PACE: Program for All-Inclusive - PowerPoint Presentation

Slide1

PACE: Program for All-Inclusive Care for the Elderly

Mark A. Newbrough, MD

Medical Director, Blue Ridge PACE

Assoc

. Prof., Section Head for Geriatrics

University of VirginiaSlide2

Disclosure

Blue Ridge PACE is a new program serving Charlottesville, and surrounding counties of Albemarle, Fluvanna, Louisa, Greene, and Nelson

I am medical director for Blue Ridge

PACE

UVA, JABA, and Riverside Health Systems are partners in Blue Ridge PACESlide3

Objectives

Describe the key aspects of the PACE model of care

Describe the proven benefits of the PACE model of care

Explain the basic components of how the PACE Interdisciplinary Team interacts with other providers, including inpatient providers to comprehensively meet the needs of frail older adultsSlide4

Mr. Jones

Mr. Jones is an 87 year old patient that has seen you in

your practice for

the past

8

years. His 54 year old daughter provides 24 hour care for him in her home. She has had to quit her job, and her marriage is threatened by the demands of caregiving. She is no longer able to take her father out to church, and despite the fact that you have worked tirelessly with the social worker to provide additional support for the patient and his family, she fears that she may have to place her father in a nursing home. She asks if you know anything about the new PACE program here in town. Slide5

What is PACE?

According to CMS website:

Medicare program for older adults and people over age 55 living with disabilities

Provides community-based care and services to people who otherwise need nursing home level of care

Created to provide participants, families, caregivers, and health professionals flexibility to meet the health needs of participants and help them to continue living in the community

Care is provided and coordinated by an interdisciplinary team (IDT) of health professionalsSlide6

CMS “Quick Facts” (cont.)

PACE provides all the care and services covered by Medicare and Medicaid, as authorized by the IDT, “as well as additional medically-necessary care and services not covered by Medicare and Medicaid”.

True “participant centered care”

PACE programs are provider sponsored health plans: “This means your PACE doctor and other care providers are also the people who work with you to make decisions about your care.”

Preventive care is covered and encouragedSlide7

PACE Services include:

Primary care (including physician and nursing care)

Hospital Care

Medical Specialty Services

Prescription Drugs

Nursing Home Care

Emergency Services

Home Care

Physical Therapy

Occupational Therapy

Adult Day Care

Recreational Therapy

Meals

Dentistry

Nutritional Counseling

Social Services

Laboratory / X-ray services

Social Work Counseling

TransportationSlide8

Who is Eligible for PACE?

Age 55 and older

Long term nursing care eligible (but only 7% of PACE participants nationally actually live in nursing homes)

Live in a PACE service area

Able to live safely in the community at the time of enrollment in PACESlide9

Long Term Nursing Eligibility

UAI: Uniform Assessment Instrument

Criteria:

Dependent in 2-4 ADL’s

PLUS semi-dependent OR dependent in behavior AND orientation

PLUS semi-dependent in joint motion OR medication administration

Dependent in 5-7 ADL’s

PLUS dependent in mobility

Semi-dependent in 2-7 ADL’s

PLUS dependent in mobility

PLUS dependent in behavior AND orientationSlide10

History of PACE (NPA website)

On Lok (Cantonese for “peaceful, happy abode”)

1971: Outlined as comprehensive system of care based on the British day hospital model

1973: Opens one of the nation’s first adult centers in

San Francisco

1974: Begins receiving Medicaid reimbursement for adult cay health servicesSlide11

PACE History (cont.)

1975:

Adds

social day care center and includes in-home care,

home-delivered

meals and housing assistance

program

1979: 4 year Dept. of HHS grant to develop a consolidated model of delivering care to person with long term care needs

1983: Develops new financing system that pays a fixed per member per month payment

1986:

Federal

legislation extends new financing system and

allows

10 additional organizations to replicate modeSlide12

PACE History (cont.)

1986:

Federal

legislation extends new financing system and

allows

10 additional organizations to replicate model

1987:

Robert

Wood Johnson support

1990:

First

PACE programs received Medicare and Medicaid

waivers

to operate the program

1997:

Balance

Budget Act of 1997 establishes PACE model as

permanently

recognized provider type under

Medicare and

Medicaid programsSlide13

1997 Review (1)

Findings:

In 1995, PACE fully operational in 11 cities, nine states

Average enrollee: 80 years old, 7.8 medical conditions, an 2.7 dependencies in Activities of Daily Living

55% with urinary incontinence

39% living alone, and 14% with no informal support

Reductions in use of institutional care w/ controlled utilization of medical services

Cost savings to Medicare and MedicaidSlide14

PACE IDT Function is Critical (3)

Findings:

Teams must include: primary care physician, nurse, social worker, PT, OT, recreational therapy, dieticians, PACE day center coordinator, home care coordinators, personal care attendants, and drivers

Prior studies had shown that patients cared for by teams have better survival, functional, and cognitive outcomes, as well as lower institutionalization rates

This study looked at PACE teams for variationSlide15

Team Function (cont.)

