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Programs of All-Inclusive Care for the Elderly: How Does it Work?

Programs of All-Inclusive Care for the Elderly: How Does it Work? . LCDR Amy Hesselgesser, OTR Account Manager, Centers for Medicare & Medicaid Service s. Stay in the home you love, visit us for the care you need. . National PACE Association , 2011.

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Programs of All-Inclusive Care for the Elderly: How Does it Work?

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  1. Programs of All-InclusiveCare for the Elderly: How Does it Work? LCDR Amy Hesselgesser, OTR Account Manager, Centers for Medicare & Medicaid Services

  2. Stay in the home you love, visit us for the care you need. • National PACE Association , 2011

  3. I was alone a lot of the time. Now I have a place to go where I have friends, I can keep my mind challenged and always have someone to talk to. National PACE Association, 2011

  4. Agenda • History of PACE • PACE Services & Eligibility • Key Program Areas • CMS/State Monitoring • Questions

  5. PACE What are Programs of All-inclusive Care for the Elderly (PACE)? PACE is a Medicare and Medicaid program for older adults and people over age 55 living with disabilities. The program provides community-based care and services to people who otherwise need nursing home level of care.

  6. PACE Regulations PACE is governed by regulations at CFR 42, Part 460, and is a three way agreement:

  7. History • On Lok, first PACE Organization (PO), developed in 1979 in San Francisco, CA • 1986 federal government expansion allowed up to ten POs nation wide • 1997 Balanced Budget Act recognized PACE as a permanent CMS provider type

  8. Enrollment • Currently over 75 PACE organizations • Serves over 23,000 beneficiaries • Located in rural and urban areas in 29 states • Twelve pilot sites offer veterans care in collaboration with the VA

  9. Growth of PACE Programs Source: National PACE Association

  10. GOAL The PACE model provides: • comprehensive medical and social services to frail, low-income seniors. • PACE is intended to help seniors stay in their homes as long as possible.

  11. PACE Eligibility Individuals who wish to participate must voluntarily enroll and: • Be at least 55 years of age. • Live in the PACE service area. • Be in need of nursing facility care as defined by the State • At the time of enrollment, be able to safely live in a community setting.

  12. Eligibility Once enrolled, participants must: • get their medical care only through PACE providers. • out of network care must be authorized by the PACE interdisciplinary team (IDT).

  13. How it works…. • PACE organizations receive a fixed monthly payment per enrollee from Medicare and Medicaid. • In return, they are responsible for providing 100% of the health services their participants require.

  14. What it Looks Like…… PACE offers & manages all the medical, social and rehabilitative services their enrollees need to preserve or restore their independence, to remain in their homes and communities, and to maintain their quality of life.

  15. Focus on Preventive Care: The PACE interdisciplinary team (IDT) provides: • treatment and preventive health care to keep seniors healthy and to avoid hospitalizations or nursing home visits.

  16. The Interdisciplinary Team The Interdisciplinary Team (IDT) manages the care of the participant. The IDT, by regulation, must consist of: • Primary care physicians and nurses • Physical, occupational, and recreational therapists • Social workers and Home Care Coordinators • Personal care attendants • Dietitians • Drivers • PACE Center Manager

  17. Plan of Care The IDT must perform participant assessments: • at enrollment • every 6 months • when a participant’s condition changes • upon participant request

  18. Plan of Care • Once the IDT assesses, they must develop a plan of care designed to meet the medical, physical, social and emotional needs of the participant. • The plan of care must reflect the participants preferences for care.

  19. PACE Services PACE regulations require PACE organizations to provide participants with all medically necessary services including prescription drugs, without any limitation or condition as to: • amount, duration, or scope and • without application of deductibles, co-payments, or coinsurance that would otherwise apply under Medicare or Medicaid.

  20. PACE Services Minimum services provided in the PACE center: • primary care services • social services • restorative therapies (physical AND occupational therapy) • personal care and supportive services, • nutritional counseling, • recreational therapy, • meals.

