The PACE Model An Overview Committee on the Future Health Care Workforce for Older Americans Institute of Medicine San F

1. The PACE Model An Overview Committee on the Future Health Care Workforce for Older Americans Institute of Medicine San Francisco June 28, 2008 Jennie Chin Hansen, MS, RN, FAAN University of California, San Francisco www.NPAonline.org

2. An integrated system of care for the frail elderly that is: Community-based Comprehensive Capitated Coordinated What is PACE?Programof AllInclusive Carefor the Elderly

3. 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 with the services of the PACE program at the time of enrollment The PACE ModelWho Does It Serve?

4. Milestones in the PACE Model History OngoingWaivers Waivers/ Full Risk Demo. Project First Center 1978 1973 1983 1985

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

6. Publication of 2nd Interim Final PACE Regulation enhancing opportunities for program flexibility (Oct) 2002 Milestones in the PACE Model History Final PACE Rule November 2006

7. Honors what frail elders want To stay in familiar surroundings To maintain autonomy To maintain a maximum level of physical, social, and cognitive function The PACE ModelPhilosophy

8. PACE Provides Transportation

9. PACE Provides PT & OT

10. PACE is Small in Scale Each PACE center and IDT can serve up to about 200 enrollees.

11. Brief Overview of PACEServices Provided • nursing • physical therapy, • occupational therapy • recreational therapy • meals • nutritional counseling • social work • medical care • home health care • personal care • prescription drugs • social services • audiology • dentistry • optometry • podiatry • speech therapy • respite care Hospital and nursing home care when necessary

12. Integrated Service Delivery and Team Managed Care Interdisciplinary Teams Social Services Pharmacy Home Care Activities Nutrition Primary Care Personal Care Transportation OT/PT

13. Medicare capitation rate adjusted for the frailty of the PACE enrollees Integration of Medicare, Medicaid and private pay payments Capitated, Pooled Financing

14. PACE Programs receive approximately: 2/3 of their revenue from Medicaid 1/3 from Medicare (A small percentage of program revenue comes from private sources or enrollees paying privately) 2006 Mean Medicare PMPM Rate: $1,809 2006 Median Medicaid PMPM Rate: $3,074 PACE Programs will be Medicare D providers Source of Service Revenue

15. Thirty-nine organizations are operating under dual capitation Seven sites are delivering services under Medicaid only capitation (aka “pre-PACE”) Approximately twenty-five entities are actively moving forward with PACE planning and development. Status of PACE Development (as of 4/07)

16. PACE Programs Around the Nation

17. Provider based model Tightly controlled care management and utilization systems Serves largely a nursing home eligible population in the community when enrolled Good care outcomes, high enrollee satisfaction and low disenrollment rates Established existing program with a proven track record PACE Core Competencies

18. Key ALIGNMENT Goals Structure and Processes Incentives PACE Lessons Learned

19. I. Goals Clear Expectations by Participant and Family Negotiated Agreed Upon Plans, clinical and quality of life Goals and outcomes drive the operating team structure Crucial and effective communication between and among team Role flexibility to execute care Lessons Learned ALIGNMENT: Goals

20. Commitment to Prevention for a Frail Population Custom primary prevention (eg. food, activities, key influencing decisions, family preparation) Secondary prevention (eg. disease management protocols, quick response to clinical changes) Tertiary prevention (knowledge of unique baseline, expectations, end of life care) Lessons Learned ALIGNMENT: Goals

21. Staff model of primary care: physicians and nurse practitioners Interdisciplinary and specific discipline meetings Structure routine assessments Episodic as needed Interventions Long range and intentional, eg family dynamics Quick and responsive Lessons Learned ALIGNMENT: Structure and Processes

22. Use of Tools Electronic Medical Records (On Lok since 1993) Cross discipline access and coordination Accountability Benchmarking and review Quality prompts Oversight by regulators Lessons Learned ALIGNMENT: Structure and Processes

23. Staff Full access to professional and paraprofessional services (physician to medications to food/transportation) Ability to provide preventive and extended services that may not be “reimburseable” (therapy sessions, recreation) Full 24/7 care coordination and management to enable a “medical and social home” Clear and defined “transition” handoffs (5pm Friday discharge can be handled routinely) Ability to use judgement and accountability without hoops Lessons Learned ALIGNMENT: Incentives

24. Education Experience in seeing “normal” self care elders manage co-morbidities in non-institutional settings as baseline Establish early interdisciplinary experiences Understand adult learning and behavior change, eg anthropology and cultural framework Don’t over medicalize/professionalize care when other carers can be effective and cost effective Licensing and Accreditation Content of chronic care process, systems and processes Lessons Learned For A Prepared Workforce

25. Financing Commensurate reimbursement for cognitive, chronic care relative to procedural medicine Open access to advance practice nurses, physician assistants Pay/penalize for quality that includes outcomes, satisfaction and safety Lessons Learned For A Prepared Workforce

26. Content Competency Teamwork Capabilty Process and Protocol Commitment Continued Learning and Commitment to Improved Quality Ability to Manage Complexity of Clinical, Cultural and Ethical Factors Cross Cutting Competencies to Models that Focus on Older Populations

27. Staff who will be competent, caring, flexible, risk taking, team and learning oriented and collaborative and accountable For…… The elder’s and family’s goals and not solely the piecework of a discipline and compliance to tasks PACE Model Workforce Summary