Post on 16-Dec-2015
transcript
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PProgram of rogram of AAll Inclusive ll Inclusive CCare for the are for the EElderly: Adapting to the IDD lderly: Adapting to the IDD
populationpopulation
Fredrick T. Sherman MD, MScFredrick T. Sherman MD, MScChief Medical Officer for Community and Managed Care ServicesChief Medical Officer for Community and Managed Care Services
Medical Director, Archcare Senior Life(PACE)Medical Director, Archcare Senior Life(PACE)ArchcareArchcare
Clinical Professor of Geriatrics and Palliative MedicineClinical Professor of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount SinaiIcahn School of Medicine at Mount Sinai
www.archcare.org
www.NPAonline.org
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PRIMARY CARE OF OLDER ADULTS WITH MULTIPLE CHRONIC CONDITIONS
• * NOT COMPREHENSIVE
• * NOT EVIDENCE-BASED
• * NOT INTEGRATED
• * NOT EFFICIENT
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PProgramrogram ofof AAllll InclusiveInclusive CCareare for thefor the EElderlylderly
An integrated system of care for the frail elderly that is:
• Community-based• Comprehensive• Coordinated• Continuous• Capitated
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The PACE ModelWho Does It Serve?• 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
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FIVE Pillars of PACE:Concurrent, Continuous processes for care of older adults with multiple chronic conditions
– *INITIAL COMPREHENSIVE ASSESSMENT AND REGULAR REASSESSMENTS
– *PLAN OF CARE– *CARE COORDINATION– *ACTIVE INVOLVEMENT IN CARE BY PATIENT,
FAMILY, CAREGIVERS, AND STAFF– *TRANSITIONAL CARE
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Milestones in the PACE Model History
Waivers/Full Risk
1983
OngoingWaivers
1985
First Center
1973 1978
Demo. Project
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First Demonstration
Sites Operational
1986
Legislation Authorizing
PACE Demonstration
1990 1997
Congress AuthorizesPermanent Provider
Status
Balanced Budget Act of 1997, H.R. 2015
Washington, D.C.
(Nov) 1999
Publication of Interim
Final PACE Regulation
First Program Achieves
Permanent PACE
Provider Status
(Nov) 2001
Milestones in the PACE Model History
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Final PACE Rule
(Oct) 2002
Publication of 2nd Interim Final PACE Regulation enhancing opportunities for program flexibility
November 2006
Milestones in the PACE Model History
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PACE Programs Around the Nation
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National Census Growth 1996 – 2012
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PACE is Small in Scale
Each PACE center and IDT can serve up to about 200 enrollees.
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Typical PACE Patient
– *Average age 80 years old– *Takes 8 medications– *90% are medically complex with 4 or more
chronic conditions, low income and dual eligibles
– *50% are demented– *50% are incontinent – >50% are dependent in at least 3 ADLS
including bathing, dressing and toileting
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Common Problems of Aging ID populations
• Mental illness: depression, dementia, delirium, anxiety• Neurological syndromes: Seizures increase in vascular
and Alzheimer’s dementia• Pressure ulcers in dysmobile IDD patients• Constipation• Falls• Dysphagia, GERD, dental erosions, esophagitis,
anemia, aspiration pneumonia• Behavioral disorders: look first for pain or other medical
problems; use behavioral management techniques; – Data poor on neuroleptics; GDR
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What are health issues over past decade in aging ID populationsPersons with ID survive and live in to late life
No studies on “multi-morbidity”
Polypharmacy studies are scarce
Cardiovascular disease and some cancers less common
Environmental risks (lack of exercise, overweight, obesity, and dental problems) are increasing
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Hospitalizations for I/DD: 1995-2001
• Mental Disorders: 33% (schizoprenia,depression)
• Dental Disorders: 40% of day-surgery admissions
• High ambulatory care sensitive conditions: 3x greater than age/sex adjusted general pop
• In-hospital surgery rates—low
• Highest hospitalization rates age 40-44
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CHALLENGES FOR PRIMARY CARE
FOR IDD • * COMMUNICATION ISSUES
• * CAREGIVER UNABLE TO PROVIDE ESSENTIAL INFORMATION
• * FREQUENT RELOCATIONS
• *FEARFUL ABOUT PHYSICAL EXAM AND TESTS
• *INCREASED # OF HEALTH ISSUES
• *EXTRA CLINICIAN TIME
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The PACE ModelPhilosophy
