Grace Li, MHA Director of Program Operations Ellen Dekker, MFT Mental Health Clinician

1. NAMI 2009 National ConventionThe On Lok Model:  Comprehensive Community Support for Older Adults of Diverse Cultures Grace Li, MHA Director of Program Operations Ellen Dekker, MFT Mental Health Clinician San Francisco, CA July 9, 2009

2. Outline • Overview of On Lok Lifeways • History of On Lok • Overview of PACE Model • Care Planning and How it Work • Legislative and Regulatory Framework • The Mental Health Program • Overview of the MHP • The Mental Health Team: Roles and Responsibilities • Case Illustrations • Discussion • Q&A

3. What Is On Lok? • Began in 1973 as one of the first adult day health care programs in the country • National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care • Family of non-profit corporations with mission of providing quality and affordable care services to seniors

4. On Lok’s History & Background

5. On Lok’sHistory & Background

6. First Program Achieves Permanent PACE Provider Status Congress Authorizes Permanent Provider Status Publication of Interim Final PACE Regulation First Demonstration Sites Operational Legislation Authorizing PACE Demonstration Balanced Budget Act of 1997, H.R. 2015 Washington, D.C. History of the PACE Model (Nov) 2001 (Nov) 1999 1986 1990 1997

7. Program Description: PACE Model • PACE is a provider-based Medicare and Medicaid managed care program • PACE serves individuals at least 55 years old and who are certified by the State to meet nursing home eligibility criteria • PACE coordinates and provides all needed preventive, primary, acute and long term care services so that individuals can continue to live in the community • PACE uses interdisciplinary teams to assess need, provide and manage care • PACE programs receive capitation payments from Medicare and Medicaid and assume full financial risk for the care of their participants

8. The PACE Model: Who Does It Serve? Eligibility Criteria: • 55 years of age or older • Living in a PACE service area • Certified as needing nursing home care • Able to live safely in the community at the time of enrollment

9. Revenues: Integrated Financing Sources MEDICAIDand/or PRIVATE PAY Rate at 90% 2 of comparable cost of long-term care population MEDICARE Risk Factor plus Frailty Adjustor X county rate1 MONTHLY CAPITATION 1 Risk Factor (based on individual demographic and medical diagnoses) combined with organizational Frailty Adjustor (based on ADL) is applied to county fee-for-service rates; new methodology for Frailty Adjustor being phased in over 2008-2012 2 California law requires DHCS to set PACE capitation rates at no less than 90% of the fee-for-service equivalent cost for a comparable long-term care population (California Welfare and Institutions Code §14592 (c))

10. Provider Services: Integrated, Team Managed Care Interdisciplinary Teams Program Manager Home Care Pharmacy Social Work Recreation Activities Nutrition Personal Care Primary Care/ Nursing OT/PT Transportation

11. PACE Comprehensive Services

12. On Lok’s PACE Participant Profile • Profile of typical participant • Female; average age of 84 • 13 medical conditions • Dependent in 2.7 ADL’s (bathing, dressing, etc.) • Has some degree of cognitive impairment (59%) • Dually-eligible for Medicare & Medi-Cal (94%) • Enrolled in program last 3-4 years of life • Serves culturally and linguistically diverse population • 64% Asian/Pacific Islander, 18% Caucasian, 12% Hispanic, 6% African American • Currently serving over 1030 participants throughout the greater Bay area

13. Participants by Living Situation -May 2009

14. Care Management • Interdisciplinary Team (IDT) care planning • Daily IDT meetings to review and discuss care needs and changes in status • Treatments • Evaluations • Frequent monitoring • Average contact with each participant is 2.2 days/week • Quarterly assessments • Collaborative care planning with participants and family members • Insures and improves quality of care • Maintains participant autonomy • ICCIS (electronic medical record) • Enables communication of treatment plan, changing conditions and tracking service utilization

15. Participant Evaluations • Each On Lok Lifeways participant receives a comprehensive team assessment upon enrollment and semi-annually. • Participants who have experienced a significant change during the preceding quarter (e.g., stroke, hospitalization, etc.) or whose chronic conditions are unstable will receive a complete, in-person assessment each quarter.

16. Participant Treatment Planning • Interdisciplinary Teams (IDT) are responsible for assessing needs, developing treatment plans, and delivering and managing services for On Lok Lifeways participants. • Treatment plans are modified as needed and reflect the Program’s flexibility in meeting the on-going and ever-changing needs of our participant population.

17. Participant Treatment Planning • The IDT considers a wide range of factors when treatment planning and discusses coordination issues such as: • Number of days per week of center attendance • (recreation/socialization, maintenance therapies, primary care and nursing services, meals, etc.) • Type and hours of in-home services • Need for alternative housing or long-term nursing home placement • Adding, reducing or stopping any given services to maximize independence • End of life care planning

18. Participant Treatment Planning • Psychosocial intervention and individual counseling/support may include: • Family counseling • Case management • Life review • Assistance with housing • Financial management • Pre-need funeral trust account • Coordination with primary care provider/psychiatrist for psychiatric intervention • Bereavement counseling • Group/individual counseling

19. Medical Management • 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 • 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 such as CHF, diabetes, chronic lung disease • Effective management of end-of-life care • Require discussion of advance healthcare directives within 6 months of enrollment • Goal is to provide care of terminal illness in home instead of acute hospital • Home health services

