by county franchise
 Commitment to expansion has faded with leadership changes within state government

 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

 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

 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

Presented by:
Roger Myers
President/CEO
Presbyterian Villages of Michigan www.pvm.org

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LeadingAge www.LeadingAge.org
National PACE Association www.npaonline.org