PACE: Program for All-Inclusive Care for the Elderly

1. 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 Virginia

2. 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 PACE

3. 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 adults

4. 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.

5. 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 professionals

6. 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 encouraged

7. 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 • Transportation

8. 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 PACE

9. 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 orientation

10. 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 services

11. 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 mode

12. 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 programs

13. 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 Medicaid

14. 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 variation

15. 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 outcomes

16. 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 home

17. 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 individuals

18. 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)

19. 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 14thcenter in Virginia, our program opened March 1, 2014

20. 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.org

21. 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 stabilized

22. 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 started

23. 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

24. 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 planning

25. 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 discharge

26. 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 be

27. 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. 227-237

28. 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 BiolSciMed Sci, 2013 January: 68(1): 47-55