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Program of All-Inclusive Care for the Elderly

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Program of All-Inclusive Care for the Elderly Powered By Docstoc
					PACE Service Delivery Model



Chris van Reenen, National PACE Association
Ann Olson, ICS
Rob McCommons, ICS

           MN PACE Summit
              July 2004
Long-Term Care for Families
and Caregivers is…
 Often unpredictable and costly due to
  the nature of chronic conditions.
 The responsibility of multiple
  jurisdictions and service sectors.
Long-Term Care for Providers
is…


Difficult because of:
   Multiple funding streams
   Disparate and conflicting regulations

   Health care service sectors with distinct
    clinical roles and responsibilities
The integration of multiple health and
service streams can…
   Eliminate gaps and fragmentation that exists in
    fee-for-service and other systems
   Coordinate primary, acute and long-term care
    delivery systems that can readily respond to
    the needs of the individual
   Create a single source of all necessary
    services for the enrollee rather than multiple
    jurisdictions and sectors
PACE is…
Program
A ll-inclusive
   of




Care
E lderly
   for the
PACE is…
The highly successful model of
fully-integrated acute and long-
term care for frail older adults.

It is the only federally qualified
provider-type which fully-integrates
all Medicare and Medicaid services
into one seamless service package
for beneficiaries.
    PACE takes multiple services…




… and reorganizes them in a way that makes sense to
 persons with long-term care needs, their families,
         health care providers and payers.
This becomes a “one-stop shopping” service package
        for those individuals at highest risk.
In the PACE Model

Beneficiaries receive all of their
health and social services
through the PACE provider
organization.
Full interdisciplinary teams, including
staff physicians, provide and
coordinate all services for the enrollee.
In the PACE Model

An adult day health center
typically becomes the
focal point of service
delivery and most
services are often
provided directly in the
day center setting.
In the PACE Model

 The services of the PACE organization
  follow the beneficiary across all care
  settings including the home, hospital
                     and nursing home.
In the PACE Model

   Beneficiaries receive the
    full range of health and
   social services they need
   to maintain their function
      and remain living at
             home.
In the PACE Model

   Care decisions at all levels are
       made through the close
  involvement of the enrollee and
     family member and service
 delivery is flexible and expedient
    in order to meet the variable
 needs of the enrollee as they age.
                    PACE Nationally
 PACE was developed to replicate On Lok
program in San Francisco
 First PACE demonstration sites became

operational in 1990
 PACE was approved as a new Medicare

Provider under the Balanced Budget Act of 1997
 Federal regulations for PACE were

promulgated in 1999 allowing for demonstrations
to transition to permanent provider status and
growth of new programs
 32 PACE and 8 Pre-PACE organizations in 21

states serve 12,000+ enrollees [7/04]
Key Features of PACE



The PACE organization has the ability to
 provide services to enrollees as they
need them and not according to fee-for-
   service schedules or other payer
              mandates.
Key Features of PACE



PACE Organizations fully integrate all
Medicare and Medicaid services into
 one package for at-risk older adults
 rather than the fragmented fee-for-
           service system.
Key Features of PACE



     The principal care management
       mechanism in PACE is the
  interdisciplinary team which directly
provides and coordinates all services for
              the individual.
Key Features of PACE



The PACE Organization pools capitated
   or fixed payments, typically from
 Medicare and Medicaid, to provide all
  of the needed services in the PACE
 benefit package. Providers are at full
   financial risk from the beginning.
                               Why PACE?
   For consumers, PACE provides:

     Caregivers who listen to and can respond to their
    individualized care needs
     The option to continue living in the community as

    long as possible (“nursing home second opinion
    program”)
     Individualized care and supportive services

    arrangements
     One-stop shopping for all health care services
                                Why PACE?
   For health care providers, PACE provides:

     Capitated, pooled funding which rewards
    providers that are flexible and creative in providing
    the best care possible
     Ability to coordinate care for the individuals

    across settings and medical disciplines
                             Why PACE?
For those who pay for care, PACE
provides:

     Cost savings and predictable expenditures
     Comprehensive service package emphasizing

    preventive vs. acute care
     A model of choice for older individuals

    focused on keeping them at home and out of
    institutional settings
    Cost predictability for the frailest subset of

    beneficiaries
                       PACE Eligibility
  Health problems and limitation that qualify
for nursing facility eligibility within State rules
 Reside in defined service area
 Minimum of 55 years of age
 Qualified for Medicare and/or Medicaid OR
willing to pay private premium
 Able to live safely at home with support
from the PACE organization at time of
enrollment
 Agree to receive covered services through
PACE organization
                  Covered Services
 Interdisciplinary   assessment and care
planning
 PACE Center services
 Primary and specialty medical care
 Nursing home (sub-acute to long- term
residence)
 Home care and home health
     Nursing
     Home  care aides
     Physical, occupational and speech therapies
     Social services
     Home-delivered meals
                  Covered Services
 In-patient and out-patient hospital
 Diagnostic services including lab and x-ray
 Emergency and non-emergency
transportation
 Prescription and non-prescription drugs
 Speech-language pathology services
 Nutrition services
 Podiatry
 Optometry and eye glasses
 Audiology and hearing aids
 Dental care
                Covered Services
   Medical equipment and supplies
   Orthotics and prosthetics
   Personal emergency response system
   Social and environmental supports
                PACE Center Services