Attendance at team meetings varies according to participant being discussed

Team meetings typically run by a facilitator

Validated team performance tool compared to rates of urinary incontinence and ADL function at 3 & 12 months

Statistically significant improvement in ADL’s at 3 months an 12 months with higher functioning teams, and urinary incontinence at 12 months

No association with mortality rates

Note: sites with higher nursing FTE had lower mortality but not better ADL or UI outcomesSlide16

2004 & 2009 Health Policy Reviews

Findings:

Lower rates of nursing home admission, shorter hospital stays, lower mortality rates, and better self-reported health

Costs for PACE enrollees are 16-38% lower than Medicare fee-for-service costs for a frail elderly population

5-15% lower costs

than

for comparable Medicaid beneficiaries

More likely to die at homeSlide17

Health Policy articles (cont.)

Challenges: Cost and Model structure

Many older adults not keen on adult day center

Reluctance to “change doctor”

Expensive start up costs, and costly to expand

For profit providers have not entered market

Challenges with state support: concern over Medicaid budgets

Unaffordable for middle income individualsSlide18

2013 Update: Medicaid costs (5)

Waiver cohort least impaired to NH most impaired

PACE cohort was a blend between waiver

and

NH when looking at burden of illness

Expected Medicaid annual costs for PACE type participants in alternative long-term care was $36,620

Actual Medicaid capitation to PACE was $27, 648 (28% below the lower limit of predicted fee-for-service payments)Slide19

PACE in Virginia

Rapid growth since mid-2000’s in Virginia

13 Centers in: Stone Gap, Newport News, Cedar Bluff, Richmond, Fairfax, Hampton, Roanoke, Lynchburg, Virginia Beach, Portsmouth, Farmville, and Petersburg

Blue Ridge PACE

is the 14

th

center in

Virginia, our program opened March

1, 2014 Slide20

Blue Ridge PACE

Non-profit corporation formed by three partners:

UVA Health Systems

Jefferson Area Board on Aging (JABA)

Riverside Health Systems

Located at:

1335 Carlton Ave.

Charlottesville, VA 22902

434-529-1300

www.blueridgepace.orgSlide21

Mr. Jones Revisited

BRP participant for 18 months,

he

has had three comprehensive team assessments, the last one 3 weeks ago

Receives 14

hrs.

of home care weekly

Visits PACE center

5

days per week

Participates in activities at the center

Daughter has returned to work, relationships have stabilizedSlide22

Mr. Jones Becomes Ill

Both

his

home aide and driver

notice he appears

ill

one morning

After a short discussion in the morning IDT meeting, he is seen

by nurse and doctor in PACE clinic same day, with normal WBC and negative CXR done, but fever and cough present

Goals of care reviewed with family, and decision made to try oral antibiotics and observe closely

Antibiotics

startedSlide23

Mr. Jones’ Follow-up

He is seen again the next day in the PACE clinic

Tolerating antibiotics, food, and water, no noticeable deterioration from previous day

That night becomes acutely short of breath, becomes frightened, and so does

his

family

They contact PACE nurse on call, who also consults with physician

Due to rural home location, and acuteness of SOB, decision made to send to ER Slide24

ER Stay

Labs and CXR confirm

diagnosis of pneumonia,

but breathing calms down with O2 supplementation

Family is unsure of next steps, and not sure they can manage patient at home

Hospital team and PACE physician

discuss case, and decide to admit Mr. Jones

Complete

medication list and summary provided

The next day, both the

Mr. Jones nurse

and the physician check on

him and

assist with care planningSlide25

Next Day

PACE team meets with family, and proposes plan of care:

Discharge from hospital to SNF for course of IV antibiotics and observation (no 3 day stay required)

Restorative therapies will assess

him

at SNF, and determine need for therapy

Additional discussions with family depending on clinical course

Discharge from SNF to home after only 3 days, with home evaluation and

clinic

evaluation within 24 hours of dischargeSlide26

PACE Summary

Comprehensive model of medical and social care

Team based, participant centered

Focus on keeping people in their home

Provide needed care at lowest cost level of care

Increased flexibility compared to usual Medicare / Medicaid fee-for-service care

A community based partner who can help care for

our

oldest and most frail patients, and will help care for them wherever they may beSlide27

References

Eng

, Catherine;

Pedulla

, James;

Eleazer

, Paul G.; McCann, Robert; and Fox, Norris. “Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing”, JAGS Vol. 45, No. 2, Feb 1997, pp. 223-232, 244

Gross, Diane L., et al, “The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACE,

The Milbank Quarterly,

2004, Vol. 82, No. 2, pp. 257-82

Mukamel

, Dana B., et al, “Team Performance and Risk-Adjusted Health Outcomes in the Program of All-Inclusive Care for the Elderly (PACE),

The Gerontologist,

2006,

Vol

46, No. 2, pp. 227-237Slide28

References (cont.)

Petigara

,

Tanaz

and Gerard Anderson. “Program of All

-Inclusive

Care for the Elderly”. Health Policy Monitor,

April 2009

http

://

www.hpm.org/en/Downloads/Health_Policy_Developments.html

Wieland

, Darryl, et al, “Does Medicaid Pay More to a

Program

of All-Inclusive Care for the Elderly (PACE) Than for

Fee

-for-Service Long-term Care?,

J of Gerontology, A

Biol

Sci

Med

Sci

,

2013 January: 68(1): 47-55