Honors what frail elders want
• To stay in familiar surroundings
• To maintain autonomy
• To maintain a maximum level of physical, social, and cognitive function
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Brief Overview of PACE Services 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
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Integrated Service Delivery and Team Managed Care
Interdisciplinary TeamsSocial Services
Home CarePharmacy
Nutrition
OT/PT
Primary Care Provider
Transportation
Nursing
Activities
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Integrated, Team Integrated, Team Managed CareManaged Care
• INTERDISCIPLINARY TEAM (IDT) MANAGED vs. individual case manager
• PLAN OF CARE implemented by IDT• Continuous process of assessment,
treatment planning, service provision and monitoring of PLAN OF CARE
• IDT focuses on preventive care, early detection and aggressive intervention
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• Over 160 PACE centers, operated by 89 organizations, in 30 states, serving over 27,000 participants
• Between 2005 and 2010, number of participants doubled
• Enrollment grew about 30% between 2009 and 2012
• 22 new programs in development “pipeline” expected to open in 2013
Status of PACE Development (as of December, 2012)
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PACE Provides Transportation
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PACE Provides PT & OT
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PACE Core Competencies
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
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Capitated, Pooled Financing
• Integration of Medicare, Medicaid and private pay payments
• Medicare capitation rate adjusted for the frailty of the PACE enrollees
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Revenue Sources 2012Revenue Sources 2012
MEDICARE $3,087 pmpm 39%
MEDICAID $4,496 pmpm
57%
Monthly Capitation
PRIVATE PAY $274 pmpm 4%
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Source of Service Revenue• 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)
• 2012 Mean Medicare PMPM Rate: $2,057
• 2012 Median Medicaid PMPM Rate: 3,343
• PACE Programs are Medicare D providers
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PACE Costs Jan – Dec 2012
31Wieland, JAGS 2000; 48:1373-1380
Hospitalization Rates I
20%
43%
16%
0%
10%
20%
30%
40%
50%
% Hospitalized/Year
All Medicare
Medicare 55+ with 3ADL deficitsPACE
32Wieland, JAGS 2000; 48:1373-1380
Hospitalization Rates II
2
14
2
0
2
4
6
8
10
12
14
Hospital Days/Year
All Medicare
Medicare 55+ with 3ADL deficitsPACE
33Flanders, Personal Communication, 2004
Hospitalization Rates III
6.9
2.6
0
1
2
3
4
5
6
7
8
Hospital Days/Year
Massachusetts Dually EligibleCommunity LTCUpham's ElderService Plan
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35Wieland, JAGS 2000; 48:1373-1380
Length of Stay
6.6
4.1
0
1
2
3
4
5
6
7
8
Average Length of Stay (Days)
All MedicarePACE
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Nursing Home Placement
100.0%
10.0%
0%10%20%30%40%50%60%70%80%90%
100%
NH CertifiedNH Placement
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• Begin to think in terms of People vs. Sentinel Events..
• Abandon the assumption that more is better.
• Understand that not all aspects of care are clinically based, some require simple creativity.
• Embrace the importance of a consistent care delivery system over time.
Challenge for ProvidersChallenge for Providers
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CAREGIVERS: PARENTS
• *Parents provide their IDD adult children with a home throughout their life course
• *Parents age
• *Parents become sick, disabled, and need care
• *Parents die
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• www.NPAonline.org• Core Resources Set for PACE (CRSP) (copyright NPA)
– Core operational program components (i.e. policies, procedures and model materials)
– Model PACE provider applications
• Financial Planning Tools (copyright NPA)– Case studies of successful sites– Baseline Scenario– Financial Proforma and Users Guide– Business Planning Checklist
• Exploring PACE Membership Category• Resources for States
National PACE Association Resources
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Fredrick T. Sherman MD, MSc.Fredrick T. Sherman MD, MSc.Chief Medical Officer Chief Medical Officer
for Community and Managed for Community and Managed Care ServicesCare Services
ArchcareArchcarefsherman@archcare.orgfsherman@archcare.org
Clinical Professor of Geriatrics Clinical Professor of Geriatrics and Palliative Medicineand Palliative Medicine
Icahn School of Medicine at Icahn School of Medicine at Mount Sinai Mount Sinai