  21. Participant Costs

  22. The Day Center Services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need.

  23. Outside the Day Center • Transportation • Home care • Other services deemed necessary by the Interdisciplinary Team

  24. Other Services Other services include but are not limited to: • medical specialists • laboratory • other diagnostic services • hospital • nursing home care

  25. Excluded Services Any service not authorized by the IDT EXCEPT emergency care Experimental procedures, cosmetic surgery Non medical items for personal convenience

  26. Key Program Areas The PACE Organization must: • have a governing board that includes community representation • be able to provide the complete service package regardless of frequency or duration of services • have a physical site to provide adult day services • have a defined service area

  27. Key Program Areas The PACE Organization must: • have safeguards against conflict of interest; • have demonstrated fiscal soundness; • have a formal Participant Bill of Rights, and • must demonstrate Interdisciplinary Team driven participant care.

  28. Quality Assessment/Performance Improvement (QAPI) PACE organizations must have written QAPI performance improvement plans which identify: • Areas to improve the delivery of services/patient care • Plans to improve or maintain quality of care

  29. Examples of PACE QAPI initiatives • Utilization of services • Caregiver/participant satisfaction • Outcome measures derived from clinical data and non-clinical data

  30. CMS/State Monitoring • Technical Advisory Visits • Trial Period Audits • Routine Audits • Focused Audits

  31. CMS/State Monitoring PACE Organizations are required to report 9 quality indicators to CMS: • Immunizations • Grievances • Appeals • Enrollments/Disenrollments • Prospective Enrollees • Readmissions • Emergency Care • Participant Deaths • Unusual Incidents

  32. Level II Reporting PACE organizations are required to: • report serious events having adverse health outcomes to CMS and the State agency. • conduct an internal investigation and report the results to CMS via teleconference.

  33. Cost Effectiveness • Statistics vary by state. Some report significant savings. • No comprehensive evaluation of PACE cost-effectiveness currently exists.

  34. Expansion Barriers include: • High start up costs • Marketing challenges • Financial risks • Lack of standardized outcome measures National PACE Association, 12/2010

  35. Do you want to know more about PACE?

  36. Questions Dallas PACE Account Manager LCDR Amy Hesselgesser, OTR amy.hesselgesser@cms.hhs.gov

  37. What’s New at CMS: PCIP Pre-Existing Condition Insurance Plan (PCIP) Program

  38. Statutory Authority for PCIP • Section 1101 of the Affordable Care Act (ACA) requires that HHS establish a “temporary high risk health insurance pool program” • Provides coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014 • Law required establishment within 90 days of enactment

  39. PCIP Offers Comprehensive Benefits… Care in medical offices for treatment of illness or injury Emergency services Inpatient and outpatient hospital services Inpatient and outpatient mental health and substance abuse services Prescription drugs Home health care and hospice services Outpatient laboratory and diagnostic services In- and out-of-network benefits

  40. …and Important Features for Consumers First-dollar coverage for preventive care No lifetime maximum on the amount the plan pays for enrollee’s care Benefits are available immediately when coverage begins, even for pre-existing conditions The ability to receive benefits at any qualified provider

  41. Eligibility for PCIP A person applying for PCIP must: • Reside within the service area of the PCIP; • Be a U.S. citizen or reside in the U.S. legally; • Have been without health coverage for a minimum of 6 months before applying; and • Have a pre-existing condition, as defined by the PCIP and approved by HHS. *Rate must equal at least 200% of corresponding PCIP rate. Permitted for select applicants.

  42. Applying for PCIP Coverage • In federally-run PCIP, apply for coverage by: • Mailing a paper application; • Calling the call center to complete an application over the phone; or • Filing out an online application at www.pcip.gov • State-run PCIP enrollment mechanisms vary

  43. For more information on the Pre-existing Condition Insurance Plan, please visit http://www.pcip.gov

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