20. On Lok’s Enhanced Program Services • Mental/Behavioral Health (MBH) Program • Hired an internal mental/behavioral health team (Psychologist, LCSW, MFT) and contract with other providers (Psychologists, Psychiatrists) • Developed practice guidelines, staff training materials, referral protocol • 29 percent of participant population utilizing services (2008) • Dementia Training • General overview • How to provide personal care • How to manage wander risk behavior • How to manage sexual behavior • Chaplaincy Program • Offer on-site chaplain to act as spiritual resource/support to participants, caregivers, families, staff

21. Mental Health Program for Culturally Diverse EldersEllen Dekker, MFTMental Health Clinician

22. Mental and Behavioral Health (MBH) Team • 2 Licensed Marriage and Family Therapists (MFT; 1.5 FTE) • 1 Licensed Psychologist (0.6 FTE) • 1 Licensed Clinical Social Worker (LCSW; 0.8 FTE) • 3 Psychiatrists (0.25 FTE)

23. MBH Team Responsibilities PSYCHIATRIST • Medication management as requested by PCP for complex psychiatric diagnoses PSYCHOLOGIST • Coordination of services • Assessment of mental and behavioral health needs for new enrollees • Neuropsychological assessment for participants with cognitive impairments and / or behavioral problems

24. MBH Team Responsibilities LCSW or MFT • Routine reassessment for participants with mental health diagnosis • Crisis intervention and management (72 hour involuntary psychiatric hospitalization (CA 5150)) • Individual therapy for participants, and support services for their families or caregivers • Psycho-education & consultation about mental illness and dementia, and trainings for staff and caregivers

25. MBH Team

26. MBH Services • Direct Services • Assessment/ Evaluation • Treatment • Indirect Services • Consultation • Staff Training

27. MBH Services Most common reasons for referral - Depression - Anxiety - PTSD - Mania/ Hypomania - Psychosis - Adjustment issues

28. MBH - Direct Services CASE OF MS. G. 64 year old bilingual Hispanic female referred to Mental Health Clinician (MHC) for recurrent MDD • Depressive episode resolved within 6 months; hypomanic symptoms observed 6 months later • PACE setting allowed MHC to note hypomanic episode and note misdiagnosis • Ms. G. successfully treated for Bipolar II Disorder

29. MBH - Direct & Indirect Services CASE OF MS. B. 79 year old Spanish speaking female, successfully treated for PTSD, was at risk for relapse because of her recent transfer to a SNF. Mental Health Clinician was able to provide both direct and indirect services to help prevent a recurrence of PTSD.

30. MBH Direct and Indirect Services CASE OF MR. Y. 78 Year old monolingual Chinese American male with history of Bipolar Disorder was involuntarily hospitalized for self-injurious behavior by bilingual Chinese MHC. CHALLENGE: How to safely maintain Mr. Y in his home environment considering high family burn-out and staff anxiety

31. MBH Direct and Indirect Services MR. Y. MHC PROVIDED: • Direct Service: supportive counseling to Mr. Y. and his family in the hospital • Indirect Service: provided education to IDT to decrease anxiety and increase knowledge CONSEQUENCE: • Mr. Y. discharged and treated with psychotropic medication and regular psychotherapy

32. MBH Direct and Indirect Services CASE OF MR. & MRS. V. Bilingual Spanish couple in their 90’s, married 50 years, require different levels of care. Mr. V. suffers from moderate-severe Dementia and Ms. V. suffers from MDD. Both are at risk in their current B & C setting. The IDT disagrees as to whether it is in the best interest of the couple to place them in separate settings (SNF and B & C).

33. MBH Direct and Indirect Services MR. & MRS. V. MHC engaged in multiple roles to help resolve the IDT’s conflict: consultant & facilitator for staff and advocate & therapist for Mrs. V.

34. MBH Indirect Services Staff Training Behavior Management Program • Why the program is needed • What the curriculum is comprised of • Who is trained • Ongoing consultation

35. MBH Indirect Services Staff Training: In-Services In-services for different disciplines and for different centers * Discipline specific ( e.g.: SW training: Suicide Assessment, Cognitive Deficits * Center specific ( e.g.: Frontal Lobe Dementia, Personality Disorders)

36. On Lok Lifeways Impact of the On-site MBH Program

37. Mental Health Utilization

38. Psychiatric Inpatient Days

39. On-site MBH program at On Lok • Increases quality of care by providing timely mental health services to the participants; • Provides mental health services to a higher percentage of enrollees; • Reduces the number of institutional psychiatric admissions and overall number of inpatient psychiatric days; • Increases Interdisciplinary Teams (IDTs) awareness of mental and behavioral issues; and • Decreases staff anxiety by regular collaboration of the IDT and MBH teams on service / treatment development.

40. DPH Regulation for Licensure 9 - ADHC 9 - Clinics DPH Regulation for Licensure 1- Home Health* DPH Regulation for Licensure SF Health Dept Regulation 2 - Dietary Program Description: Regulatory Framework CMS PACE Regulation Knox-Keene HMO Regulation Medi-Cal Regulation/DHCS Contract On Lok • CMS = Centers for Medicare and Medicaid Services • DHCS = California Department of Health Care Services • DPH = California Department of Public Health • Licensed, but not Medicare certified as a Home Health Agency. • PACE Regulations found at: http://www.cms.hhs.gov/PACE/03_Regulation&Background.asp#TopOfPage

41. On Lok’s Ten PACE Centers

42. Jade Center – Lion Dance

43. Montgomery Center – Intergenerational Program

44. Fremont Center – Recreation with the Sisters

45. 30th Street Center - Mural

46. PACE Programs Around the Nation 70 PACE providers, 33 States

47. Thank you!Q & A and Wrap Up All