The PACE Center is the hub of primary care
and other service delivery
Participants are brought to and from their
homes to receive service at the Center
Monitoring of medical conditions
Receive medications or supplies
Exercise and restorative equipment and instruction
Specialty services such as dental care, optometry,
and podiatry are also often on site
Center services must include:
Primary care, nursing, social services,
rehabilitation, recreation, personal care, meals and
nutrition counseling
                        Other Services
 Some routine chronic care services can be
provided by the PACE organization or
contracted
  Home care
  Transportation
  Social and environmental supports
 PACE  organization arranges all contracted
services from diagnostic to specialty
treatment to institutional care
 Excluded services
  Any service not authorized by the Team (except
 emergency care)
  Inpatient private duty or non-medical services
  Experimental or cosmetic procedures
PACE Interdisciplinary Team
   PACE Center Manager
   Primary Care Physician
   Nurse
   Personal Care/Health Worker
   Physical Therapist
   Occupational Therapist  Dietitian
   Recreational Therapist  Home Care Coordinator
   Social Worker           Drivers
Participant and Family/Caregiver
   The success of the provider’s operations is
    predicated on the success of the
    relationship that’s built between the
    organization and the participant/family
    member.
   Can access the team at any time.
   HIGH level of interface between the team
    and family/caregiver occurs in the
    continuous process of assessment/
    reassessment.
   Regulations provide elaborate grievance
    and appeal process should participant
    experience dissatisfaction and choose this
    option.
PACE Interdisciplinary Team
Responsibilities
 Initial comprehensive assessment
 Routine reassessment
 Reassessment in response to any
  significant change in health status
 Individualized care planning
 Service delivery and care
  coordination across entire
  continuum of services
Care Management Mechanism:
PACE Interdisciplinary Team
 PACE provides and coordinates all
  levels of care for the participant
 Integration allows for focused,
  longitudinal care management which
  spans time, setting and health care
  professions
 Chronic care trajectory can be
  controlled and necessary
  services accessed immediately
Significant Areas of PACE Team
Decision-making

   Days of attendance          Capability of
   Allocation of in-home        family/informal systems
    supportive services          in meeting participant
                                 needs
   Need for alternative
    housing or NF               Rehabilitative vs
    placement                    Habilitative services
   Ethical issues              Determining when to
    between “quality”            add or stop services in
    and “quantity” of life       order to maximize
                                 independence
Center Manager


 Oversees day-to-    Troubleshooting
day operations       in event of an
 Leadership and     emergency or
continuity in case   unusual incident
conferences           Problem solving
 Facilitates        with participants
interdisciplinary    and/or staff
team conferences                  1:PACE
                                  Center
Primary Care Providers

 Provides continuity      Educates and
of care in all settings   counsels participants,
 Provides                families, and staff
assessment and             Must be a team
routine re- evaluation    player
 Coordinates all
aspects of inpatient
and specialty care
                          1.7 (MD+NP):100
Center Nurse


 Monitors            Counsels and
medications          educates participants
 Provides skilled   and their families
nursing treatment     Maintains medical
 Coordinates        supplies in clinic
medical services

                 3.3 RN :100
                 1.2 LPN :100
                 (includes nursing in
                 both Center and home)
Social Work

 Initial and routine assessment
 Problem solving
 Family conferences
 Monitors participant's spirituality needs
 Links with social services in the community
 Integrates social component into medical
model
                       2.1:100
Recreation Therapy
 Provides  group        Adapts activities
and individual          to maintain/improve
activities              physical, mental,
 Provides              social and
opportunities for       emotional well-
community outings       being
 Reality orientation    Provides leisure
activities              education
 Provides special
programming for               1 RT: 100
dementia care
Occupational, Physical,
and Speech Therapies
  Initialand routine assessment
  Assess for assistive equipment
  Provide therapies at the center, in
 participant's home and nursing
 facility
   Ongoing therapy related to disabilities
  and changes in independence
   Crisis intervention   .6 OT: 100
   Discharge planning .7 PT: 100
                         2.3 Therapy Aides: 100
Dietitian
 Counsels   on proper  Oversees kitchen
nutrition, food         operations
selection and diet plan  Initial and subsequent
 Monitors special      assessments
diets, nutrition levels
and hydration
 Coordinates
distribution of home
delivered meals
 Personal Care Aides

 Reports   on personal     Monitors  for changes
care services and self-    in participant’s health
care abilities             and social condition
 Provides personal care    Helps maintain clean
and ADL assistance         and safe home
                           environment
                            Provides escort
      21.1:100             services
   (includes care           Orders supplies and
  provided in both         coordinates delivery of
     Center and            supplies
       home)                Assists in recreation
                           therapy activities
 Transportation
 Provides             Maintains
transportation to and cleanliness and safety
from the PACE Center of vehicles used for
and medical           transport
appointments           Reports to Team
 Delivers portable   regarding changes in
meals                 health and social
                      condition
Factors Critical to PACE
Success
   Achieve census growth to achieve sufficient
    size to spread fixed costs (e.g. Center
    expenses and staffing)
   Manage care to control variable costs (e.g.
    home care, ADHC attendance, pharmacy,
    inpatient utilization)
   Manage risks for acute and long-term care
    services
   Obtain working capital to sustain losses
    until operating reserves can be achieved
   Develop staffing, PACE center facility and
    services, and establish provider network
Creativity
 Creating viable alternatives to more
  costly services
 Going beyond the traditional
  Medicare and Medicaid fee-for-
  service package
 Working collaboratively with families
  or other informal social networks to
  achieve effective outcomes
Communication
   High level of communication
    ensures changes in participant
    social, health and functional abilities
    are identified, services delivered and
    status is monitored closely
Coordination
 Ensures all services are managed
  consistently and appropriately
 May require reducing services if
  necessary
Collaboration

 Removing barriers between
  professions creates care
  management that is greater than the
  sum of its parts
 Caring holistically for all areas of the
  participant’s life creates unique
  opportunity to achieve outcomes not
  found in other models

				
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